World AIDS Day falls on December 1

Say ĎNoí to risky behaviour

By Carol Aloysius
The Human Immuno Deficiency virus is still the single infectious agent which causes the highest number of deaths globally. This virus caused about 2 million deaths globally, in 2008, and the numbers are increasing at a frightening pace due to thousands of newly infected persons on a daily basis.
The first case of HIV infection in Sri Lanka was reported in 1986, the victim of which was a foreigner. In the 24 years that have lapsed since then, of the 285 infections that have been reported till the end of June 2010, many of them are from local transmission.
The cumulative number of infected persons with AIDS is now 332. Tragically a growing number of children too are being infected with the deadly disease. Of the total number of infected persons, 44 children received the virus from their infected mothers, at birth.
While the total cumulative number of deaths, from HIV/AIDS now stands at 216, more than 3,000 persons are estimated to be living with HIV in this country. If not treated, they can pose a threat to the rest of society as the disease can spread.
According to health officials, cases of HIV positive people are being reported in every province in Sri Lanka, both urban and rural, with a larger percentage of victims living in the western province where more people engage in risky lifestyles.
The highest number of victims fall into the age group 24-49, and are thus in the prime of their lives, resulting in a serious impact on the nationís economic development.
Unlike in some countries, sexual transmission is still the main mode of transmission, with 94.8% of the total number of HIV patients being infected in this manner. In contrast, mother to child transmission amounts to only 4.5%, transmissions from HIV infected blood transfusions 0.7%, while a mere 0.3% represent injecting drug users.
Although compared to other countries, the prevalence of HIV/AIDS is very low in Sri Lanka, almost all the risk factors such as a growing youth population, rising number of commercial sex workers, and internal and external migration, are present for an epidemic of HIV/AIDS in the not too distant future.
The only way to prevent this is to raise more awareness on the dangers of getting infected with HIV/AIDS among those engaged in sexually risky behaviour, and to underline the importance of changing their lifestyles, health officials told The Nation. They said recent studies have found that the chief culprits for the spread of this fatal disease are married men who are leading risky lifestyles Ė and the majority of victims, their spouses.
Around 50 per cent of infected women in our country have contracted HIV from their spouses without their knowledge.
There is thus an urgent need to detect the disease early and treat it at its initial stage. If not, those with HIV/AIDS can in turn infect the rest of society. If it reaches epidemic levels as in many of our neighbouring countries, including India, it will be virtually impossible for our small island nation to turn back the clock and reverse the situation.
World AIDS Day falls on December 1. Since this yearís theme is on the prevention of HIV and giving access to all who have the disease to be treated without discrimination, The Nation spoke to health officials from the National STD/AIDS Control Programme for their expertise on detecting signs and symptoms of HIV/AIDS, and the kind of treatments available to them free in our government hospitals.

Dr Kulasiri Buddhakorala, Consultant, National STD Control Programme

Q: What is AIDS?
AIDS is caused by the Human Immune Deficiency virus ( HIV). This virus is different from other viruses, because it attacks the immune system which gives our body the ability to fight infections. HIV finds and destroys cells (T cells or CD4 cells) of the white blood corpuscles which destroys the immune system of the body. Various pathogens can enter the body and cause diseases due to immune deficiency.

Q: How does one recognise the signs and symptoms of this disease?
Many people donít have any symptoms when they first become infected with HIV. Some have a flu-like illness, called HIV sero-conversion syndrome, a month or two after exposure to the virus. This illness may cause a variety of symptoms, including the following: Diarrhea, enlarged liver or spleen, fever, enlarged or swollen lymph nodes, headache, muscle pain, nausea and vomiting, neurological symptoms, rash on the abdomen, arms and legs and face, sore throat, thrush, a common fungal infection of the mouth caused by candida, a yeast-like fungus.
These symptoms usually disappear in a week to a month and may be mistaken for other viral infections. During this period, people are very infectious and HIV is present in large quantities in genital fluids.
An infected person may not experience severe symptoms for 8 to 10 years or more.

