![](media/image1.png){width="1.0270833333333333in"
height="1.582638888888889in"}

**Module 1** Introduction to HIV/AIDS

![](media/image2.png){width="0.5597222222222222in"
height="0.5597222222222222in"} **Total Time:** 120 minutes

[]{.mark}

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SESSION 1 Scope of the HIV/AIDS Pandemic

+-------------------------------+--------------------------+-----------+
| **Activity/Method**           | **Resources Needed**     | **Time**  |
+-------------------------------+--------------------------+-----------+
| Exercise 1.1 Hope exercise:   | Summary of information   | 30        |
| group discussion              | on                       | minutes   |
|                               | local/national/regional  |           |
|                               | epidemiology of HIV/AIDS |           |
|                               |                          |           |
|                               | If available, HIV        |           |
|                               | prevalence among women   |           |
|                               | at local prenatal        |           |
|                               | clinics.                 |           |
+-------------------------------+--------------------------+-----------+

SESSION 2 Natural History and Transmission of HIV

  -------------------------------- -------------------------- -----------
  **Activity/Method**              **Resources Needed**       **Time**

  Exercise 1.2 HIV 1, 2, 3         Prizes, such as sweets or  90 minutes
  Knowledge interactive game       condoms (optional), for    
                                   the winning team           
  -------------------------------- -------------------------- -----------

**Also have available the following:**

-   Overheads or PowerPoint slides for this Module (in Presentation
    Booklet)

-   Overhead or LCD projector, extra extension cord/lead

-   Flipchart or whiteboard and markers or blackboard and chalk

-   Pencil or pen for each participant

+-----------------------------------------------------------------------+
| > **Relevant Policies for Inclusion in National Curriculum**          |
+-----------------------------------------------------------------------+
| Session 1                                                             |
|                                                                       |
| -   Brief summary of local/national/regional epidemiology of HIV      |
|                                                                       |
| -   If available, a graph illustrating HIV prevalence among pregnant  |
|     women at antenatal clinics (a local variation on Figure 1.2)      |
+-----------------------------------------------------------------------+

  ----------- -----------------------------------------------------------
              

  ----------- -----------------------------------------------------------

SESSION 1 Scope of the HIV/AIDS Pandemic

  ------------------------------------- ------------------------------------------------------------
  ![](media/image3.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}        

                                        For the Hope Exercise (Exercise 1.1), prepare a list of
                                        positive responses to HIV in your area.
  ------------------------------------- ------------------------------------------------------------

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image2.png){width="0.6263888888888889in"   **Total Session Time:** 30 minutes
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Begin by reviewing the module objectives listed below.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 1 and 2**                                         |
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After completing the module, the participant will be able to:

-   Describe the global and local impact of the epidemic.

-   Answer basic questions about HIV/AIDS in women, children, and
    families.

-   Discuss the natural history of HIV infection.

-   Present information about HIV transmission.

    Discuss the scope of the global HIV/AIDS pandemic.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 3, 4 and 5**                                      |
| 4.png){ |                                                            |
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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
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  ---------------------------------------------------- ------------------------------------------------------------

-   **More than 90% of people living with HIV/AIDS (PLWHA) are in the
    developing world.**

-   95% of all HIV-related deaths have been in the developing world,
    largely among young adults.

Figure 1.1 Worldwide epidemiology of HIV/AIDS

![](media/image6.png){width="6.009722222222222in" height="4.0in"}

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  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

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Explain the effects of HIV/AIDS on children.

HIV in children, 2003

UNAIDS estimates that at the end of 2003:

-   40 million people worldwide were living with HIV/AIDS

-   2.5 million people with HIV/AIDS were children younger than 15 years
    old

-   90% of the children living with HIV/AIDS were from sub-Saharan
    Africa

-   700,000 children worldwide were newly infected in 2003

-   500,000 child deaths are estimated to have occurred from HIV/AIDS
    during 2003

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Emphasise the number of new infections using the most recently
    available data.

    **New infections, 2003**

According to UNAIDS, about 14,000 new infections occurred *each day* in
2003. Of these new infections

-   About 6,000 each day were among persons 15 to 24 years old

-   Almost 2,000 each day were in children younger than 15 years old

-   Most of the infections in children younger than 15 years old
    occurred through mother-to-child transmission (MTCT) of HIV.

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  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Briefly highlight the regional HIV/AIDS data as detailed in Table 1.1.
This table also appears in the Participant Manual, so you need not
discuss the information in detail.

+-------------+--------------+---------------+----------+--------------+
| **Table 1.1 |              |               |          |              |
| Regional    |              |               |          |              |
| HIV/AIDS    |              |               |          |              |
| statistics  |              |               |          |              |
| and         |              |               |          |              |
| features,   |              |               |          |              |
| through     |              |               |          |              |
| 2003**      |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| Region      | **Adults and | **Adults and  | **Adult  | **Adult and  |
|             | Children     | Children      | Preval   | Child Deaths |
|             | Living with  | Newly         | ence\*** | Due to       |
|             | HIV/AIDS**   | Infected with |          | AIDS**       |
|             |              | HIV**         | **(%)**  |              |
+-------------+--------------+---------------+----------+--------------+
| Sub-Saharan | 25.0--28.2   | 3.0--3.4      | 7.5--8.5 | 2.2--2.4     |
| Africa      | million      | million       |          | million      |
+-------------+--------------+---------------+----------+--------------+
| North       | 470,         | 4             | 0.2--0.4 | 35           |
| Africa and  | 000--730,000 | 3,000--67,000 |          | ,000--50,000 |
| Middle East |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| South and   | 4.6--8.2     | 610,00        | 0.4--0.8 | 330,         |
| South-East  | million      | 0--1.1million |          | 000--590,000 |
| Asia        |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| East Asia   | 700,000--1.3 | 150           | 0.1--0.1 | 32           |
| and Pacific | million      | ,000--270,000 |          | ,000--58,000 |
+-------------+--------------+---------------+----------+--------------+
| Latin       | 1.3--1.9     | 120           | 0.5--0.7 | 49           |
| America     | million      | ,000--180,000 |          | ,000--70,000 |
+-------------+--------------+---------------+----------+--------------+
| Caribbean   | 350,         | 4             | 1.9--3.1 | 30           |
|             | 000--590,000 | 5,000--80,000 |          | ,000--50,000 |
+-------------+--------------+---------------+----------+--------------+
| Eastern     | 1.2--1.8     | 180           | 0.5--0.9 | 23           |
| Europe and  | million      | ,000--280,000 |          | ,000--37,000 |
| Central     |              |               |          |              |
| Asia        |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| Western     | 520,         | 3             | 0.3--0.3 | 2,600--3,400 |
| Europe      | 000--680,000 | 0,000--40,000 |          |              |
+-------------+--------------+---------------+----------+--------------+
| North       | 790,000--1.2 | 3             | 0.5--0.7 | 12           |
| America     | million      | 6,000--54,000 |          | ,000--18,000 |
+-------------+--------------+---------------+----------+--------------+
| Australia   | 12           | 700--1,000    | 0.1--0.1 | \<100        |
| and New     | ,000--18,000 |               |          |              |
| Zealand     |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| **Total**   | **40         | **5 million\  | **1.1\   | **3 million\ |
|             | million\     | (4.2--5.8     | (0.9     | (2.5--3.5    |
|             | (34--46      | million)**    | --1.3)** | million)**   |
|             | million)**   |               |          |              |
+-------------+--------------+---------------+----------+--------------+
| \*          |              |               |          |              |
| Percentage  |              |               |          |              |
| of adults   |              |               |          |              |
| age 15 to   |              |               |          |              |
| 49 years    |              |               |          |              |
| living with |              |               |          |              |
| HIV/AIDS in |              |               |          |              |
| 2003, using |              |               |          |              |
| 2003        |              |               |          |              |
| population  |              |               |          |              |
| data        |              |               |          |              |
|             |              |               |          |              |
| The ranges  |              |               |          |              |
| in this     |              |               |          |              |
| table are   |              |               |          |              |
| based on    |              |               |          |              |
| the best    |              |               |          |              |
| available   |              |               |          |              |
| i           |              |               |          |              |
| nformation. |              |               |          |              |
| These       |              |               |          |              |
| ranges are  |              |               |          |              |
| more        |              |               |          |              |
| precise     |              |               |          |              |
| than in     |              |               |          |              |
| previous    |              |               |          |              |
| years, and  |              |               |          |              |
| work is     |              |               |          |              |
| under way   |              |               |          |              |
| to further  |              |               |          |              |
| improve the |              |               |          |              |
| precision   |              |               |          |              |
| of the      |              |               |          |              |
| estimates   |              |               |          |              |
| to be       |              |               |          |              |
| published   |              |               |          |              |
| in          |              |               |          |              |
| mid-2004.   |              |               |          |              |
+-------------+--------------+---------------+----------+--------------+

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  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Explain that to estimate HIV prevalence in the general population,
researchers often measure HIV prevalence in antenatal clinics.

