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Women and HIV
Sudha Salhan
ONE:
Epidemiology of HIV Infection and AIDS
INTRODUCTION
CHARACTERISTICS OF HIV
NATURAL HISTORY OF HIV
MODES OF TRANSMISSION OF HIV
Sexual Transmission
Use of Condoms and Other Protective Agents
Transmission among Injecting Drug Users (IDUs)
Perinatal (Vertical) Transmission
Transmission by Blood Transfusion, Blood Products and Organ Transplantation
Transmission to Health Care Workers
Environmental and Casual Contact Transmission
An Overview of the HIV/AIDS Pandemic
Sub-Saharan Africa
Asia and the Pacific
Problem In India
Evolution of HIV Epidemic in India
STD Patients
Bridge’ Population
Blood Donors and Recipients
Pregnant Women
Gender-related Issues
Men Who have Sex with Men
TWO:
HIV: The Virus
HISTORY AND ORIGIN
CLASSIFICATION
STRUCTURE AND GENETIC MAP WITH FUNCTIONS
Replication Cycle
HIV REPLICATION STEPS
HETEROGENEITY/GENETIC DIVERSITY
Human Cells and Tissues Susceptible to HIV as Shown by in vitro and in vivo Study11
How the Virus Kills the Cells
Viral Dynamics and its Implications
SUSCEPTIBILITY OF HIV
STERILIZATION
Chemical Disinfectants which Inactivate the Virus Include
TRANSMISSION
THREE:
Syndromic Management of Reproductive Tract Infections and Sexually Transmitted Infections in Females
LEARNING OBJECTIVES
RELATIONSHIP OF RTI/STI AND HIV/AIDS
WOMEN REPORT LATE BECAUSE
Sequelae and Complications and RTI/STI are
Death due to any one or all of them may occur
Comprehensive RTI/STI and HIV/AIDS Control Programme Requires Three Levels of Action
Primary Prevention Emphasizes
Endogenous
Iatrogenic
Sexual transmission
Strategies for Primary Prevention
Infection sexually
Endogenous
Iatrogenic
The main concepts of tertiary prevention are:
Secondary prevention
TWO TRADITIONAL APPROACHES TO STD DIAGNOSIS
PROBLEMS
THE MAIN FEATURE OF THE SYNDROMIC APPROACH
EDUCATION AND COUNSELLING IS TO INCLUDE
COMMON STDs IN INDIA
WHAT ARE THE MOST COMMON STD ASSOCIATED SYNDROMES?
TRICHOMONIASIS
ON EXAMINATION
CANDIDIASIS
BACTERIAL VAGINOSIS
TREATMENT OF VAGINAL DISCHARGES
LOWER ABDOMINAL PAIN IN THE FEMALE (PID)
TREATMENT FOR PID
SINGLE DOSE TREATMENT FOR GONORROHEA
TREATMENT OF GENITAL ULCER
SYPHILIS
GENITAL ULCER
CHANCROID
HERPES
Symptomatic Treatment
FOUR:
Voluntary Counselling and Testing and Its Rationale for HIV Infection
WHAT IS COUNSELLING?
INTRODUCTION
Voluntary Counselling and Testing
Benefits of VCT
Voluntary Counselling and Testing Centres (VCTC)
The VCTC can be:
Remember
HIV TESTING
WHEN TO DECLARE HIV POSITIVE?
Counselling Process
Pre-test Counselling
The Aim of pre-test counselling
Issues in pre-test counselling
In summary pre-test counselling should:
Post-Test Counselling
Counselling After a Negative Result
Counselling after a Positive Result
Guidelines on Prevention of Further Sexual Transmission of HIV
Recommendations to HIV Infected Persons
Recommendations to Sexual Partners of Known HIV Infected Persons
Counselling after an Equivocal Test Result
Unresolved Issues in HIV-antibody Testing
Practical Information for People with HIV Infection or Disease
LIVING POSITIVELY WITH AIDS
Follow-up Counselling
Confidentiality
The Counsellors
EFFECTIVE VCT SERVICES
FIVE:
Establishing the Diagnosis of HIV Infection
INTRODUCTION
LABORATORY TESTS USED FOR THE DIAGNOSIS/DETECTION OF HIV INFECTION
Detection of Specific Antibodies
Screening Tests
ELISA/EIA (Enzyme-linked Immunosorbent Assay/Enzyme Immunoassay)
Rapid Tests Include
Supplemental Tests
The Choice of Test Protocol
Objectives of HIV Testing
STRATEGIES OF HIV TESTING
Causes of False-positive or False-negative HIV EIA Results
1. Causes of False-positive Results for HIV on EIA
2. Causes of False-negative Results for HIV on EIA
ANTIBODY TESTS ON OTHER FLUIDS
Oral HIV Testing
Urine HIV Testing
Home HIV Testing
OTHER BLOOD TESTS
Detection of p24 antigen
Polymerase Chain Reaction (PCR)
Virus Culture
Viral Load Assay
Surrogate Markers
Indirect Predictors of HIV Infection
DIFFERENT PROCEDURES FOR TESTING
ISSUES RELATED TO HIV TESTING
Technical Considerations
Whom to Test ?