Q: What do you call this period?
It is called the asymptomatic period. It varies in length for each person. Some people may have symptoms within a few months and others may be symptom-free for years.

Q: What about children?
Children born with HIV usually have symptoms within two years of birth. Children may grow slowly or become sick frequently.
Q: Tell us how the disease progresses.
When you look at the disease spectrum, you will find that the disease progresses in three stages:
(1) the early stage
(2) intermediate stage
(3) advanced stage.
In the early stage most people are unaware they have got the disease due to the lack of symptoms and signs. As the immune system weakens, other complications may occur. For many people, the first signs of infection are large lymph nodes or swollen glands that may be enlarged for more than three months. Other symptoms before the onset of AIDS include: fevers and sweats, herpes infections that cause severe mouth, genital or anal sores, lack of energy, pelvic inflammatory disease in women that does not respond to treatment, persistent skin rashes or flaky skin, shingles - a painful nerve disease often accompanied by a rash or blisters, short-term memory loss and weight loss.

Q: How does a doctor identify them?
It is the responsibility of the doctor, depending on the symptoms and signs, to take the initiative to test the patient for HIV and refer him/her to a clinic to make a correct diagnosis.

Q: What are the symptoms of the next stage?
At this stage they are gradually becoming sick and need to see a doctor because of certain symptoms that are manifested.

Q: What kind of symptoms?
AIDS is the final stage of HIV infections. When someone has one or more of these infections and a low number of T cells he or she probably has AIDS.
When an HIV infected person becomes an AIDS patient (Acquired Immuno Deficiency Syndrome), he would show the following symptoms: recurrent chest infections, respiratory infections such as bronchitis, sinusitis, tonsillitis, pharyngitis, middle ear infections, herpes zoster, oral ulcers. They will also develop sub-skin conditions like seborrhoeic dermatitis and fungal nail infections, papular pluratic eruptions which is a skin allergy with itching and which afterwards heals with rashes, anal sores, and a thick coating on the tongue. Nocturnal fevers and heavy sweating at night are also common. Chronic diarrhea, frequent fevers lasting for several weeks without explanation, extreme fatigue and weakness, a cough that wonít go away and trouble with memory are other symptoms.

Q: Any other symptoms?
They are likely to also experience moderate unexplained weight loss below ten percent of the body weight. Sexually transmitted diseases (STDs) are also an indicator. Girls may experience severe vaginal yeast infections which donít respond to usual treatment, as well as pelvic inflammatory disease (PID). The chances of getting TB are also much higher for persons with HIV/AIDS.

Q: Will they get all these symptoms at once or only some?
Some or several. If they have several of these symptoms they are likely to be worried enough to visit a doctor.

Q: What should the doctor do at this stage?
He must screen their immunodeficiency and refer them for further investigations. There have been cases of misdiagnosis and so medical doctors need a high degree of clinical suspicion.
When they arrive at the hospital for these investigations, the patient will be investigated for symptoms such as
(1) Extra pulmonary TB
(2) Toxoplasmosis of the brain
(3) Progressive multi focal Leuko-encephalopathy.
They may also present many unusual infections.
When patients present themselves with these unusual infections the doctor must immediately refer them for investigations.

Q: What is the treatment given to them?
Antiretroviral Therapy. While there is still no cure for HIV/AIDS, ARV drugs can dramatically reduce death rates, prolong life span and improve quality of life, and transform HIV/AIDS from a fatal condition to a manageable chronic illness. But patients need to get this treatment at an early stage. If not, their life span will be shorter and their quality of life too will be diminished.

Dr Chandrika Jayakody, Senior Registrar, National STD/AIDS Control Programme

Q: What are the main modes of transmission for HIV/AIDS?
There are only three ways one can get this disease. They are as follows:
(1) Through unprotected sex with an HIV infected person.
(2) Through HIV infected blood and blood products.
(3) through an HIV infected pregnant woman to her child.