Figure 1.2 below is a good example of the results of a prevalence study
among pregnant women, which shows the extent of the South African
epidemic.

**Figure 1.2 HIV prevalence: pregnant women in South Africa,
1991--2002**

![](media/image7.png){width="5.999305555555556in" height="4.0in"}

Most of these estimates are based on surveillance systems that focus on
pregnant women who attend selected antenatal clinics. This method
assumes that HIV prevalence among pregnant women is a good approximation
of prevalence among the adult population (aged 15--49 years). A direct
comparison of HIV prevalence among pregnant women at antenatal clinics
and the adult population in the same community in a number of African
communities has provided evidence for this method of estimating HIV
prevalence.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slide 6**                                                |
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+---------+------------------------------------------------------------+

**Explain that the impacts of HIV occur at all levels of society from
the individual to the family, community and country level. The social
and economic consequences are far reaching.**

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

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-   HIV/AIDS affects every region of the world.

-   Millions of people are infected with HIV or live in families
    affected by HIV.

-   The number of new infections continues to grow.

-   The HIV/AIDS pandemic contributes to:

    -   Childhood malnutrition

    -   Shortened life span with illness and suffering

    -   Economic loss, personal and countrywide

    -   Weakened family system

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  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

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Begin a group discussion about some of the pandemic\'s global outcomes,
based on the following information:

Global impact of HIV

The global impact of the HIV/AIDS pandemic is especially severe in
resource-constrained settings and results in the following:

-   Negative impact on countries' economic development

-   Overwhelmed healthcare systems

-   Decreasing life expectancy in many countries

-   Deteriorating child survival rates

-   Increasing number of orphans

Effects of the HIV/AIDS pandemic on individuals include the following:

-   Illness and suffering

-   Shortened life span

-   Loss of work and income

-   Death of family members, grief, poverty, and despair

-   Barriers to health care related to stigma and discrimination

-   Deteriorating child health and survival

-   Weakened integrity and support structure of the family unit

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 7, 8 and 9**                                      |
| 4.png){ |                                                            |
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+---------+------------------------------------------------------------+

**Slides 7, 8 and 9 feature national epidemiologic data; review this
data with participants. Invite the participants to share individual and
family outcomes they have witnessed related to the HIV pandemic.**

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  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

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**Lead an interactive discussion based on Exercise 1.1.**

+-----------+----------------------------------------------------------+
| *         |                                                          |
| *Exercise |                                                          |
| 1.1 Hope  |                                                          |
| exercise: |                                                          |
| group     |                                                          |
| dis       |                                                          |
| cussion** |                                                          |
+-----------+----------------------------------------------------------+
| **        | To begin the PMTCT training with a feeling of hope and   |
| Purpose** | optimism despite the devastation left by decades of HIV. |
+-----------+----------------------------------------------------------+
| **D       | 20 minutes                                               |
| uration** |                                                          |
+-----------+----------------------------------------------------------+
| **Intro   | Explain to participants that this activity is intended   |
| duction** | to introduce hope and optimism about the response to     |
|           | HIV/AIDS.                                                |
+-----------+----------------------------------------------------------+
| **Act     | Ask participants to share their ideas about positive     |
| ivities** | responses to the HIV/AIDS pandemic. Record their         |
|           | responses on the flipchart or board. Typical responses   |
|           | include:                                                 |
|           |                                                          |
|           | -   Groups in the community that have never worked       |
|           |     together before have connected with each other to    |
|           |     address HIV/AIDS.                                    |
|           |                                                          |
|           | -   Global community has allocated increased funding for |
|           |     healthcare systems in the developing world,          |
|           |     especially HIV/AIDS care systems.                    |
|           |                                                          |
|           | -   The Ministry of Health in many countries has become  |
|           |     a stronger advocate for the healthcare needs of      |
|           |     people in all sectors of society.                    |
|           |                                                          |
|           | -   Global community has become more attentive to TB     |
|           |     because of its connection to HIV.                    |
|           |                                                          |
|           | -   There is increased awareness of safer sex practices  |
|           |     that protect people from other STIs and HIV.         |
|           |                                                          |
|           | If no one identifies PMTCT as a positive response, ask   |
|           | what the participants know about preventing transmission |
|           | from mothers to babies.                                  |
+-----------+----------------------------------------------------------+
| **Deb     | Summarise the session by noting the following points:    |
| riefing** |                                                          |
|           | -   Much of the progress in HIV treatment and care in    |
|           |     developed nations relates to HIV-positive people     |
|           |     living longer, healthier lives.                      |
|           |                                                          |
|           | -   Fewer infants are infected from their mothers.       |
|           |                                                          |
|           | -   Participants can be part of the progress in PMTCT.   |
|           |                                                          |
|           | -   Even though HIV has brought devastation, it also has |
|           |     brought positive responses such as bringing together |
|           |     many different kinds of people to fight for a common |
|           |     goal.                                                |
|           |                                                          |
|           | -   This PMTCT course begins on a note of hope.          |
+-----------+----------------------------------------------------------+

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Despite the devastation caused by HIV, there are reasons to be
    hopeful and optimistic.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 10, 11 and 12**                                   |
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+---------+------------------------------------------------------------+

**Use this part of the session to present an overview of HIV infection
and AIDS. For some participants, this may be a review.**

Discuss the definitions of HIV and AIDS and highlight the differences.
Allow time to respond to questions.

Overview of HIV and AIDS

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  ![](media/image8.png){width="0.7597222222222222in"   Refer to *Pocket* *Guide.*
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- -----------------------------------------------------------

Definitions of HIV and AIDS

**HIV** stands for *human immunodeficiency virus,* the virus that causes
AIDS.

> **H: H**uman

**I: I**mmunodeficiency

> **V: V**irus

-   HIV breaks down the body\'s defence against infection and
    disease---the body\'s immune system---by infecting specific white
    blood cells, leading to a weakened immune system.

-   When the immune system becomes weak or compromised, the body loses
    its protection against illness.

-   As time passes, the immune system is unable to fight the HIV
    infection and the person may develop serious and deadly diseases,
    including other infections and some types of cancer.

    **When a person is infected with HIV, the person is known as
    "HIV-infected."**

    **"HIV-positive" is when person who is HIV-infected has tested
    positive for HIV.**

**AIDS** is an acronym for *acquired immunodeficiency syndrome* and
refers to the most advanced stage of HIV infection.

**A: A**cquired, (not inherited) to differentiate from a genetic or
inherited condition that causes immune dysfunction

**I: I**mmuno-, because it attacks the immune system and increases
susceptibility to infection

**D:** **D**eficiency of certain white blood cells in the immune system

**S: S**yndrome, meaning a group of symptoms or illnesses that result
from the HIV infection

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
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-   Emphasise the differences between HIV and AIDS.

Differences between HIV, HIV infection, and AIDS

-   HIV is the virus that causes infection.

-   The person who is HIV-infected may have no signs of illness but can
    still infect others.

-   Most people who are HIV-infected will develop AIDS after a period of
    time, which may be several months to more than 15 years.

-   AIDS is a group of serious illnesses and opportunistic infections
    that develop after being infected with HIV for a long period of
    time.

-   A diagnosis of AIDS is based on specific clinical criteria and
    laboratory test results.

(See Appendix 1-A for information about the World Health Organization
(WHO) staging systems for HIV infection and Disease and Appendix 1-B for
the U.S. Centers for Disease Control and Prevention (CDC) AIDS
Surveillance Case Definitions.)

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 13 and 14**                                       |
| 4.png){ |                                                            |
| width=" |                                                            |
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+---------+------------------------------------------------------------+

**Discuss HIV-1 and HIV-2, highlighting the similarities and differences
between them.**

Types of HIV

HIV-1 and HIV-2 are types of HIV. Both types are transmitted the same
way, and both are associated with similar opportunistic infections and
AIDS. HIV-1 is more common worldwide. HIV-2 is found predominantly in
West Africa, Angola, and Mozambique.

Differences between HIV-1 and HIV-2

HIV-2 is less easily transmitted than is HIV-1, and it is less
pathogenic, meaning that the period between initial infection and
illness is longer. In some areas, a person may be infected with both
HIV-1 and HIV-2. While HIV-2 can be transmitted from an infected mother
to her child, this appears to be rare (0% to 5% transmission rate in
breastfed infants in the absence of any interventions).

A discussion of preventing mother-to-child-transmission (PMTCT) from
women who are infected with HIV-2 to their infants is included in
*Module 2, Overview of HIV Prevention in Mothers, Infants, and Young
Children, Appendix 2-A.* Women who are infected with both HIV-1 and
HIV-2 should follow all PMTCT recommendations for HIV-1-infected women.

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Emphasise the differences between HIV-1 and HIV-2 and be sure that
    participants understand the information.

