Objective Facts And Their Implications Rationale and Purpose

A basic body of knowledge exists in relation to the conditions under which the virus is transmitted between people, the dynamics of its spread and the natural history of infection. Understanding this information is essential for policy and programme development. This activity allows participants to consider the relevance of these facts to the way in which the epidemic spreads, the ways in which HIV infection affects people's lives and well-being, and the severity and extent of the epidemic.

Procedure

Distribute the questionnaire and accompanying sheets and ask participants to read the instructions, complete the questionnaire and read the information sheet before the relevant session. Make it clear that the exercise is not a test. It is a participatory way of stimulating discussion and sharing knowledge among participants. Discussion will take place in facilitated small groups. Any critical emerging issues should be shared in plenary.

Materials: Questionnaire/instructions/information sheets/ flipcharts, markers.
Time: 60 minutes.

Questionnaire Instructions

This questionnaire covers basic facts about the HIV epidemic. Please read the questions and circle your response to each. After completing the questionnaire, check your answers against the information sheet. The information covered in the questionnaire and information sheet will be discussed in small groups.

The information in this section is important for creating a shared understanding of the epidemic. It is essential that it be made locally relevant and be updated regularly. The following information has been drawn mostly from relevant UNAIDS publications. The issues identified below are not intended to be exhaustive. They are examples of the kinds of issues and questions which may be useful to stimulate discussion. Feel free to adapt it according to the needs of the groups with whom you work.

1. It is estimated that 1 in 200 adults worldwide, and 1 in 50 adults in the Caribbean, are
living with HIV/AIDS.

True

¬ UNAIDS estimates for the end of 1998 suggest a total of 33.4 million people worldwide living with HIV/AIDS, more than 95% of whom live in developing countries.

¬ Since the beginning of the epidemic, more than 47 million people worldwide were infected by HIV, of whom nearly 14 million have already died.

¬ At the end of December 1998, 330,000 adults and children were living with HIV/AIDS in the Caribbean and 45,000 are estimated to have been newly infected during 1998.

¬ Overall adult prevalence in the Caribbean is estimated at 1.96%. There is however extensive variation in HIV prevalence levels between and within different populations, reflecting the concentrated nature of the epidemic in the majority of the Caribbean countries.

¬ For Barbados, at the end of 1997, UNAIDS/WHO estimate:

· a cumulative total of 2300 cases of AIDS
· a total of 4300 adults and children living with HIV/AIDS

¬ and for Guyana:

· a cumulative total of 2300 cases of AIDS
· a total of 10,000 adults and children living with HIV/AIDS

¬ The most recent estimates available suggest that worldwide 16,000 individuals (14,000 adults and 2,000 children) had become infected with HIV each and every day.

¬ The most significant transmission category for adults is sexual, and for children it is transmission from the mother.

Discussion Questions

· What is the popular perception of the epidemic in your country?

· What are the implications of these statistics for economic and social development in your country?

2. A person with HIV can transmit the virus for life

True

¬ It is now understood that there are also specific periods when a person with HIV is likely to transmit the virus more than others (i.e. around the time of initial infection and later when they become symptomatic).

¬ However between these two periods there may be a gap of many years, during which it is assumed that an individual with HIV can transmit infection to others.

¬ It is important to recognise that HIV infection is transmitted only in very specific ways:

· through unprotected sexual intercourse (anal or vaginal, and less commonly, oral) thought to be responsible for around 90% of all HIV transmission
· through blood to blood contact (e.g. through transfusion, occupational exposures or sharing drug-injecting equipment)
· from mother to child during pregnancy, at delivery, or through breast-feeding

¬ It is impossible to tell whether or not someone is HIV infected by looking at them.

Discussion Questions

· What is known about the particular pattern of the epidemic in your country?

· What has been done in your country so far to minimize the spread and reduce the impact of the epidemic?

