![](media/image1.png){width="1.0291666666666666in" height="1.58125in"}

T**Module 1**T Introduction to HIV/AIDS

T**SESSION 1**T Scope of the HIV/AIDS Pandemic

T**Session 2**T Natural History and Transmission of HIV

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.

+-----------------------------------------------------------------------+
| **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

Figure 1.1 Worldwide epidemiology of HIV/AIDS

![](media/image2.png){width="6.0159722222222225in" height="4.0in"}

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

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.

+------------+-------------+--------------+---------+-----------------+
| ### Table  |             |              |         |                 |
|  1.1 Regio |             |              |         |                 |
| nal HIV/AI |             |              |         |                 |
| DS statist |             |              |         |                 |
| ics and fe |             |              |         |                 |
| atures, th |             |              |         |                 |
| rough 2003 |             |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| Region     | **Adults    | **Adults and | **Prev  | **Adult and     |
|            | and         | Children     | alence\ | Child\          |
|            | Children    | Newly        | In      | Deaths Due to   |
|            | Living with | Infected     | Adu     | AIDS**          |
|            | HIV/AIDS**  | with HIV**   | lts\*** |                 |
+------------+-------------+--------------+---------+-----------------+
| S          | 25.0--28.2  | 3.0--3.4     | 7       | 2.2--2.4        |
| ub-Saharan | million     | million      | .5--8.5 | million         |
| Africa     |             |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| North      | 470,0       | 43           | 0       | 35,000--50,000  |
| Africa and | 00--730,000 | ,000--67,000 | .2--0.4 |                 |
| Middle     |             |              |         |                 |
| East       |             |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| South and  | 4.6--8.2    | 610,000      | 0       | 3               |
| Southeast  | million     | --1.1million | .4--0.8 | 30,000--590,000 |
| Asia       |             |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| East Asia  | 7           | 150,         | 0       | 32,000--58,000  |
| and        | 00,000--1.3 | 000--270,000 | .1--0.1 |                 |
| Pacific    | million     |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| Latin      | 1.3--1.9    | 120,         | 0       | 49,000--70,000  |
| America    | million     | 000--180,000 | .5--0.7 |                 |
+------------+-------------+--------------+---------+-----------------+
| Caribbean  | 350,0       | 45           | 1       | 30,000--50,000  |
|            | 00--590,000 | ,000--80,000 | .9--3.1 |                 |
+------------+-------------+--------------+---------+-----------------+
| Eastern    | 1.2--1.8    | 180,         | 0       | 23,000--37,000  |
| Europe and | million     | 000--280,000 | .5--0.9 |                 |
| Central    |             |              |         |                 |
| Asia       |             |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| Western    | 520,0       | 30           | 0       | 2,600--3,400    |
| Europe     | 00--680,000 | ,000--40,000 | .3--0.3 |                 |
+------------+-------------+--------------+---------+-----------------+
| North      | 7           | 36           | 0       | 12,000--18,000  |
| America    | 90,000--1.2 | ,000--54,000 | .5--0.7 |                 |
|            | million     |              |         |                 |
+------------+-------------+--------------+---------+-----------------+
| Australia  | 12,         | 700--1,000   | 0       | \<100           |
| and New    | 000--18,000 |              | .1--0.1 |                 |
| 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  |             |              |         |                 |
| in         |             |              |         |                 |
| formation. |             |              |         |                 |
| 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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**Figure 1.2 HIV prevalence: Pregnant women in South Africa,
1991--2002**

![](media/image3.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.

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 healthcare related to stigma and discrimination

-   Deteriorating child health and survival

-   Weakened integrity and support structure of the family unit

+------------------+---------------------------------------------------+
| Exercise 1.1     |                                                   |
| Hope exercise:   |                                                   |
| group discussion |                                                   |
+------------------+---------------------------------------------------+
| **Purpose**      | To begin the PMTCT training with optimism despite |
|                  | the devastation left by decades of HIV.           |
+------------------+---------------------------------------------------+
| **Duration**     | 20 minutes                                        |
+------------------+---------------------------------------------------+
| **Instructions** | -   Think for a few moments about positive        |
|                  |     responses to the HIV/AIDS pandemic in your    |
|                  |     country.                                      |
|                  |                                                   |
|                  | -   Record your responses on paper and share in   |
|                  |     the large group discussion.                   |
|                  |                                                   |
|                  | **Examples**:                                     |
|                  |                                                   |
|                  | Groups in the community that have never worked    |
|                  | together before have connected with each other to |
|                  | address HIV/AIDS.                                 |
|                  |                                                   |
|                  | The 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.        |
|                  |                                                   |
|                  | The 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 HIV and STIs.  |
+------------------+---------------------------------------------------+