SESSION 2 Natural History and Transmission of HIV

+---------+------------------------------------------------------------+
| ![](med | Advance Preparation                                        |
| ia/imag |                                                            |
| e3.png) |                                                            |
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| "0.6in" |                                                            |
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| 3333333 |                                                            |
| 333in"} |                                                            |
+---------+------------------------------------------------------------+
|         | Review Exercise 1.2 HIV 1, 2, 3 Knowledge interactive      |
|         | game: although a few easy questions and a few difficult    |
|         | ones help to make the game fun, re-write any questions     |
|         | that are inappropriate for participants.                   |
|         |                                                            |
|         | Before the session, draw on flipchart paper in the front   |
|         | of the room (or on a blackboard or whiteboard) one circle  |
|         | for each team. Each circle should be approximately 30 cm   |
|         | to 60 cm in diameter so that people in the back of the     |
|         | room can see it clearly. Divide each circle into sixths.   |
|         |                                                            |
|         | Optional: Purchase sweets or condoms to be used for prizes |
|         | for Exercise 1.2.                                          |
+---------+------------------------------------------------------------+

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image2.png){width="0.6263888888888889in"   **Total Session Time:** 90 minutes
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 15, 16 and 17**                                   |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Review the basic information about the natural history of HIV
infection using Figure 1.3.**

Explain the \"Natural Course of HIV Disease\" graph, and describe the
presentation of HIV at each stage of infection.

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
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-   Emphasise that HIV is transmitted during each stage and that many
    people do not know that they are infected until they become
    symptomatic.

-   Examine the relation of viral load and increased risk of
    transmitting infection.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slide 18**                                               |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Discuss CD4 count and viral load highlighting the relationship between
them.**

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  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   CD4 count and viral load are difficult concepts. Spend adequate time
    on them and ask participants for feedback to verify that they
    understand both concepts.

-   Explain that although CD4 and viral load are both indicators of
    disease progression, they measure different things---one measures
    the amount of suppression of the immune system and the other
    measures the amount of virus in the blood.

-   Participants may find it confusing that a low CD4 count is a bad
    sign and a low viral load is a good sign. Take the time to clarify
    these measures to be sure the participants understand the concepts
    clearly.

-   Emphasise that high maternal viral load increases the risk of
    mother-to-child transmission of HIV.

Background information on CD4 count and viral load

# Figure 1.3 Characteristic viral load and CD4 changes over time in HIV/AIDS

![](media/image10.png){width="5.686111111111111in"
height="4.339583333333334in"}

[]{.mark}

The CD4 count and viral load are two measures of the progression of HIV.
When HIV actively multiplies, it infects and kills CD4 T cells---a
specific type of white blood cell---that are the immune system\'s key
infection fighters. The effects of HIV are measured by the decline in
the number of CD4 cells.

The CD4 count is the number of CD4 cells in the blood and reflects the
state of the immune system. The normal count in a healthy adult is
between 600 and 1,200 cells/mm^3^. When the CD4 count of an adult falls
below 200 cells/mm^3^, the risk of opportunistic and serious infection
is high.

Viral load is the amount of HIV virus in the blood. It can be measured
by the HIV ribonucleic acid polymerase chain reaction blood test
(HIV-RNA PCR). The test is used as a marker of response to
antiretroviral (ARV) treatment.

The viral load is very high shortly after primary HIV infection. It
falls steeply when the body develops antibodies and rises again after a
number of years as the CD4 count drops. High viral load leads to higher
transmission risk. Most often, after a number of years, high viral load
is also a sign of more severe disease as people develop AIDS (Figure
1.3).

Natural history (or course) of HIV infection

Seroconversion

People infected with HIV usually develop antibodies 4 to 6 weeks after
being infected, but it may take as long as 3 months for antibodies to
develop. The period of time between when a person is infected with HIV
and when the antibody test result is positive is called the \"window
period.\"

Unlike for most diseases, having antibodies for HIV does not indicate
protection but indicates infection.

When a recently infected person develops antibodies that can be measured
using a laboratory test, seroconversion is occurring. Some people may
experience a glandular illness (fever, rash, joint pains, and enlarged
lymph nodes) at the time of seroconversion.

HIV testing detects antibodies or antigens associated with HIV in whole
blood, saliva, or urine.

A person whose blood test results show HIV infection is said to be
seropositive or\
HIV-positive.

A person whose blood test results do not show HIV infection is said to
be seronegative or HIV-negative.

> **A person who tests HIV-negative but who has engaged in behaviour
> within the past 3 months that places him or her at risk for HIV should
> be tested again in 3 months.**

Asymptomatic HIV infection

A person who is HIV-infected but looks and feels healthy is
asymptomatic. None of the physical signs or symptoms that indicate HIV
infection are present.

Whether they have symptoms or not, people who are HIV-positive can still
pass the virus to others.

The duration of the asymptomatic phase varies greatly from person to
person. Some adults may develop symptoms of HIV as quickly as a few
months after primary infection; others may take as long as 15 years or
more to develop symptoms.

For children infected with HIV through MTCT, during pregnancy, labour
and delivery, and breastfeeding, the asymptomatic phase is shorter. A
few infants who are HIV-positive will become ill within the first weeks
of life. Most children start to develop symptoms before they are 2 years
old; a few remain well for several years.

Symptomatic HIV infection

A person who has developed physical signs of HIV and reports symptoms
related to HIV is *symptomatic**.***

The immune system weakens and CD4 count decreases during this phase.

The progression of HIV depends on the type of virus and specific host
characteristics including general health, nutritional, and immune
status.

AIDS

Almost all people who are HIV-positive will ultimately develop
HIV-related disease and AIDS, the end stage of HIV infection. As HIV
infection progresses, the CD4 count continues to decrease and the
infected person becomes susceptible to opportunistic infections.

An *opportunistic infection* is an illness caused by a germ that might
not cause illness in a healthy person, but will cause illness in a
person who has a weakened immune system. For example, co-infection with
tuberculosis (TB) is very common in people infected with HIV.

People living with advanced HIV infection suffer from opportunistic
infections of the lung, brain, eyes, and other organs. Other common
opportunistic infections in persons diagnosed with AIDS are
*pneumocystis carinii* pneumonia (PCP); cryptosporidiosis;
histoplasmosis; other parasitic, viral and fungal infections; and some
types of cancers, such as Kaposi\'s sarcoma.

*ARV treatment and prophylaxis and treatment of opportunistic infections
help preserve the CD4 cells, lower viral load, and prolong the time it
takes for HIV to progress to the symptomatic phase and, ultimately, to
AIDS.*

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 19, 20, 21, and 22**                              |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Discuss and reinforce the concept of HIV disease progression.**

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Point out that the transition from the stages of asymptomatic to
    symptomatic to AIDS occurs when CD4 counts decrease and immune
    function deteriorates.

-   Note that HIV infects many organ systems and causes a range of
    symptoms and opportunistic infections.

-   Emphasise the role of high viral load and low CD4 counts in the
    development of clinical symptoms.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

**Review the staging systems for HIV and their purpose so that the
participants are familiar with these topics.**

Take a few moments to go over the tables in Appendix 1-A with the
participants.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Tell the participants that staging systems continue to be modified
    as we learn more about the disease.

Staging systems for HIV

Staging systems for HIV can:

-   Contribute to the care of individuals who are HIV-infected

-   Provide a framework for follow-up and management

-   Help define prognosis and guide patient counselling

-   Be used to help evaluate new treatments

World Health Organization (WHO) staging system for HIV

The WHO staging system groups HIV progression into four clinically
relevant stages---Stages I to IV---that correspond to the natural
history of HIV. (See Appendix 1-A.)

The staging system for HIV infection in children is scheduled to be
revised by WHO in consultation with paediatric experts in 2004. In the
interim, using the WHO staging system can help define parameters for
initiating treatment in resource-constrained settings.

*However, adapting the staging system at the country level may be
appropriate.*

U.S. Centers for Disease Control and Prevention (CDC) surveillance case
definition

The CDC AIDS Surveillance Case Definitions include clinical and
immunologic categories. (See Appendix 1-B.) This system uses a
combination of symptoms and\
CD4 count levels to establish criteria for AIDS.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slide 23**                                               |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Review the natural history summary slide slowly and carefully and take
the opportunity to invite additional questions.**

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 24, 25 and 26**                                   |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Discuss transmission of HIV.**

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image5.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   The main source of HIV transmission is unprotected sex with a
    partner who is\
    HIV-positive.

-   Myths and misinformation regarding the transmission of HIV infection
    exist and require clarification.

-   Condoms used consistently and correctly prevent HIV and other
    sexually transmitted infections (STIs).

-   Effective PMTCT programmes reduce the risk of perinatal transmission
    of HIV.

Routes of HIV transmission

HIV can be transmitted through blood, sexual contact, or injection drug
use, and from mother-to-child (also known as perinatal or vertical
transmission).