3. Condoms, when used consistently, can significantly reduce the risk of HIV transmission

True

¬ Carefully monitored studies, have demonstrated that consistent and correct use of natural rubber latex condoms (together with water based lubricants as required) are an effective means of preventing unwanted pregnancy and sexually transmitted diseases (including HIV).

¬ In the last few years non-latex synthetic condoms for both men and women have been introduced. However it is likely to be several more years before these are made widely available.

¬ Poor quality condoms break more frequently than condoms which pass internationally recognized manufacturing standards.

¬ Younger and less experienced users break condoms more frequently than do those who have learned to use condoms properly.

¬ Promising research on microbicides is underway to provide a safe, effective, female- controlled method of prevention.

¬ The female condom can be inserted several hours before sex occurs. It is safe and less likely to break than the male latex condom.

¬ The female condom may also give women more control over determining whether or not condoms are used in a sexual encounter.

Discussion Questions

· What is the current situation concerning condom quality control, distribution and availability in your country?

· What institutions in your country are against promotion condom use and sex education among youth?

· What more do you think needs to be done?

4. HIV can be transmitted from a mother living with the virus to her unborn or newly born
child

True

¬ Study results vary but they suggest that the rate of mother to child transmission of HIV is around 25 to 30% in the Caribbean. (66% of that transmission occurs during pregnancy and delivery and 34% through breast feeding).

¬ The specific conditions under which the virus is transmitted prenatally are being studied.

¬ However it is likely that HIV is more likely to be transmitted to the child during the period of initial acute infectivity (see 2 above) and after the development of symptomatic illness (when there is an important quantity of virus in the blood).

¬ The virus can be transmitted to an infant during breast-feeding. HIV positive women are advised not to breast-feed where safe alternatives exist and are available.

¬ It is possible that a woman's general health and nutritional status may be factors.

¬ Studies have now indicated that by providing anitretroviral treatment to women during pregnancy and delivery, and depending on the regimen, to the infant after birth, HIV transmission from mother to child can be reduced by 50 to 66%. However provision of this treatment can be expensive and requires access to confidential HIV testing, adequate counselling, as well as the delivery of effective health and psycho-social services.

Discussion Questions

· What is being done to reduce mother to child transmission of HIV in your country?

· What are the specific development implications of mother to child transmission of HIV and its prevention?

5. Most people living with HIV do not know they have the virus

True

¬ A conservative estimate from UNAIDS/WHO suggests that 9 out of 10 people who are infected with HIV are unaware of their infection. This means that more than 29 million people in the world today have no idea that they are infected by HIV.

¬ Facilities for voluntary, confidential counselling and testing are not widely available (despite the fact that such services are an important component of any effective national response).

¬ People are more likely to seek testing if, in addition to confidentiality and a non-discriminatory environment, adequate care and support services are made available and accessible.

¬ Where HIV infection is stigmatized and discrimination occurs against those living with HIV/AIDS, there is little incentive for those who may have been at risk to go for an HIV test.

¬ The importance of confidentiality and positive attitudes of Health Care Providers towards people infected by HIV can not be over-stated. People are far less likely to be tested in the absence of these attributes among Health Care Providers.

¬ Advantages of being tested include the ability to protect loved ones, to be able to plan for the future and motivation to seek prompt treatment in the event of subsequent illness.

Discussion Questions

· Have you knowingly met anyone with HIV or AIDS? What difference has it made to you?

· A national AIDS policy and legislation are very important tools to ensure respect for individual rights and protection of persons living with HIV/AIDS. Are any such policies and/or laws existent in your country?

· How can people living with HIV and AIDS become a meaningful resource in your national response?

6. HIV infection is always fatal

False

¬ It is not yet known whether all people with HIV will die as a result of their infection.

¬ Having HIV infection is not synonymous with having AIDS. HIV and its replication trigger a gradual state of immune deficiency, affecting principally T-cell lymphocites. An AIDS diagnosis confirms the presence of one or more diseases which are associated with the depletion and dismantling of the body's complex immune system. Many of these diseases associated with AIDS can be treated.