Overview of HIV and AIDS

  ---------------------------------------------------- ------------------------------------------------------
  ![](media/image4.png){width="0.7631944444444444in"   Refer to *Pocket* *Guide*
  height="0.625in"}                                    

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

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

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.)

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.

SESSION 2 Natural History and 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/image6.png){width="5.679861111111111in"
height="4.334722222222222in"}

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/mmP^3P^. When the CD4 count of an adult
falls below 200 cells/mmP^3P^, 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.*

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 programme 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.

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 and
    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:**

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-   Coughing or sneezing

-   Being bitten by an insect

-   Touching or hugging

-   Kissing

-   Going to a public bath/pool

-   Using a public toilet

-   Shaking hands

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

-   Using telephones

-   Drinking water or preparing or eating 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:

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-   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.

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-   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

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-   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 mothers who are HIV-positive

-   Provide ARV treatment when indicated and available.

-   Provide ARV prophylaxis during labour and delivery.

-   Provide appropriate 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.)

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.

+----------------+-----------------------------------------------------+
| Exercise 1.2   |                                                     |
| HIV 1, 2, 3    |                                                     |
| Knowledge      |                                                     |
| interactive    |                                                     |
| game           |                                                     |
+----------------+-----------------------------------------------------+
| **Purpose**    | To provide an interesting, challenging way to       |
|                | review basic HIV/AIDS information and to present    |
|                | advanced HIV/AIDS information.                      |
+----------------+-----------------------------------------------------+
| **Duration**   | 60 minutes                                          |
+----------------+-----------------------------------------------------+
| **             | -   Review the HIV/AIDS-related questions in        |
| Instructions** |     Exercise 1.2 (located after the appendices).    |
|                |                                                     |
|                | -   Select one member of your team to record the    |
|                |     group's answers on the question sheet provided. |
|                |                                                     |
|                | -   You will be asked to choose a question from one |
|                |     of the categories above and answer it in 10     |
|                |     seconds. If the answer is correct, your team    |
|                |     will be credited for a proper response. If the  |
|                |     answer is not correct, the question will be     |
|                |     passed on to the next team.                     |
|                |                                                     |
|                | -   You cannot choose a question that has already   |
|                |     been answered.                                  |
|                |                                                     |
|                | -   The first team to correctly answer 6 questions  |
|                |     from 6 different categories wins.               |
|                |                                                     |
|                | ```{=html}                                          |
|                | <!-- -->                                            |
|                | ```                                                 |
|                | -   The winning team will receive a prize.          |
+----------------+-----------------------------------------------------+

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 syndromeP^aP^      | -   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 encephalopathyP^bP^     |
|                                    |                                 |
| -   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        |                                 |
+------------------------------------+---------------------------------+
| > ^Pa\ P^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)                    |                                 |
| >                                  |                                 |
| > ^Pb\ P^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        |
|     etiologyP^aP^                                                     |
|                                                                       |
| -   Progressive encephalopathy                                        |
|                                                                       |
| -   Malignancy                                                        |
|                                                                       |
| -   Recurrent septicaemia or meningitis                               |
+-----------------------------------------------------------------------+
| ^PaP^ Persistent weight loss of more than 10% of baseline or less     |
| than 5P^thP^ 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 |                |              |               |
+---------------------+----------------+--------------+---------------+
| #                   | A              | **B**        | **C\***       |
| CD4 Cell Categories |                |              |               |
+---------------------+----------------+--------------+---------------+
| **m                 | Asymptomatic,  | **Sympt      | **AIDS        |
| m**P^**3**P^**(%)** | PGL or Acute   | omatic\*\*** | Indicator     |
|                     | HIV Infection  |              | Condition     |
|                     |                | **(not A or  | (1987)**      |
|                     |                | C)**         |               |
+---------------------+----------------+--------------+---------------+
| **1**               | A1             | B1           | C1            |
| \>500/mmP^3P^\      |                |              |               |
| (U[\                |                |              |               |
| >]{.underline}U29%) |                |              |               |
+---------------------+----------------+--------------+---------------+
| **2** 200 --        | A2             | B2           | C2            |
| 499/mmP^3P^\        |                |              |               |
| (14--28%)           |                |              |               |
+---------------------+----------------+--------------+---------------+
| **3**               | A3             | B3           | C3            |
| \<200/mmP^3P^\      |                |              |               |
| (\<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/mmP^3P^.        |                |              |               |
|                     |                |              |               |
| \*\* 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)*          |                |              |               |
| <http://www.cdc.g   |                |              |               |
| ov/mmwr/preview/mmw |                |              |               |
| rhtml/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**P^**3**P^      **mm**P^**3**P^ **(%)**   **mm**P^**3**P^
                            **(%)**                                        **(%)**