> **The most common route of HIV transmission is through sexual contact,
> especially heterosexual intercourse.**

Blood-to-blood transmission

-   Transfusion with HIV-infected blood

-   Direct contact with HIV-infected blood

Sexual contact

-   Unprotected sexual intercourse (vaginal, oral, or anal)

-   Direct contact with HIV-infected body fluids such as semen, cervical
    and vaginal secretions

> **Women of childbearing age are at particular risk for acquiring HIV.
> The main behaviour that places them at risk is unprotected sex with an
> infected male partner.**

Drug use

-   Injection of drugs with needles or syringes contaminated with HIV

Perinatal transmission (MTCT)

-   From mothers who are HIV-positive to their infants during pregnancy,
    labour, delivery, and breastfeeding

    **HIV cannot be transmitted by:**

```{=html}
<!-- -->
```
-   Coughing or sneezing

-   Insect bites

-   Touching or hugging

-   Kissing

-   Public baths/pools

-   Public toilets

-   Shaking hands

-   Working or going to school with a person who is HIV-infected

-   Telephones

-   Water or food

-   Sharing cups, glasses, plates, or other utensils

Public health strategies to prevent HIV infection

Blood-to-blood transmission

-   Screen all blood and blood products for HIV.

-   Follow universal precautions which include:

    -   Use of protective equipment

    -   Safe use and disposal of sharps

    -   Sterilisation of equipment

    -   Safe disposal of contaminated waste products

Sexual contact

-   Promote abstinence or being faithful to one uninfected partner.

-   Provide instruction on the consistent and correct use of barrier
    methods.

```{=html}
<!-- -->
```
-   Male or female condoms for vaginal intercourse

-   Non-lubricated condoms for oral intercourse on a male

-   Dental dams, plastic wrap, or latex panties for oral intercourse on
    a female

-   Condoms for anal intercourse

    -   Prevent, identify, and provide early treatment for sexually
        transmitted infections (STIs).

    -   Provide access to HIV testing and counselling.

*Condoms provide protection from HIV transmission as well as other
sexually transmitted infections (STIs) when used correctly and
consistently.*

Drug use

-   Educate about the risks of infection through drug use with
    contaminated needles and syringes.

-   Provide referral for treatment of drug dependence.

Drug use in any form may increase the risk of HIV infection by limiting
judgment and facilitating engagement in risky behaviours. Even
occasional use of alcohol, marijuana, and other "recreational" drugs may
increase risk of HIV infection.

Perinatal transmission from HIV-positive mothers

-   Provide ARV treatment when indicated and available.

-   Provide ARV prophylaxis during labour and delivery.

-   Provide ARV prophylaxis to the infant.

-   Offer elective caesarean section when safe and feasible.

-   Follow safer delivery practices.

-   Provide linkages to treatment, care, and social support for mothers
    and families with HIV infection.

-   Provide infant-feeding counselling.

(Module 2, Overview of HIV Prevention in Mothers, Infants, and Young
Children contains detailed information on a comprehensive PMTCT
approach.)

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | **Slides 27 and 28**                                       |
| 4.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

**Summarise key points for Module 1.**

**Module 1: Key Points**

-   HIV is a global pandemic.

-   The number of people living with HIV worldwide continues to
    increase.

-   The HIV epidemic is especially severe in many resource-constrained
    countries.

-   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 15 years.

-   The most common route of HIV transmission worldwide is heterosexual
    transmission.

-   Women of childbearing age are at particular risk for acquiring HIV.
    The main behaviour that places them at risk is unprotected sex with
    an infected male partner.

-   Pregnant women who are HIV-infected 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 programmes.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image4.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

**Close the module by facilitating Exercise 1.2, the HIV 1, 2, 3
Knowledge Game. Your copy of the game (pages 1-22 to 1-29) includes the
answers in the column on the right.**

The participant copy of the HIV 1, 2, 3 Knowledge Game is on pages 1-13
of the *Participant Manual.*

+------------+---------------------------------------------------------+
| ### E      |                                                         |
| xercise 1. |                                                         |
| 2 HIV 1, 2 |                                                         |
| , 3 Knowle |                                                         |
| dge intera |                                                         |
| ctive game |                                                         |
+============+=========================================================+
| > *        | > To present basic and advanced HIV/AIDS information in |
| *Purpose** | > an easy and enjoyable way while allowing participants |
|            | > an opportunity to demonstrate what they know. This    |
|            | > game also gives the participants a chance to get to   |
|            | > know each other.                                      |
+------------+---------------------------------------------------------+
| > **       | 60 minutes                                              |
| Duration** |                                                         |
+------------+---------------------------------------------------------+
| > **Intr   | > Set up round tables that will accommodate 4--6        |
| oduction** | > participants at each table. Divide the group into two |
|            | > to four teams of equal size, depending on the size of |
|            | > the group and the amount of time you have. The more   |
|            | > teams there are, the longer the game will take.       |
|            | >                                                       |
|            | > Distribute the groups somewhat evenly by discipline,  |
|            | > so that each group has the same number of nurses,     |
|            | > doctors, and so on. Number the teams 1, 2, 3, and 4   |
|            | > and ask the participants to sit with their teams.     |
|            | >                                                       |
|            | > Start the exercise by explaining that the objective   |
|            | > is to be the first team to complete the circle. Each  |
|            | > team can fill in one-sixth of the circle each time    |
|            | > the team gets a correct answer in six of the          |
|            | > following seven categories:                           |
|            |                                                         |
|            | -   HIV/AIDS transmission                               |
|            |                                                         |
|            | -   Prevention                                          |
|            |                                                         |
|            | -   Infant feeding                                      |
|            |                                                         |
|            | -   Testing                                             |
|            |                                                         |
|            | -   Mother-to-child transmission                        |
|            |                                                         |
|            | -   Linkages to treatment, care, and support            |
|            |                                                         |
|            | -   Prevention in healthcare settings                   |
|            |                                                         |
|            | > Distribute one question sheet to each participant.    |
|            | > Use the Wild Card category *only* in the event of a   |
|            | > tie.                                                  |
+------------+---------------------------------------------------------+
| > **Ac     | > Give the participants 15--20 minutes to answer the    |
| tivities** | > questions working together in their teams.            |
|            | >                                                       |
|            | > Remind the teams to record their answers on the       |
|            | > question sheet.                                       |
|            | >                                                       |
|            | > Suggest that they keep the answers simple and not     |
|            | > linger on any one question.                           |
|            | >                                                       |
|            | > To begin play, the first team chooses a category and  |
|            | > a question, then reads the question aloud and gives   |
|            | > the answer. The team has 10 seconds to answer.        |
|            | >                                                       |
|            | > If correct, the team colours in one-sixth of its      |
|            | > circle and records next to the circle the name of the |
|            | > category from which the question came.                |
|            | >                                                       |
|            | > A team may only answer one question per category.     |
|            | >                                                       |
|            | > If incorrect, the next team gets to answer that       |
|            | > question or another question of its choosing.         |
|            | >                                                       |
|            | > Once a question has been answered correctly, no other |
|            | > team may use it.                                      |
|            | >                                                       |
|            | > The facilitator should clarify any misconceptions     |
|            | > that may have surfaced during the discussion once the |
|            | > question is correctly answered.                       |
|            | >                                                       |
|            | > The next team takes a turn.                           |
|            |                                                         |
|            | *The first team to fill its circle by colouring in all  |
|            | six pieces (representing six correct answers in six     |
|            | different categories) is the winner and receives the    |
|            | prize.*                                                 |
+------------+---------------------------------------------------------+
| **De       | > Point out that each participant knows more than they  |
| briefing** | > think they know and that by working together, they    |
|            | > are able to respond correctly to many of the HIV/AIDS |
|            | > questions in the Knowledge Game.                      |
+------------+---------------------------------------------------------+

Answers to Exercise 1.2 HIV 1, 2, 3 Knowledge Game

Category 1: HIV/AIDS Transmission

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| List at least three | -   Unprotected sex with an infected person    |
| ways in which HIV   |                                                |
| infection is        | -   From an infected mother to her infant      |
| transmitted.        |     before birth, during birth, or during      |
|                     |     breastfeeding                              |
|                     |                                                |
|                     | -   Blood transfusion in countries in which    |
|                     |     blood is not routinely screened            |
|                     |                                                |
|                     | -   Blood-to-blood transmission, including any |
|                     |     of the following:                          |
|                     |                                                |
|                     | ```{=html}                                     |
|                     | <!-- -->                                       |
|                     | ```                                            |
|                     | -   Injection drug use or                      |
|                     |                                                |
|                     | -   Accidental exposure to needles or sharps   |
|                     |     in a health care setting---razors, scalpel |
|                     |     blades, lancets, or scissors---that were   |
|                     |     used by a person who was HIV-infected and  |
|                     |     not cleaned                                |
+---------------------+------------------------------------------------+
| Name the two types  | HIV-1 and HIV-2                                |
| of HIV.             |                                                |
+---------------------+------------------------------------------------+
| What body fluids    | -   Blood                                      |
| contain high        |                                                |
| concentrations of   | -   Semen                                      |
| HIV?                |                                                |
|                     | -   Vaginal secretions                         |
|                     |                                                |
|                     | -   Breastmilk                                 |
+---------------------+------------------------------------------------+
| What is the major   | > Unprotected heterosexual sex                 |
| route of HIV        |                                                |
| transmission        |                                                |
| worldwide?          |                                                |
+---------------------+------------------------------------------------+
| What specific part  | HIV infects the immune system, specifically    |
| of the human body   | the CD4 cells. Over time, the weakened immune  |
| does HIV attack and | system has a progressively more difficult time |
| what does\          | fighting infections.                           |
| this cause?         |                                                |
+---------------------+------------------------------------------------+