¬ There is no evidence that anyone can become immune to infection but people may have HIV or AIDS for many years and continue to live rich fulfilling lives.

¬ There are indications that the time of progression from asymptomatic HIV infection to symptomatic illness, including AIDS, is shorter in developing than developed countries, and among women and children, in comparison to men.

¬ In some countries, most notably industrialized nations, some countries in Latin America and Thailand, many people who are found to have HIV infection have access to combination antiretroviral therapy which reduces the amount of HIV in the blood, delays the onset of AIDS and its disease manifestations, and increases the survival time of people living with HIV and AIDS.

¬ Such treatments are expensive, difficult to administer and require regular medical monitoring.

¬ One United States (US) based study has shown that even in a wealthy country there are potentially significant difficulties in ensuring equitable provision of drugs.

¬ Nonetheless, in countries all over the world people living with HIV/AIDS are sharing information and campaigning for more equitable access to treatment.

¬ Much can be done to prevent and treat symptomatic illness. For example, other sexually transmitted infections can facilitate HIV transmission. However most of these infections can be detected and treated at affordable cost.

Discussion Questions

· What is the situation in your country in terms of availability treatments and services for people living with HIV and AIDS?

· What are the specifically development implications of HIV-related treatment, care and support?

7. As a group, women in the Caribbean become infected at a younger age than men

True

¬ Most HIV infection rates among women begin in the early teens, rising steeply, peaking in the early to mid-twenties while for men infections peak five to ten years later.

¬ HIV transmission is more efficient from a man to a woman than vice versa. Reasons for this include: greater vaginal surface and longer survival of the virus in the vagina; tearing of the vaginal mucosa during sexual intercourse and asymptomatic untreated STDs.

¬ Young women are often particularly vulnerable: the result of a combination of physical (e.g. immaturity of, or trauma to, the genital tract), social and cultural factors (including coerced sexual activity e.g. rape, incest).

¬ Women are increasingly affected by HIV. They account for more than 40% of all adults living with HIV/AIDS worldwide. Since 1996 the number of infected women has been approaching that of newly infected men.

¬ Already in sub-Saharan Africa there are six women with HIV for every five infected men.

¬ In the worst affected areas, up to a quarter of young women are becoming infected while they are still in their teens.

¬ In the Caribbean, for the period up to December 1998, UNAIDS estimated that 35% of infected adults were women.

¬ In countries where young people account for 60% of all new infections, young women outnumber young men by a ratio of 2 to 1.

¬ 9 out of every 10 infected women live in developing countries and more than 80% become infected through unprotected sex with men. The remainder are infected through blood transfusion or through sharing infected drug-using equipment.

¬ For many women worldwide, their principal risk factor is to be married.

Discussion Questions

· What is the breakdown in terms of gender and HIV in your country?

· How specifically are gender issues integrated within development efforts and is HIV addressed within these?

8. Studies show that teaching young people about sex and condom use encourages them to
have sexual intercourse

False

¬ Studies support the notion that teenagers are highly sexually active with most young people beginning sexual activity in their teenage years. Rates of partner change are also higher during the teens and early twenties.

¬ Studies in several Caribbean countries indicate that multiple sexual partnerships are very common among youth.

¬ Young people are also especially vulnerable to HIV and other STIs: in many countries, 60% of all new infections occur among 15-24 year olds. .

¬ While condom use tends to be higher among younger age groups than older, it also tends not to be peak until the early 20s, highlighting the importance of work with teenagers who may be less able or comfortable in obtaining and using condoms.

¬ Multicultural, multi-country studies show that teenagers who receive sex education are more likely to postpone initiation of sexual activity, and when they do initiate sex, they are better able to negotiate protected sexual intercourse than those who do not receive sexual education.

¬ Where information, skills training and services are made available to young people, they are often more likely to make use of it than older people. Young people may be most willing to adopt safer behaviours at the beginning of their sexual `careers'. Peer education which includes young people talking to other young people, has been shown to be an effective strategy.