  Category 1: No evidence   U[\>]{.underline}U   U[\>]{.underline}U1,000   U[\>]{.underline}U
  of suppression            1,500 (\> 25)        (\> 25)                   500 (\> 25)

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

  **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 (U[\>]{.underline}U 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/mmP^3P^), or
    thrombocytopenia (\<100,000/mmP^3P^) persisting U[\>]{.underline}U
    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)

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

**CATEGORY C:** SEVERELY SYMPTOMATIC

-   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
    U[\>]{.underline}U 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 U[\>]{.underline}U 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).

MODULE 1 Participant exercise

Exercise 1.2 HIV 1, 2, 3 Knowledge interactive game

Category 1: HIV/AIDS Transmission

  --------------------------------- -------------------------------------
  **Question**                      **Answer**

  List at least three ways in which 
  HIV infection is transmitted.     

  Name the two types of HIV.        

  What body fluids contain high     
  concentrations of HIV?            

  What is the major route of HIV    
  transmission worldwide?           

  What specific part of the human   
  body does HIV attack and what     
  does this cause?                  
  --------------------------------- -------------------------------------

Category 2: Prevention

  --------------------------------- -------------------------------------
  **Question**                      **Answer**

  What are the ABCs of prevention   
  (on an individual level)?         

  Universal precautions are a set   
  of practices designed to protect  
  health workers and patients from  
  infection. Name at least four     
  interventions that are universal  
  precautions.                      
  --------------------------------- -------------------------------------

Category 3: Infant Feeding

+--------------------------------+-------------------------------------+
| **Question**                   | **Answer**                          |
+--------------------------------+-------------------------------------+
| > Exclusive breastfeeding is   |                                     |
| > defined by WHO as giving an  |                                     |
| > infant only breastmilk       |                                     |
| > (including expressed         |                                     |
| > breastmilk), with the        |                                     |
| > exception of                 |                                     |
| > \_\_\_\_\_\_\_\_\_\_\_\_     |                                     |
| > (fill in the blank).         |                                     |
+--------------------------------+-------------------------------------+
| > List two reasons why cup     |                                     |
| > feeding is preferred over    |                                     |
| > bottle feeding when the      |                                     |
| > mother chooses replacement   |                                     |
| > feeds (rather than           |                                     |
| > breastfeeding).              |                                     |
+--------------------------------+-------------------------------------+
| > At what age does WHO         |                                     |
| > recommend starting a child   |                                     |
| > on complementary foods (food |                                     |
| > in addition to milk)?        |                                     |
+--------------------------------+-------------------------------------+
| > Name two reasons why a woman |                                     |
| > may choose to breastfeed     |                                     |
| > rather than give a           |                                     |
| > breastmilk substitute to her |                                     |
| > infant.                      |                                     |
+--------------------------------+-------------------------------------+

MODULE 1 Participant exercise *(continued)*

Category 4: Testing

  --------------------------------- -------------------------------------
  **Question**                      **Answer**

  What is specifically measured     
  when an HIV screening test is     
  done?                             

  With regard to HIV testing, what  
  does the \"window period\" mean?  