Category 2: Prevention

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| What are the\       | > A. Abstain from sex completely.              |
| ABCs of prevention\ | >                                              |
| (on an individual   | > B. Be faithful to one partner who is         |
| level)?             | > uninfected.                                  |
|                     | >                                              |
|                     | > C. Use a new condom properly each time you   |
|                     | > have sexual intercourse.                     |
|                     |                                                |
|                     | *Note*: There is also a "D". Do not use drugs  |
|                     | and do not share injection equipment.          |
+---------------------+------------------------------------------------+
| Universal           | -   Wash hands after any direct contact with   |
| precautions are a   |     patients.                                  |
| set of practices    |                                                |
| designed to protect | -   Do not recap needles, whenever possible.   |
| health workers and  |                                                |
| patients from       | -   Dispose of needles (hypodermic and suture) |
| infection. Name at  |     and sharps (scalpel blades, lancets,       |
| least four          |     razors and scissors) safely, putting them  |
| interventions that  |     into puncture- and leak-proof safety       |
| are universal       |     boxes.                                     |
| precautions.        |                                                |
|                     | -   Wear gloves to prevent contact with body   |
|                     |     fluids, broken skin and mucous membranes.  |
|                     |                                                |
|                     | -   Wear a mask, eye protection, and gown (and |
|                     |     sometimes a plastic apron) if blood or     |
|                     |     other body fluids might splash.            |
|                     |                                                |
|                     | -   Cover cuts and abrasions with a waterproof |
|                     |     dressing.                                  |
|                     |                                                |
|                     | -   Promptly and carefully clean up spills of  |
|                     |     blood and other body fluids.               |
|                     |                                                |
|                     | -   Use a safe system for hospital waste       |
|                     |     collection and disposal.                   |
+---------------------+------------------------------------------------+

**Category 3: Infant Feeding**

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| > Exclusive         | > Drops or syrups consisting of vitamins,      |
| > breastfeeding is  | > mineral supplements, or medicines            |
| > defined by WHO as |                                                |
| > giving an infant  |                                                |
| > only breastmilk   |                                                |
| > (including        |                                                |
| > expressed         |                                                |
| > breastmilk), with |                                                |
| > the exception of  |                                                |
| > \_                |                                                |
| \_\_\_\_\_\_\_\_\_\ |                                                |
| _\_\_\_\_\_\_\_\_\_ |                                                |
| >                   |                                                |
| > (Fill in the      |                                                |
| > blank).           |                                                |
+---------------------+------------------------------------------------+
| > List two reasons  | -   Cups are safer because they are easier to  |
| > why cup feeding   |     clean with soap and water than bottles.    |
| > is preferred over |                                                |
| > bottle feeding    | -   Cups are less likely than bottles to be    |
| > when the mother   |     carried around for a long time, giving     |
| > chooses           |     bacteria the opportunity to multiply.      |
| > replacement foods |                                                |
| > (rather than      | -   Cup feeding requires the mother or other   |
| > breastfeeding).   |     caregiver to hold and have more contact    |
|                     |     with the infant, providing more            |
|                     |     psychosocial stimulation than              |
|                     |     bottle-feeding.                            |
|                     |                                                |
|                     | -   Cup feeding is better than feeding with a  |
|                     |     cup and spoon because spoon feeding takes  |
|                     |     longer and the mother may stop before the  |
|                     |     infant has had enough.                     |
+---------------------+------------------------------------------------+
| > At what age does  | 6 months                                       |
| > WHO recommend     |                                                |
| > starting a child  |                                                |
| > on complementary  |                                                |
| > foods (food in    |                                                |
| > addition to       |                                                |
| > milk)?            |                                                |
+---------------------+------------------------------------------------+
| > Name two reasons  | -   To avoid stigma                            |
| > why a woman may   |                                                |
| > choose to         | -   To avoid inadvertently disclosing her HIV  |
| > breastfeed rather |     status                                     |
| > than give a       |                                                |
| > breastmilk        | -   To accommodate family pressure             |
| > substitute to her |                                                |
| > infant.           | -   To maintain denial of her HIV status       |
|                     |                                                |
|                     | -   To manage finances if she cannot afford a  |
|                     |     breastmilk substitute (or if one is not    |
|                     |     available)                                 |
|                     |                                                |
|                     | -   To comfort the infant in an easy way       |
|                     |                                                |
|                     | -   To compensate for a feeling that she is    |
|                     |     missing out on something                   |
+---------------------+------------------------------------------------+

# Category 4: Testing

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| What is             | > HIV antibodies                               |
| specifically        | >                                              |
| measured when an    | > *Note*: In some settings infants who are     |
| HIV screening test  | > HIV-exposed may be "screened" using antigen  |
| is done?            | > tests.                                       |
+---------------------+------------------------------------------------+
| With regard to HIV  | This is the period between the initial         |
| testing, what does  | infection and the time when the HIV test can   |
| the \"window        | detect the antibodies the body has generated   |
| period\" mean?      | in reaction to HIV. People infected with HIV   |
|                     | usually develop antibodies 4 to 6 weeks after  |
|                     | being infected, but it may take as long as 3   |
|                     | months for antibodies to develop.              |
+---------------------+------------------------------------------------+
| Name two advantages | -   The result is ready on the same day, so a  |
| of the HIV rapid    |     woman does not need to leave the clinic    |
| screening test      |     and then return for the results.           |
| (compared with the  |                                                |
| traditional ELISA   | -   Rapid tests are cost-effective because     |
| test).              |     they do not need special laboratory        |
|                     |     equipment and can be conducted in the      |
|                     |     clinic setting.                            |
|                     |                                                |
|                     | -   There is less potential for specimen       |
|                     |     mix-up\                                    |
|                     |     and loss.                                  |
|                     |                                                |
|                     | -   Providers do not have to spend time        |
|                     |     tracking down test results weeks after the |
|                     |     test was done.                             |
|                     |                                                |
|                     | -   Pregnant women with positive HIV test      |
|                     |     results can immediately receive            |
|                     |     information on treatment for themselves    |
|                     |     and interventions to protect their infants |
|                     |     from mother-to-child HIV transmission.     |
+---------------------+------------------------------------------------+

**Category 5: Mother-to-Child Transmission**

+---------------------+------------------------------------------------+
| ######## Question   | **Answer**                                     |
+---------------------+------------------------------------------------+
| If 100 women who    | > During pregnancy 5--10                       |
| were HIV-infected   | >                                              |
| gave birth to 100   | > During labour and delivery About 15          |
| infants, how many   | >                                              |
| of the infants      | > During breastfeeding 5--15                   |
| would typically     |                                                |
| become infected     | ##### Total 25--40                             |
| during pregnancy?   |                                                |
+---------------------+------------------------------------------------+
| If 100 women who    |                                                |
| were HIV-infected   |                                                |
| gave birth to 100   |                                                |
| infants, how many   |                                                |
| of the infants      |                                                |
| would typically     |                                                |
| become infected     |                                                |
| delivery?           |                                                |
+---------------------+------------------------------------------------+
| If 100 women who    |                                                |
| were HIV-positive   |                                                |
| gave birth to 100   |                                                |
| infants, how many   |                                                |
| of these infants    |                                                |
| would typically     |                                                |
| become infected     |                                                |
| during              |                                                |
| breastfeeding?      |                                                |
+---------------------+------------------------------------------------+
| Name two maternal   | -   New HIV infection during pregnancy         |
| factors that may    |                                                |
| increase the risk   | -   Viral, bacterial, and parasitic placental  |
| of HIV transmission |     infection\                                 |
| during pregnancy.   |     (especially malaria)                       |
|                     |                                                |
|                     | -   Maternal malnutrition                      |
|                     |                                                |
|                     | -   STIs                                       |
|                     |                                                |
|                     | -   Advanced HIV or late-stage AIDS            |
+---------------------+------------------------------------------------+
| Name two factors    | -   New maternal HIV infection during          |
| that may increase   |     breastfeeding                              |
| the risk of HIV     |                                                |
| transmission during | -   Duration of breastfeeding                  |
| breastfeeding.      |                                                |
|                     | -   Mixed feeding (breastmilk along with       |
|                     |     replacement feeding such as foods and      |
|                     |     fluids other than breastmilk)              |
|                     |                                                |
|                     | -   Breast abscesses, nipple fissures (cracked |
|                     |     nipples),\                                 |
|                     |     and mastitis                               |
|                     |                                                |
|                     | -   Advanced HIV or AIDS in the mother         |
|                     |                                                |
|                     | -   Maternal malnutrition                      |
|                     |                                                |
|                     | -   Oral disease in the infant, such as thrush |
|                     |     and mouth sores                            |
+---------------------+------------------------------------------------+