¬ Barriers to providing HIV/AIDS and sexual health education in schools may include the sensitive nature of the subject and fear of opposition together with the difficulties inherent in balancing priorities between this and other topics in an already full curriculum.

¬ Collaborative approaches to addressing these obstacles might include: the development of partnerships between policy-makers, religious and community leaders, parents and teachers, establishment of a clear policy framework for such activities and the development of locally appropriate and sensitive curricula.

Discussion Questions

· What is the situation for young people in your country in terms of receiving sex education and having access to condoms and sexual health services?

9. It is unlikely that a vaccine will ever be developed

False

¬ Research is currently under way on the development of three types of vaccines:

C to prevent infection
C to prevent progression after infection, and
C to prevent perinatal transmission

¬ Several issues affect the effective availability of vaccines in developing countries. These include the cost of transportation and administration as well as the cost of the vaccine itself.

¬ The ethical issues associated with such vaccine and treatment trials, in particular the continuing availability of successful vaccines or drugs in the country where the trial is conducted, urgently need to be addressed.

¬ False hopes in relation to vaccine development could reduce the effectiveness of behaviour change and a balance in the allocation of scarce resources will need to be sustained between behaviour change programmes, vaccine trials and treatment programmes.

¬ Some developing countries are participating in the International HIV Vaccine Initiative. When a cost-effective and efficient HIV vaccine is developed this should be made available to those countries where the HIV transmission rate is very high. Additionally, the international effort to introduce the antiretroviral therapies in that part of the world should be sustained to ensure accessibility to those drugs by those most in need.

10. Mosquitoes transmit HIV

False

¬ The parasite which causes malaria is transmitted through saliva of the mosquitoes and not through sucked blood. HIV thrives in blood, not in saliva, and is a specifically human-hosted virus. When mosquitoes bite, they suck blood into the stomach. They then inject saliva which contains the malaria parasite to replace that blood. This fluid is toxic to humans and is what produces the itching reaction. Mosquitoes do not inject blood.

¬ There are significant differences in the infection rates among different age groups. If the virus were transmitted by mosquitoes, infection rates would be evenly distributed among all age groups.

¬ Several studies of families of people with AIDS show that those household members who are not sex partners are no more likely to be infected with HIV than members of other households. If mosquitoes, bedbugs, lice or other insects in a crowded home could spread the virus, there would be more people infected with HIV in the households of people with HIV/AIDS.

11. Most AIDS deaths occur among those in the prime of their productive and reproductive
lives

True

¬ Three quarters of men in the most affected age groups are the main bread-winners or heads of household.

¬ For the family, HIV-related illness leads to lost earnings, medical expenses and eventually to funeral costs: all of which can drive a household into ever-deepening poverty.

¬ To some extent female-headed households are common in the Caribbean. This is on the rise in heavily affected areas. The introduction of HIV to these households tend to make them poorer and less able to provide education and health care for children than households which include a male income earner.

¬ HIV/AIDS causes illness and death among providers, thereby altering the ratio of productive to dependent members of society.

¬ At the household level, savings will fall as income has to be spent on healthcare and on funerals. At the national level, the loss of human capital and revenue will be especially devastating in countries where educated, skilled and professional people are most affected by the epidemic.

Discussion Questions

· To what extent do you think the social and economic development dimensions of the epidemic are clearly understood among policy makers in your country?

· How will the situation be affected by public sector reform and specifically the health sector reform programme?

· What implications do you predict for your country's future social and economic development?

12. In your opinion, what are the three most important driving forces behind the epidemic in your own country?

Discussion Questions:

· Would you answer this question differently if you were to do it again? Why?

· What do you see as the relationship between these driving forces and development within your country?

13. In your opinion, what are the three most important social or professional groups most affected by the HIV epidemic in your country?

· What are the implications of infection among these groups for your country's social and economic development?