Ethical and Legal Considerations
Confidentiality
Informed consent
Counseling (Fig. 5.1)
The Indian National Testing Policy Reiterates the Following:
SIX:
Women and HIV Infection including Mother to Child Transmission
INTRODUCTION
Factors Increasing Vulnerability of Females
Sexual Relationship
Male to Female Transmission of HIV
The Social Factor
Biological Factor
Previous RTI/STI
Economic Factor
Blood
Issues Concerning Pregnancy
Determinants of Vertical Transmission
Viral Load
Concurrent STI
Unprotected Sexual Intercourse
Maternal CD-4 and Lymphocyte Count
Mother's Neutralizing Antibody Monoclonal HIV-3
Nutritional Status
Membranes
Type of Virus
Placental Barrier
Presence and Amount of Virus in the Genital Tract
Foetal Factor
Breastfeeding
Caesarean Delivery
Newborn Immune Response
TIMING OF VERTICAL TRANSMISSION
EFFECT OF PREGNANCY ON HIV DISEASE
EFFECT OF HIV ON PREGNANCY
MANAGEMENT OF HIV POSITIVE PREGNANT WOMEN
INTERVENTIONS AIMED AT DECREASING THE RISK OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV INFECTION
Counseling
General Measures
Obstetric Measures
Immunological
Antiretroviral Drugs
ZIDOVUDINE
NEVIRAPINE—(HIV/NET 0/2)
COMBINED THERAPY
PRECAUTIONS TAKEN
Precautions Taken During MTP or Delivery of HIV Positive Women
Barrier
Disinfectant Solution
Precaution during Operation
HIV-EXPOSED NEWBORN
GYNAECOLOGICAL CARE
CONTRACEPTION AND HIV
Intrauterine Contraceptive Devices
Barrier and Spermicide
Oral Contraception
NATURAL HISTORY OF HIV DISEASE IN WOMEN
ETHICS and HIV DISEASE IN WOMEN
CONCLUSIONS
SEVEN:
Management of HIV Infected Individuals
INTRODUCTION
Clinical Management of HIV-infected Women
Clinical Spectrum of HIV/AIDS
Group I: Acute Retroviral Syndrome
Group II: The Asymptomatic Diseas-Clinical Latency
Group III: Persistent Generalized Lymphadenopathy (PGL)
Group IV: Other Diseases
Subgroup A: Early Symptomatic Disease
Subgroup B: Neurologic Disease
HIV ENCEPHALOPATHY
Subgroup C: Opportunistic Infections
1. Bacterial Infections
Tuberculosis
Disseminated infection with Mycobacterium avium complex
2. Fungal Infections
Pneumocystis carinii pneumonia (PCP)
Cryptococcosis
Candidiasis
3. Protozoal Infections
Toxoplasmic Encephalitis (TE)
Cryptosporidiosis
4. Viral Infections
Cytomegalovirus disease
Subgroup D: Neoplastic Diseases
Subgroup E: Generalized Wasting
Organ-specific Syndromes
Clinical Spectrum of HIV Infected Patients at All India Institute of Medical Sciences
Evaluation before Initiating Therapy in HIV Infection
Viral Load Assays and CD4 T Cell Counts
Antiretroviral Therapy
National Guidelines in India
Antiretroviral Drugs Available in India
Timing to start treatment?
What drugs to start with?
Problems during antiretroviral regimens
Adherence
Pill burden
Drug interactions
Side Effects
Food Effects
When to Change Treatment?
What to Change Treatment with?