######## Category 6: Linkages to Treatment, Care, and Support 

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| Name at least two   | -   Assessment of healing, which includes:     |
| activities that     |                                                |
| should be included  |     -   Wound healing                          |
| in the 6-week       |                                                |
| postnatal visit for |     -   Uterine involution                     |
| the woman who is\   |                                                |
| HIV-infected.       |     -   Cessation of postnatal bleeding        |
|                     |                                                |
| #                   | -   Infant feeding support                     |
|                     |                                                |
|                     | -   Family planning and contraception          |
|                     |                                                |
|                     | -   Supporting the mother\'s choice of         |
|                     |     contraception                              |
|                     |                                                |
|                     | -   Discussing importance of safer sex to      |
|                     |     prevent other\                             |
|                     |     STIs and the further spread of HIV         |
|                     |                                                |
|                     | -   Providing advice about early treatment of  |
|                     |     STI                                        |
+---------------------+------------------------------------------------+
| Name one test that  | An HIV antibody test (typically ELISA or one   |
| will tell you if an | of the rapid HIV tests), done at 18 months of  |
| infant who is       | age or older                                   |
| HIV-infected.       |                                                |
|                     | An HIV antigen test, such as the DNA           |
| #                   | polymerase chain reaction (PCR) test, done     |
|                     | beginning in the first month of life (*Note*:  |
|                     | Definitive diagnosis requires 2 positive       |
|                     | antigen tests done at least a month apart.)    |
+---------------------+------------------------------------------------+
| Name one symptom    | -   Low weight and/or growth failure           |
| associated with HIV |                                                |
| infection in the    | -   Pneumonia, including PCP                   |
| infant or child.    |                                                |
|                     | -   Oral candidiasis (thrush)                  |
|                     |                                                |
|                     | -   Lymphadenopathy                            |
|                     |                                                |
|                     | -   Diarrhoea                                  |
|                     |                                                |
|                     | -   TB                                         |
+---------------------+------------------------------------------------+

**Category 7: Prevention in Healthcare Settings**

+----------------------------+------------------------------------------+
| ### Question               | **Answer**                               |
+----------------------------+------------------------------------------+
| Name one disinfectant that | -   Soap and water                       |
| is capable of inactivating |                                          |
| HIV.                       | -   10% chlorine bleach solution         |
|                            |                                          |
|                            | -   70% alcohol                          |
|                            |                                          |
|                            | -   Hydrogen peroxide                    |
+----------------------------+------------------------------------------+
| If a healthcare worker     | > The risk of HIV transmission in        |
| accidentally got stuck     | > situations in which the skin is        |
| with a needle that had     | > punctured by a needle stick or other   |
| previously been used on a  | > sharp is less than 1%. The risk of HIV |
| patient with HIV (and not  | > transmission from exposure to infected |
| cleaned), what would be    | > fluids or tissues is believed to be    |
| the chance that he or she  | > lower than from exposure to infected   |
| would become HIV-infected? | > blood.                                 |
|                            |                                          |
| A.  1%                     |                                          |
|                            |                                          |
| B.  5%                     |                                          |
|                            |                                          |
| > C. 3%                    |                                          |
| >                          |                                          |
| > D. 20%                   |                                          |
+----------------------------+------------------------------------------+
| What are two things that   | -   Cover broken skin or open wounds     |
| you can do when attending  |     with watertight dressings.           |
| to a patient in obstetrics |                                          |
| to reduce risk of          | -   Wear gloves when expecting exposure  |
| occupational exposure to   |     to blood or body fluids.             |
| HIV?                       |                                          |
|                            | -   Wear an impermeable plastic apron    |
|                            |     for the birth.                       |
|                            |                                          |
|                            | -   Pass all sharp instruments on to a   |
|                            |     receiver, rather than hand-to-hand.  |
|                            |                                          |
|                            | -   Use long cuffed gloves for manual    |
|                            |     removal of a placenta.               |
|                            |                                          |
|                            | -   Modify surgical practice to use      |
|                            |     needle holders and avoid using your  |
|                            |     fingers in needle placement.         |
|                            |                                          |
|                            | -   When available, wear an eye shield   |
|                            |     for operating, assisting a cesarean  |
|                            |     section, and suturing episiotomies.  |
|                            |                                          |
|                            | -   If blood splashes on skin,           |
|                            |     immediately wash the area with soap  |
|                            |     and water. If blood splashes in the  |
|                            |     eye, wash the eye with water only.   |
|                            |                                          |
|                            | -   Dispose of solid waste, such as      |
|                            |     blood-soaked dressings or placentas, |
|                            |     safely and according to local        |
|                            |     procedures.                          |
+----------------------------+------------------------------------------+

**Category 8: Wild Card**

+---------------------+------------------------------------------------+
| **Question**        | **Answer**                                     |
+---------------------+------------------------------------------------+
| AIDS is the         | A. Number 1                                    |
| \_\_\_\_\_\_\_\_    |                                                |
| (choose number)     |                                                |
| cause\              |                                                |
| of death in Africa? |                                                |
|                     |                                                |
| > A. Number 1       |                                                |
| >                   |                                                |
| > B. Number 2       |                                                |
| >                   |                                                |
| > C. Number 3       |                                                |
| >                   |                                                |
| > D. Number 4       |                                                |
+---------------------+------------------------------------------------+
| # The HIV/AIDS      | Eastern Europe and Central Asia                |
| pandemic is growing |                                                |
|  fastest in what re |                                                |
| gions of the world? |                                                |
+---------------------+------------------------------------------------+
| In sub-Saharan      | C. 58%                                         |
| Africa, women       |                                                |
| represent what      |                                                |
| percentage of all   |                                                |
| people living with  |                                                |
| HIV/AIDS?           |                                                |
|                     |                                                |
| A. 78%              |                                                |
|                     |                                                |
| B. 72%              |                                                |
|                     |                                                |
| C. 58%              |                                                |
|                     |                                                |
| D. 48%              |                                                |
+---------------------+------------------------------------------------+
| What is the         | Stigma refers to attitudes and thoughts.       |
| difference between  |                                                |
| stigma and          | Discrimination is a behaviour based on         |
| discrimination?     | stigmatising attitudes and thoughts.           |
+---------------------+------------------------------------------------+
| What is the         | Monitoring is concerned primarily with         |
| difference between  | describing the costs of an intervention, for   |
| monitoring and      | example, the number of staff, hours worked,    |
| evaluation?         | schedules, and costs.                          |
|                     |                                                |
|                     | Evaluation relates to the benefits, such as    |
|                     | how the project\'s objectives were realised    |
|                     | (eg what percentage of ANC women were tested   |
|                     | for HIV? What percentage of women who are      |
|                     | HIV-infected received NVP? Was there a         |
|                     | reduction in the number of infants who were    |
|                     | HIV-infected?).                                |
+---------------------+------------------------------------------------+

APPENDIX 1-A WHO staging systems for HIV infection and disease in
adults, adolescents, and children