Q: Could you elaborate?
Transmission can occur when semen, pre-seminal fluid and vaginal fluid of an infected person enters the body of the un-infected person during sexual activity.
HIV infected blood given to a non HIV patient during a blood transfusion can also transmit the infection.
In the case of mother to child transmission, it can happen in three ways if the mother is HIV infected;
(1) During pregnancy
(2) At delivery. If it is a normal vaginal delivery there is a high risk of infection being transmitted to the baby because of contact between maternal and foetal blood. Or if thereís a forceps delivery or a vacuum delivery or any other intervention takes place, which can increase the risk.

Q: So does that mean that delivery by ceasarian section would be safer if the mother is HIV infected?
To some extent yes, because most of the time, the baby will not be exposed to the motherís blood or vaginal secretions.

Q: What about breast feeding?
Thereís a 5-15 % risk of the motherís milk being infected and entering the babyís body.

Q: So that means not every new born baby whose mother is HIV infected will get the disease?
Thatís right.

Q: Is it possible to tell right way that a new born baby is HIV infected?
Most of the time, when babies are born to HIV infected mothers it is difficult to say whether he/she has got the infection because they are asymptomatic.

Q: If they are severely affected what are their chances of survival?
Only for a few years. If not their prognosis is good.

Q: What are the symptoms of HIV in a new born baby?
(1) Low birth weight i.e., less than 2.5 kgs
(2) Failure to thrive
(3) Chronic diarrhoea
(4) Pneumonia
(5) TB
(6) Recurrent upper respiratory infections such as ear infections (otismedi)
(7) Retarded cognitive development
There can also be neurological involvement as well, such as toxoplamosis but we rarely see this in infants.

Q: When the mother has been tested positive for HIV/AIDS what steps do you take to safeguard the child?
Even if the baby is healthy and shows no signs of the disease, we donít take any chances. We monitor the child and the mother for life.

Q: Having AIDS is a traumatic experience. What role does counselling play in therapy and rehabilitation of patients?
As doctors working with STD patients, we are trained for this job. We do pre-test counselling when someone comes to be tested for an STD, and after that, whether the patientís test is negative or positive, we counsel him/her.

Q: Why?
Because that patient has come to us as he felt he was at risk of getting the disease. So what we do is to address the risk factor.
We also pay attention to partner disclosure on the grounds of confidentiality. We also do Adherence Counselling before administering Antiretroviral therapy.
In addition, we do contraceptive-use counseling, and whenever there is a need, we encourage them to bring the family members so that they can be present at these counselling sessions.

Q: Has counselling helped?
Definitely. Many patients who come to us are shattered when they discover they have HIV/AIDS and have suicidal thoughts. After counselling them, many of them have told us that they have been helped since this is a personal and very private problem which they cannot share with others.

Q: Where are most patients treated?
At home or at the IDH. There are no separate wards for them as the disease cannot be transmitted except for the three ways I have already mentioned.

Q: If a person wants to get himself tested for HIV/AIDS where should he go?
We have STI ( Sexually Transmitted Infection) clinics all over the island at general and base hospitals. Or else they can come to the Central Clinic at De Saram Place, Colombo 10.

Q: One final question. Since there are so many myths about transmission of HIV/AIDS, tell us how the disease cannot be transmitted.
It cannot be transmitted by:
(1) Touching
(2) Shaking hands
(3) Kissing
(4) Using the same cup, spoon or plate
(5) From flies or mosquitoes.
Q: Do you have a message to convey to our readers on this subject?
Since risky life styles and having sexual relationships with many partners can make you vulnerable to getting the disease, my advice is: stick to one partner, refuse to have sexual relationships when forced to have unprotected sex and insist on condoms. Remember that HIV/AIDS cannot be cured, but can be easily prevented.
Finally, donít isolate or discriminate HIV infected persons in the family, in society or at your workplace. Any discrimination and stigma can only aggravate the mental trauma of the person living with HIV/AIDs.