Prevention of Perinatal/Vertical Transmission in India
1. Pediatric ACTG 076 Clinical Trial
2. “Short Course”
3. Nevirapine
CONCLUSIONS
EIGHT:
HIV and Adolescent Girl
INTRODUCTION
MODE OF ACQUIRING HIV
OBSTACLES TO CARE OF HIV POSITIVE ADOLESCENTS
Counseling and Testing
Clinical Case
Physical Examination
Adolescent Girl and HIV Treatment
Prevention
NINE:
Infection Control and Bio-safety Practices in Health Care Settings
LEARNING OBJECTIVES
Infections Acquired in the Health Care Settings (Nosocomial Infections)
Definition
Mode of infection
Risk factors
Diagnosis
Surveillance of Nosocomial Infections
Principles of Infection Control
Patients
Microbe
Environment
Infection Control Programme
Transmission of Blood Borne Infections in Health Care Set-ups
Risk of Transmission of Blood Borne Infections in Health Care Settings
Patient to HCW Transmission
Survival of HIV in the Environment
The Risk of Occupational HIV Transmission Depends on
Patient to patient transmission
How to patient transmission
Importance of Bio-safety Practices for Prevention of Transmission of Blood Borne Infections
Blood Borne Infection Control in Health Care Settings
History
Standard Blood and Body Fluid Precautions for Laboratory Workers (Recommended by CDC Guidelines)
Body Fluids to which Standard Precautions Apply
Body Fluids to which Standard Precautions do not Apply
Barrier protection
Gowns
Facial Protection
Occlusive Bandage
Hand Washing
Handling Sharp Objects
HANDLING SPECIMENS OF BLOOD/BODY FLUIDS
HANDLING BLOOD/BODY FLUID SPILLS
Patient Placement
High Risk Procedures in the Health Care Set-Ups
Laundry and Linen
Blankets
Mattresses
Mortuary
MANAGEMENT OF ACCIDENTAL EXPOSURE TO HIV IN THE WORK PLACE
Effective Use of Sterilization and Disinfection
Definitions
Classification of Infection Risk from Equipment or Environment into Three Categories and Suggested Levels of Decontamination
Low Risk
Intermediate Risk
High Risk
Methods
• Cleaning of Equipments/Glassware
• Environmental Cleaning
• Disinfection
HIV CAN BE disinfected BY
Decontamination/Disinfection of used Needles and Syringes prior to Sterilization/Disposal
Sterilization
Setting up of Biomedical Waste Facility
Containing Waste at Generation Point
Sharps
Glass Wares
Culture Plates with Viable Culture
Swabs
Disposable Items
Liquid Wastes
Collection Bags
Packing, Storage and Transport
Treatment and Disposal
Municipal Corporation
Sanitary landfill
Incineration (Temp.750°C)
Guidelines for Waste Disposal
Maintenance of Records
Training
IMPLEMENTATION OF BIO-SAFETY PRACTICES IN HEALTH CARE SETTINGS
TEN:
Post-exposure Prophylaxis against HIV
INTRODUCTION
Important Definitions
Risk in HCWs
Rationale for Post-exposure Prophylaxis (PEP) for HIV
RECOMMENDATIONS FOR THE MANAGEMENT OF POTENTIALLY EXPOSED HCWs (Annexure-1, 2)13
Written Protocols (Most Valuable)
Prompt Exposure Report (Is Must)
Evaluation of Exposure (Both Source Patient and HCW are Evaluated)
Exposure Management
Clinical Evaluation and Base-line Testing of Source-person and Exposed HCWs (Assessment of Infection Risk)
Treatment (HIV PEP) (Immediate)
Explaining PEP to HCWs
Factors in Selection of a PEP Regimen
1. Timing of PEP Initiation
2. Recommendations for the Selection of Drugs for PEP
2a. Known or Suspected Pregnancy in the HCW
3. Monitoring and Management of PEP Toxicity
Follow-up of HCWs Exposed to HIV (Post-Exposure Testing)
Counselling and Education
Why is PEP and Universal Precautions Must?
Government of India Policy
CONCLUSIONS
MANAGEMENT OF OCCUPATIONAL EXPOSURE OF HIV TO HCWS (EACH HOSPITAL TO HAVE ITS OWN PLAN)
• Immediate Treatment
• Prompt Reporting
• Evaluation
• Treatment
• Monitoring of PEP Toxicity
• Counseling and Education
• Follow up of HCWs
CHECK LIST FOR UNIVERSAL PRECAUTIONS
Hands are Appropriately Washed to Prevent Cross Infection
A Protective Barrier is Worn to Prevent Exposure to Blood
Sharps are Handled Safely to Minimize the Risk of Sharp Injury
Instruments Decontaminated Fully
Waste Disposal Safety
ELEVEN:
Psychiatric Aspect of HIV/AIDS in Women
INTRODUCTION
Psychological Issues Associated with HIV Disease
Anxiety Disorders
Treatment
Depression
Treatment
Suicide
Mania
Treatment
Sleep Disorder
HIV Associated Neurocognitive Disorders
Mild Neurocognitive Disorder (MND)
Sign and Symptoms
HIV Associated Dementia
Sign and Symptoms
Treatment
Delirium
Treatment
HIV and Drug Abuse
Postpartum Psychosis
Clinical Features
Treatment
Psychotic Disorders
Treatment
CONCLUSION
INDEX
TOC
Index
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