> WHO staging system for HIV infection and disease in adults

+------------------------------------+---------------------------------+
| > **Clinical stage I**             |                                 |
+------------------------------------+---------------------------------+
| -   Asymptomatic                   |                                 |
|                                    |                                 |
| -   Generalised lymphadenopathy    |                                 |
|                                    |                                 |
| > **Performance Scale 1**:         |                                 |
| > asymptomatic, normal activity    |                                 |
+------------------------------------+---------------------------------+
| > **Clinical Stage II**            |                                 |
+------------------------------------+---------------------------------+
| -   Weight loss of less than 10%   |                                 |
|     of body weight                 |                                 |
|                                    |                                 |
| -   Minor mucocutaneous            |                                 |
|     manifestations (seborrhoeic    |                                 |
|     dermatitis, prurigo, fungal    |                                 |
|     nail infections, recurrent     |                                 |
|     oral ulcerations, angular      |                                 |
|     cheilitis)                     |                                 |
|                                    |                                 |
| -   Herpes zoster within the last  |                                 |
|     5 years                        |                                 |
|                                    |                                 |
| -   Recurrent upper respiratory    |                                 |
|     tract infections (e.g.,        |                                 |
|     bacterial sinusitis)           |                                 |
|                                    |                                 |
| > And/or **Performance Scale 2**:  |                                 |
| > symptomatic, normal activity     |                                 |
+------------------------------------+---------------------------------+
| > **Clinical Stage III**           |                                 |
+------------------------------------+---------------------------------+
| -   Weight loss of more than 10%   |                                 |
|     of body weight                 |                                 |
|                                    |                                 |
| -   Unexplained chronic diarrhoea  |                                 |
|     lasting for more than 1 month  |                                 |
|                                    |                                 |
| -   Unexplained prolonged fever    |                                 |
|     (intermittent or constant)     |                                 |
|     lasting for more than 1 month  |                                 |
|                                    |                                 |
| -   Oral candidiasis (thrush)      |                                 |
|                                    |                                 |
| -   Oral hairy leukoplakia         |                                 |
|                                    |                                 |
| -   Pulmonary tuberculosis         |                                 |
|                                    |                                 |
| -   Severe bacterial infections    |                                 |
|     (e.g., pneumonia, pyomyositis) |                                 |
|                                    |                                 |
| > And/or **Performance Scale 3:**  |                                 |
| > bedridden less than 50% of the   |                                 |
| > day during the past month        |                                 |
+------------------------------------+---------------------------------+
| > **Clinical Stage IV**            |                                 |
+------------------------------------+---------------------------------+
| -   HIV wasting syndrome^a^        | -   Candidiasis of the          |
|                                    |     oesophagus, trachea,        |
| -   *Pneumocystis carinii*         |     bronchi                     |
|     pneumonia                      |                                 |
|                                    | -   Atypical mycobacteriosis,   |
| -   Toxoplasmosis of the brain     |     disseminated or pulmonary   |
|                                    |                                 |
| -   Cryptosporidiosis with         | -   Non-typhoid salmonella      |
|     diarrhoea lasting more than 1  |     septicaemia                 |
|     month                          |                                 |
|                                    | -   Extrapulmonary tuberculosis |
| -   Cryptococcosis, extrapulmonary |                                 |
|                                    | -   Lymphoma                    |
| -   Cytomegalovirus (CMV) disease  |                                 |
|     of an organ other than liver,  | -   Kaposi\'s sarcoma (KS)      |
|     spleen or lymph node (e.g.,    |                                 |
|     retinitis)                     | -   HIV encephalopathy^b^       |
|                                    |                                 |
| -   Herpes simplex virus (HSV)     |                                 |
|     infection, mucocutaneous       |                                 |
|     (lasting for more than 1       |                                 |
|     month), or visceral            |                                 |
|                                    |                                 |
| -   Progressive multifocal         |                                 |
|     leukoencephalopathy (PML)      |                                 |
|                                    |                                 |
| -   Any disseminated endemic       |                                 |
|     mycosis                        |                                 |
+------------------------------------+---------------------------------+
| > And/or **Performance Scale 4**:  |                                 |
| > bedridden more than 50% of the   |                                 |
| > day during the last month        |                                 |
+------------------------------------+---------------------------------+
| > ^a^ HIV wasting syndrome: weight |                                 |
| > loss of more than 10% body       |                                 |
| > weight, plus either unexplained  |                                 |
| > chronic diarrhoea (lasting       |                                 |
| > longer than 1 month) or chronic  |                                 |
| > weakness and unexplained         |                                 |
| > prolonged fever (lasting longer  |                                 |
| > than 1 month)                    |                                 |
| >                                  |                                 |
| > ^b^ HIV encephalopathy: clinical |                                 |
| > findings of disabling cognitive  |                                 |
| > and/or motor dysfunction         |                                 |
| > interfering with activities of   |                                 |
| > daily living progressing over    |                                 |
| > weeks to months, in the absence  |                                 |
| > of a concurrent illness or       |                                 |
| > condition other than HIV         |                                 |
| > infection that could explain the |                                 |
| > findings                         |                                 |
|                                    |                                 |
| *Source:* World Health             |                                 |
| Organization (WHO). 2004. *Scaling |                                 |
| up antiretroviral therapy in       |                                 |
| resource-limited settings:         |                                 |
| Treatment guidelines for a public  |                                 |
| health approach, 2003* *Revision,* |                                 |
| Appendix D: WHO staging system for |                                 |
| HIV infection and disease in       |                                 |
| adults and adolescents, p. 42      |                                 |
+------------------------------------+---------------------------------+

APPENDIX 1-A WHO staging systems for HIV infection and disease in
adults, adolescents, and children *(continued)*

WHO staging system for HIV infection and disease in children

+-----------------------------------------------------------------------+
| > **Clinical Stage I**                                                |
+-----------------------------------------------------------------------+
| -   Asymptomatic                                                      |
|                                                                       |
| -   Generalised lymphadenopathy                                       |
+-----------------------------------------------------------------------+
| > **Clinical Stage II**                                               |
+-----------------------------------------------------------------------+
| -   Chronic diarrhoea lasting more than 30 days in the absence of     |
|     known etiology                                                    |
|                                                                       |
| -   Severe persistent or recurrent candidiasis outside the neonatal   |
|     period                                                            |
|                                                                       |
| -   Weight loss or failure to thrive in the absence of known etiology |
|                                                                       |
| -   Persistent fever lasting longer than 30 days in the absence of    |
|     known etiology                                                    |
|                                                                       |
| -   Recurrent severe bacterial infections other than septicaemia or   |
|     meningitis (eg, osteomyelitis, bacterial (non-TB) pneumonia,      |
|     abscesses)                                                        |
+-----------------------------------------------------------------------+
| > **Clinical Stage III**                                              |
+-----------------------------------------------------------------------+
| -   AIDS-defining opportunistic infections                            |
|                                                                       |
| -   Severe failure to thrive (wasting) in the absence of known        |
|     etiology ^a^                                                      |
|                                                                       |
| -   Progressive encephalopathy                                        |
|                                                                       |
| -   Malignancy                                                        |
|                                                                       |
| -   Recurrent septicaemia or meningitis                               |
+-----------------------------------------------------------------------+
| ^a^ Persistent weight loss of more than 10% of baseline or less than  |
| 5^th^ percentile on weight for height chart on 2 consecutive          |
| measurements more than 1 month apart in the absence of another        |
| etiology or concurrent illness.                                       |
|                                                                       |
| *Source:* World Health Organization (WHO). 2004. *Scaling up          |
| antiretroviral therapy in resource-limited settings: Treatment        |
| guidelines for a public health approach, 2003* *Revision,* Appendix   |
| E: WHO staging system for HIV infection and disease in children, p.   |
| 44                                                                    |
+-----------------------------------------------------------------------+

APPENDIX 1-B CDC AIDS surveillance case definitions for\
adolescents, adults, and children

I. CDC AIDS surveillance case definition for adolescents and adults

+-------------------+----------------+----------------+---------------+
| Clinical          |                |                |               |
| Categories        |                |                |               |
+-------------------+----------------+----------------+---------------+
| **CD4 Cell        | A              | **B**          | **C\***       |
| Categories**      |                |                |               |
+-------------------+----------------+----------------+---------------+
| **mm^3^ (%)**     | *              | **Sym          | **AIDS        |
|                   | *Asymptomatic, | ptomatic\*\*** | Indicator     |
|                   | PGL, or Acute  |                | Condition     |
|                   | HIV            | **(not A or    | (1987)**      |
|                   | Infection**    | C)**           |               |
+-------------------+----------------+----------------+---------------+
| **1**             | A1             | B1             | C1            |
| \>500/mm^3^\      |                |                |               |
| ([\>              |                |                |               |
| ]{.underline}29%) |                |                |               |
+-------------------+----------------+----------------+---------------+
| **2**             | A2             | B2             | C2            |
| 200--499/mm^3^\   |                |                |               |
| (14--28%)         |                |                |               |
+-------------------+----------------+----------------+---------------+
| **3**             | A3             | B3             | C3            |
| \<200/mm^3^\      |                |                |               |
| (\<14%)           |                |                |               |
+-------------------+----------------+----------------+---------------+
| \* All patients   |                |                |               |
| in categories A3, |                |                |               |
| B3 and C1-3 are   |                |                |               |
| defined as having |                |                |               |
| AIDS, based on    |                |                |               |
| the presence of   |                |                |               |
| an AIDS-indicator |                |                |               |
| condition (see    |                |                |               |
| the following     |                |                |               |
| table) and/or a   |                |                |               |
| CD4 cell count of |                |                |               |
| less than         |                |                |               |
| 200/mm^3^.        |                |                |               |
|                   |                |                |               |
| \*\* Symptomatic  |                |                |               |
| conditions not    |                |                |               |
| included in       |                |                |               |
| Category C that   |                |                |               |
| are: a)           |                |                |               |
| attributed to HIV |                |                |               |
| infection or      |                |                |               |
| indicative of a   |                |                |               |
| defect in         |                |                |               |
| cell-mediated     |                |                |               |
| immunity or b)    |                |                |               |
| considered to     |                |                |               |
| have a clinical   |                |                |               |
| course or         |                |                |               |
| management that   |                |                |               |
| is complicated by |                |                |               |
| HIV infection.    |                |                |               |
| Examples of B     |                |                |               |
| conditions        |                |                |               |
| include but are   |                |                |               |
| not limited to    |                |                |               |
| bacillary         |                |                |               |
| angiomatosis;     |                |                |               |
| thrush;           |                |                |               |
| vulvovaginal      |                |                |               |
| candidiasis that  |                |                |               |
| is persistent,    |                |                |               |
| frequent or       |                |                |               |
| poorly responsive |                |                |               |
| to therapy;       |                |                |               |
| cervical          |                |                |               |
| dysplasia         |                |                |               |
| (moderate or      |                |                |               |
| severe); cervical |                |                |               |
| carcinoma in      |                |                |               |
| situ;             |                |                |               |
| constitutional    |                |                |               |
| symptoms such as  |                |                |               |
| fever (38.5º C)   |                |                |               |
| or diarrhoea      |                |                |               |
| lasting longer    |                |                |               |
| than 1 month;     |                |                |               |
| oral hairy        |                |                |               |
| leukoplakia;      |                |                |               |
| herpes zoster     |                |                |               |
| involving two     |                |                |               |
| episodes or more  |                |                |               |
| than 1 dermatome; |                |                |               |
| idiopathic        |                |                |               |
| thrombocytopoenic |                |                |               |
| purpura (ITP);    |                |                |               |
| listeriosis;      |                |                |               |
| pelvic            |                |                |               |
| inflammatory      |                |                |               |
| disease (PID)     |                |                |               |
| (especially if    |                |                |               |
| complicated by a  |                |                |               |
| tubo-ovarian      |                |                |               |
| abscess); and     |                |                |               |
| peripheral        |                |                |               |
| neuropathy.       |                |                |               |
|                   |                |                |               |
| *Source:* U.S.    |                |                |               |
| Centers for       |                |                |               |
| Disease Control   |                |                |               |
| and Prevention.   |                |                |               |
| 1992. 1993        |                |                |               |
| Revised           |                |                |               |
| classification    |                |                |               |
| system for HIV    |                |                |               |
| infection and     |                |                |               |
| expanded          |                |                |               |
| surveillance case |                |                |               |
| definition for    |                |                |               |
| AIDS among        |                |                |               |
| adolescents and   |                |                |               |
| adults. *MMWR     |                |                |               |
| 41(RR-17)*        |                |                |               |
| <htt              |                |                |               |
| p://www.cdc.gov/m |                |                |               |
| mwr/preview/mmwrh |                |                |               |
| tml/00018179.htm> |                |                |               |
+-------------------+----------------+----------------+---------------+

