Download Natural History of HIV/AIDS in Africa: Entry Points for WASH

Water and HIV/AIDS
Dr. Kate Tulenko
WSP
February 20, 2007
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Purpose
To make WSP staff familiar with common
HIV/AIDS concepts and terminology so they
can “talk shop” with health specialists.
 Train WSP staff to give assistance to MOWs
and water utilities to design HIV/AIDS
programs for their staff and clients.
 Train WSP staff to start a dialogue with MOWs
on the health benefits of providing improved
WSH to PLWHAs and the need for programs
and research.

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Outline
Overview of the Human Immunodeficiency
Virus
 Overview of the HIV/AIDS Pandemic
 HIV/AIDS, MOWs, & Water Utilities
 Role of WSH in Improving the Lives of
PLWHA

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Overview of the Human
Immunodeficiency Virus
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HIV Virus
Believed to be a zoonosis (transmitted
from animals)
 Found in almost all body fluids
 Virus: Cannot replicate outside of a living
cell
 Enters and damages white blood cells,
especially helper T cells (CD4)

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Transmission
Unprotected Sex
 Maternal to Child Transmission

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During pregnancy
Breastfeeding
Sharing of Needles
 Blood Transfusions

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Risk Factors
STDs
 Multiple partners
 Partner with a risk factors
 Use of alcohol and drugs
 Lack of power within the relationship
 Women, age

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Diagnosis
Rapid diagnosis kits and now the gold
standard
 Detect HIV proteins
 Acquired-Immune Deficiency Syndrome

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Low CD4 count
Opportunistic infections

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TB
Rare cancers
Rare pneumonias
Overwhelming fungal infections (Candida)
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Natural History
 Time
from infection to significant
symptoms (Opportunistic Infections)
5 to 10 years
 Time from significant symptoms to
death: 3 to 5 years if untreated
 AIDS in Africa dominated by “Slim
Disease”: chronic diarrhea and
weight loss
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Weakened Immune System

Opportunistic infections (harmless to
normal immune system)



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
Candida
Pneumocystis
Toxoplasmosis
CMV
Lowered infectious doses for standard
pathogens
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Overview of the
HIV/AIDS Pandemic
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2006 AIDS Statistics

39 million people infected in the world

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24.7 million in Sub-Saharan Africa
7.8 million in South East Asia
2.2 million in Europe and North America
1.7 million in Latin America
4.3 million new infections in 2006
 2.9 million HIV/AIDS related deaths in
2006
 Estimated that around 2million people are
receiving ARVs in developing countries

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Stages in the Epidemic

Focal: in high risk groups

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Commercial sex workers and their clients
Men who have sex with men (MSM)
IV Drug Users (IVDU)
Other high risk occupations: truck drivers,
miners, migrant workers
Generalized

General population
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Responses

Target messages to high risk groups

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
Reduce high risk behaviors
Mitigate risk
Counseling and testing
General population

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Awareness
Reduction of stigma
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TB and Malaria

The AIDS epidemic caused a surge in the
TB epidemic

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
Most PLWHA should be on medication to
prevent TB
Hygiene issues associated with TB
People with low grade malaria infections
are much more likely to get HIV when
exposed

Water issues associated with breeding sites for
malaria transmitting mosquitoes
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Mitigating Risk

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Reduction in number of sexual partners
Decrease in age of first sex
Increase in condom use
Needle cleaning or needle exchange
Male circumcision
Rapid treatment of STDs
Switch infant formula only if it is AFASS. In
most low resource settings, HIV+ women
should breastfeed
Changes in societal attitudes
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The Scourge of Stigma
Prevents people from seeking diagnosis
and care
 Dying vs Dying from AIDS
 In Uganda, the CDC Safe Water System
became identified with HIV/AIDS
 Use readily available WASH methods

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Life with ART Depends on the
Quality of Care
Goal: to maximize functional years and
delay resistance
 Delay ART treatment as long as possible
 Criteria

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White blood cell count (CD4)
Viral loads
Symptoms
Resistance (what drugs to start on)
Compliance
Monitor

The above plus liver enzymes
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Why is it so Difficult to Treat HIV/AIDS?

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The virus is protected within cells.
HIV attacks the immune system, the systems
that is responsible to eliminating infections.
HIV reproduces rapidly and mutates rapidly. A
recipe for drug resistance.
Drugs have to be taken frequently and regularly
Drugs have to be taken for the rest of the
patient’s life.
Drugs need to be adjusted for resistance.
Resistance and blood cell count levels, and viral
load levels need to be monitored.
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Why is it so Difficult to Treat HIV/AIDS?

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The drugs have side effects
In addition of ARVs, drugs need to be take to
prevent Opportunistic Infections (IOs)
Most PLWHA do not know they are infected.
Even those who know they are infected refuse
treatment do to stigma.
HART requires a team of highly trained clinicians
and support staff, a strong laboratory system, a
good drug stocking.
To prevent resistance, patients usually need to be
on three ARVs
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Major HIV/AIDS Initiatives
World Bank MAP (Multi-Country AIDS
Program): prevention, community based
funding, required non-health sectors to be
involved
 Global Fund: Little technical assistance
provided
 PEPFAR (USAID): ARV therapy, Prevention
of Mother to Child Transmission (PMCT)
 WHO 3x5: ARV therapy
 Clinton Foundation: ARV therapy

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The Role of WSH in
Improving the Lives of
PLWHA
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What We Do Know
Improved water can reduce the number and
severity of episodes of diarrhea of PLWHA
(Increases functional days)
 Improved WASH eases the family caregiving
burden, especially at the end of life
 Issues of disposal of large quantities of HIV
infected diarrhea
 Infant formula made with improved water can
eliminate transmission from breast feeding
but ACCESS TO IMPROVED WATER AND
FORUMLA MUST BE GUARENTEED FOR AT
LEAST 6 MONTHS!! (AFASS)

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Key Entry Point: Priority Clients
 Higher
priority to provide WASH
services to symptomatic nontreated PLWHA
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Key Entry Point

Mothers and Infants who received PMTCT
should receive at least 6 months worth of
guaranteed improved water and infant
formula
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What We Don’t Know:
Research Needs
1.
2.
3.
4.
5.
6.
7.
Safe water away from home.
Can sanitation alone or hygiene alone reduce
diarrhea in PLWHAs?
Can improved WASH reduce the number of
respiratory infections in PLWHAs?
Can improved WASH help maintain weight and
nutritional status?
Can improved WASH provided at onset of
symptoms delay the need for ART initiation?
(delays resistance)
Can improved WASH prolong lifespan?
What has the water sector done internally to
mitigate HIV/AIDS?
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HIV/AIDS, MOWs, &
Water Utilities
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Job Site Programs
Involve employees and families
 Management should take a lead role in
 Mandatory sessions
 Maintaining confidentiality
 Offer services off-site if feasible
 Programs should be evaluated and improved
on a regular basis

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Job Site Program Services
Education
 BCC
 Reducing stigma
 Tackling sexual harassment in the workplace
 Making people aware of company rules and
benefits
 Counseling and testing
 Treatment
 Care
 Death benefits and survivor benefits

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Questions?
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