  Name two advantages of the HIV    
  rapid test (compared with the     
  traditional ELISA test).          
  --------------------------------- -------------------------------------

Category 5: Mother-to-Child Transmission

+--------------------------------+-------------------------------------+
| ######## Question              | **Answer**                          |
+--------------------------------+-------------------------------------+
| If 100 women who were          |                                     |
| HIV-infected gave birth to 100 |                                     |
| infants, how many of the       |                                     |
| infants will typically become  |                                     |
| infected during pregnancy?     |                                     |
+--------------------------------+-------------------------------------+
| If 100 women who were          |                                     |
| HIV-infected gave birth to 100 |                                     |
| infants, how many of these     |                                     |
| infants will typically become  |                                     |
| infected during labour and     |                                     |
| delivery?                      |                                     |
+--------------------------------+-------------------------------------+
| Name two maternal factors that |                                     |
| may increase the risk of HIV   |                                     |
| transmission during pregnancy. |                                     |
+--------------------------------+-------------------------------------+
| Name two factors that may      |                                     |
| increase the risk of HIV       |                                     |
| transmission during            |                                     |
| breastfeeding.                 |                                     |
+--------------------------------+-------------------------------------+

Category 6: Linkages to Treatment, Care and Social Support

  --------------------------------- -------------------------------------
  **Question**                      **Answer**

  Name at least two activities that 
  should be included in the 6-week  
  postnatal visit for the woman who 
  is HIV- infected.                 

  Name one test that will tell you  
  if an infant is infected with     
  HIV.                              

  Name one of the more common       
  symptoms associated with HIV      
  infection in the infant or child. 
  --------------------------------- -------------------------------------

MODULE 1 Participant exercise *continued*

Category 7: Prevention in Healthcare Settings

+--------------------------------+-------------------------------------+
| **Question**                   | **Answer**                          |
+--------------------------------+-------------------------------------+
| Name one disinfectant that is  |                                     |
| capable of inactivating HIV.   |                                     |
+--------------------------------+-------------------------------------+
| If a healthcare provider       |                                     |
| accidentally got stuck with a  |                                     |
| needle that had previously     |                                     |
| been used on a patient with    |                                     |
| HIV (and not cleaned), what is |                                     |
| the chance that he or she      |                                     |
| would become HIV-infected?     |                                     |
|                                |                                     |
| A.  1%                         |                                     |
|                                |                                     |
| B.  5%                         |                                     |
|                                |                                     |
| > C. 3%                        |                                     |
| >                              |                                     |
| > D. 20%                       |                                     |
+--------------------------------+-------------------------------------+
| List two things that you can   |                                     |
| do when attending to a client  |                                     |
| in obstetrics to reduce risk   |                                     |
| of occupational exposure to    |                                     |
| HIV.                           |                                     |
+--------------------------------+-------------------------------------+

Category 8: Wild Card

+--------------------------------+-------------------------------------+
| **Question**                   | **Answer**                          |
+--------------------------------+-------------------------------------+
| AIDS is the \_\_\_\_\_\_\_\_   |                                     |
| *(choose number)* cause of     |                                     |
| death in Africa?               |                                     |
|                                |                                     |
| > A. Number 1                  |                                     |
| >                              |                                     |
| > B. Number 2                  |                                     |
| >                              |                                     |
| > C. Number 3                  |                                     |
| >                              |                                     |
| > D. Number 4                  |                                     |
+--------------------------------+-------------------------------------+
| # The HIV/A                    |                                     |
| IDS epidemic is growing fastes |                                     |
| t in what region of the world? |                                     |
+--------------------------------+-------------------------------------+
| In sub-Saharan Africa, women   |                                     |
| represent what percentage of   |                                     |
| all people living with         |                                     |
| HIV/AIDS?                      |                                     |
|                                |                                     |
| A. 78%                         |                                     |
|                                |                                     |
| B. 72%                         |                                     |
|                                |                                     |
| C. 58%                         |                                     |
|                                |                                     |
| D. 48%                         |                                     |
+--------------------------------+-------------------------------------+
| What is the difference between |                                     |
| stigma and discrimination?     |                                     |
+--------------------------------+-------------------------------------+
| What is the difference between |                                     |
| monitoring and evaluation?     |                                     |
+--------------------------------+-------------------------------------+