II\. CDC AIDS case surveillance definition for infants and children

CDC immunologic categories based on age-specific CD4 counts and percent
of total lymphocytes

  ------------------------- ------------------ ----------------------- ------------------
  **Immunologic category**  **\<12 mos**       **1--5 yrs**            **6--12 yrs**

                            **mm^3^ (%)**      **mm^3^ (%)**           **mm^3^ (%)**

  Category 1: No evidence   [\>]{.underline}   [\>]{.underline}1,000   [\>]{.underline}
  of suppression            1,500 (\> 25)      (\> 25)                 500 (\> 25)

  **Category 2:** Evidence  750--1,499         500--999 (15--24)       200--499 (15--24)
  of moderate suppression   (15--24)                                   

  **Category 3:** Severe    \< 750 (\<15)      \< 500 (\<15)           \< 200 (\<15)
  suppression                                                          
  ------------------------- ------------------ ----------------------- ------------------

**APPENDIX 1-B CDC AIDS surveillance case definitions for adolescents,
adults, and children** *(continued)*

**Clinical categories for children with HIV**

**CATEGORY N:** NOT SYMPTOMATIC

Children who have no signs or symptoms considered to be the result of
HIV infection or who have only one of the conditions listed in Category
A.

**CATEGORY A:** MILDLY SYMPTOMATIC

Children with two or more of the conditions listed below but none of the
conditions listed in Categories B and C.

-   Lymphadenopathy (\> 0.5 cm at more than two sites; bilateral = one
    site)

-   Hepatomegaly

-   Splenomegaly

-   Dermatitis

-   Parotitis

-   Recurrent or persistent upper respiratory infection, sinusitis, or
    otitis media

**CATEGORY B:** MODERATELY SYMPTOMATIC

Children who have symptomatic conditions other than those listed for
Category A or C that are attributed to HIV infection.

Examples of conditions in clinical Category B include but are not
limited to:

-   Anemia (\<8 gm/dL), neutropenia (\<1,000/mm^3^), or thrombocytopenia
    (\<100,000/mm^3^) persisting [\>]{.underline} 30 days

-   Bacterial meningitis, pneumonia, or sepsis (single episode)

-   Candidiasis, oropharyngeal (thrush), persisting (\>2 months) in
    children \>6 months of age

-   Cardiomyopathy

-   Cytomegalovirus infection, with onset before 1 month of age

-   Diarrhea, recurrent or chronic

-   Hepatitis

-   Herpes simplex virus (HSV) stomatitis, recurrent (more than two
    episodes within 1 year)

-   HSV bronchitis, pneumonitis, or esophagitis with onset before 1
    month of age

-   Herpes zoster (shingles) involving at least two distinct episodes or
    more than one dermatome

-   Leiomyosarcoma

-   Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid
    hyperplasia complex

-   Nephropathy

-   Nocardiosis

-   Persistent fever (lasting \>1 month)

-   Toxoplasmosis, onset before 1 month of age

-   Varicella, disseminated (complicated chickenpox)

-   Leiomyosarcoma

-   Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid
    hyperplasia complex

-   Nephropathy

-   Nocardiosis

-   Persistent fever (lasting \>1 month)

-   Toxoplasmosis, onset before 1 month of age

-   Varicella, disseminated (complicated chickenpox)

    **CATEGORY C:** SEVERELY SYMPTOMATIC

    Conditions included in clinical Category C for children infected
    with human immunodeficiency virus (HIV)

-   Serious bacterial infections, multiple or recurrent (i.e., any
    combination of at least two culture-confirmed infections within a
    2-year period), of the following types: septicemia, pneumonia,
    meningitis, bone or joint infection, or abscess of an internal organ
    or body cavity (excluding otitis media, superficial skin or mucosal
    abscesses, and indwelling catheter-related infections)

-   Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs)

-   Coccidioidomycosis, disseminated (at site other than or in addition
    to lungs or cervical or hilar lymph nodes)

-   Cryptococcosis, extrapulmonary

-   Cryptosporidiosis or isosporiasis with diarrhea persisting \>1 month

-   Cytomegalovirus disease with onset of symptoms at age \>1 month (at
    a site other than liver, spleen, or lymph nodes)

-   Encephalopathy (at least one of the following progressive findings
    present for at least 2 months in the absence of a concurrent illness
    other than HIV infection that could explain the findings): a)
    failure to attain or loss of developmental milestones or loss of
    intellectual ability, verified by standard developmental scale or
    neuropsychological tests; b) impaired brain growth or acquired
    microcephaly demonstrated by head circumference measurements or
    brain atrophy demonstrated by computerized tomography or magnetic
    resonance imaging (serial imaging is required for children \<2 years
    of age); c) acquired symmetric motor deficit manifested by two or
    more of the following: paresis, pathologic reflexes, ataxia, or gait
    disturbance

-   Herpes simplex virus infection causing a mucocutaneous ulcer that
    persists for \>1 month; or bronchitis, pneumonitis, or esophagitis
    for any duration affecting a child \>1 month of age

-   Histoplasmosis, disseminated (at a site other than or in addition to
    lungs or cervical or hilar lymph nodes)

-   Kaposi's sarcoma

-   Lymphoma, primary, in brain

-   Lymphoma, small, noncleaved cell (Burkett's), or immunoblastic or
    large cell lymphoma of B-cell or unknown immunologic phenotype

-   Mycobacterium tuberculosis, disseminated or extrapulmonary

-   Mycobacterium, other species or unidentified species, disseminated
    (at a site other than or in addition to lungs, skin, or cervical or
    hilar lymph nodes)

-   Mycobacterium avium complex or Mycobacterium kansasii, disseminated
    (at site other than or in addition to lungs, skin, or cervical or
    hilar lymph nodes)

-   *Pneumocystis carinii* pneumonia

-   Progressive multifocal leukoencephalopathy

-   Salmonella (nontyphoid) septicemia, recurrent

-   Toxoplasmosis of the brain with onset at \>1 month of age

-   Wasting syndrome in the absence of a concurrent illness other than
    HIV infection that could explain the following findings: a)
    persistent weight loss \>10% of baseline OR b) downward crossing of
    at least two of the following percentile lines on the weight-for-age
    chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child
    [\>]{.underline} 1 year of age OR c) \<5th percentile on
    weight-for-height chart on two consecutive measurements, \>=30 days
    apart PLUS a) chronic diarrhea (i.e., at least two loose stools per
    day for \>30 days) OR b) documented fever (for [\>]{.underline} 30
    days, intermittent or constant)

Adapted from: US Centers for Disease Control and Prevention. 1994.
*Revised classification system for human immunodeficiency virus
infection in children less than 13 years of age*. MMWR (RR--22).