Download What is HIV?

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HIV/AIDS
Introduction to HIV Disease and
AIDS
What is HIV?
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HIV stands for the Human Immunodeficiency Virus :
Can only infect humans
Virus attacks the Immune System making it weaker
Virus, antibiotics don’t work
HIV vs. AIDS: What’s the Difference?
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HIV Disease consists of
5 basic stages, of which
AIDS is the final stage
To be diagnosed with
AIDS, an individual
must be HIV+ and….
Have a special infection
or cancer that only
affects those with
severely weakened
immune systems:
OPPORTUNISTIC
INFECTIONS
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CD4 cell (T-cells)
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The “quarterback” or “brain” of the immune system: it
coordinates your body’s response to infections
The cell that HIV targets, infects, and kills”
“Normal” range can be anywhere from 500-1500 CD4
cells per teaspoon of blood
A routine blood test for PHAs to assess immune
function (~every 3 months)
HIV
CD4 Cell
Viral Load
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Refers to the amount of HIV in an individuals blood
Amount can vary over time and with HIV medicine
Goal of treatment is to reduce the viral load to “undetectable”.
Even at the undetectable level, the virus is still present in
“reservoirs” like the lymphatic system and some organs.
“Undetectable” range is less than 50 copies of virus per mm3
A routine blood test for PHAs to assess when to start treatment,
assess treatment effectiveness
1. Primary Infection (Acute)
2. Seroconversion
3. Asymptomatic Infection
4. Symptomatic Infection
5. AIDS
Primary (Acute) Infection
1.
Virus multiplies rapidly
2.
CD4 cell count drops during
this period and Viral Load
can be very high as the body
has not yet responded to the
infection
3.
Individual may test negative
for HIV antibodies, but
VIRUS IS EASILY
TRANSMITTED
CD4+/Viral Load: HIV Disease
HIV Treatment
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HIV meds can reduce the amount of HIV in the blood to an
undetectable (but still present) level which allows the body’s
CD4 cells to replenish to a “healthy” level.
Undetectable viral load reduces the likelihood of transmission
People usually start meds around 500 CD4 cell count and this
can basically prolong (possibly indefinitely) the asymptomatic
phase. (most major OIs occur at <200 CD4 cells)
Adherence must be greater than 95% to prevent virus from
becoming resistant to the medications (right dose, right time,
right amount of food/no food).
Side effects to treatment can be serious and difficult to endure ,
though many of the newer medications have improved
tolerability. Long term toxicities are also a concern with some
medications
HIV Transmission
Body Fluids (cont’d)
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Not all body fluids can transmit HIV
The ONLY body fluids that can transmit HIV
are:
BLOOD
 SEMEN
 VAGINAL FLUIDS
 RECTAL FLUIDS
 BREAST MILK
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HIV
Transmission Equation
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There are certain things that must be in place for
HIV to transmit from one person to another. It is
sometimes called the TRANSMISSION
EQUATION
HIV + Body
Fluid
•Blood
•Semen
•Vaginal Fluids
•Rectal Fluids
•Breast Milk
Means of
Transmission
•Sexual
Transmission
•Sharing
Needles and
Works
•Mother
to Child
Entry Into
the Body
•Break in the Skin
•Mucosal Lining
Contact**
•Direct Contact with
Blood Stream (IV)
Possible HIV
Transmission
Mucous Membranes (MMs)
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Form the surface of body cavities
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(nostrils, vagina, anus, mouth, throat, respiratory/digestive/reproductive systems)
MMs cover 400m2 surface area (1 and ½ tennis courts)
It is wet, and in some places, secretes mucous that helps keep out foreign
invaders
Lined by an epithelium (protective layer of cells); similar to skin but alive
Many immune cells within and right below the surface of MMs to protect
against possible infection
Since HIV can infect immune cells, it provides many targets for HIV in
exactly the areas of the body that it will contact
ANUS/RECTUM
•Many immune cells in the anus,
rectum, and large intestine to
protect against high number of
invaders
•Easier for HIV to find a
target
•Epithelium of rectum is only 1
cell thick, so it is easier to get
through
•Large surface area
•Lots of room for HIV to
come into contact with an
immune cell
FEMALE REPRODUCTIVE TRACT –
Vagina, Cervix, and Uterus
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HIV can transmit through
any part; but most easily
through the cervix
Vaginal wall has multiple
overlapping layers of
epithelial cells, so it is a bit
harder to cross
Epithelium in the upper part
of the cervix and uterus is 1
cell thick, like the anus, so it
is more vulnerable to HIV
and STIs
Many immune cells naturally
present at cervix to protect a
potential fetus
THE UNCIRCUMCISED PENIS
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The urethra is lined with
mucous membrane
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The area under the foreskin is a
mucous membrane with lots of
dendritic cells*
MOUTH AND THROAT
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Saliva has a MUCH lower
viral load than blood or
genital fluids
Activities involving the
mouth are generally
considered low risk activities
Oral mucosa is tough and
quick to heal
Tonsils are most vulnerable to
HIV
Risk increases with
ejaculation, menstruation,
poor oral health, or
inflammation
Role of Inflammation
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Body’s immune response to injury, irritation, or
infection by foreign object/organism
Causes:
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Redness and heat : increased blood flow which brings
immune cells to the region
Localized swelling as walls of blood vessels become thinner :
allows more immune cells to migrate from the blood into the
MM to find invaders
Inflammation
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ANYTHING that increases inflammation increases and
HIV+ person’s chance of transmitting it to someone
else, AND increases an HIV- person’s vulnerability to
infection
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Infl. increases viral shedding in genital/rectal tracts of HIV+
persons
Some proteins in immune response increase ability of HIV to
reproduce
Activated target cells (CD4,macrophage, dendritic cell) come
to the area and have increased chance of contact with HIV
INFLAMMATION – Influx of Immune Cells
Biological Factors in HIV
Transmission
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What bio. factors increase the infectiousness of an
HIV+ person?
Viral Load in semen, vaginal fluids, anal fluids
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Affected by changes in blood VL, coinfection with an STI,
inflammation, or stage of HIV disease
HIV+ people are more likely to transmit in the first 5
months after being infected
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Astronomically high VL, unaware of infection, sexually
active, sometimes with multiple partners
HIV and Women
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It is 4-6 x easier for a man to infect a woman, than vice
versa:
Vagina is very large mucosal area
Semen has, on average, a higher viral load than vaginal
fluids
Up to 75% of some STIs show no symptoms in women
(vs. 40% in men), women are more likely to be infected
and be unaware
Socio-economic factors can make women more
vulnerable to infection
Women are not being educated about their increased
risk for HIV infection in schools
Transmission Basics
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CAS categorizes activities into risk levels:
No risk, Negligible Risk, Low Risk, High Risk
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1. Is it theoretically possible? (exchange of body fluids)
2. Have their been documented cases? How many?
Helps people make knowledgeable choices as to how much risk
they are willing to take
HOWEVER:
Quantifying risk is very difficult and these categories are not
clear or absolute
HIV risk is a continuum based on various social and biological
vulnerabilities, as well as the infectiousness of the HIV+ partner
High Risk
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Penile – Vaginal Sex (without condom)
Penile – Anal Sex (without condom)
Receiving shared sex toys
Injecting with shared needles
Low Risk
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Kissing (with exchange of blood)
Performing fellatio/cunnilingus (no barrier)
Vaginal/Anal Sex with a condom
Injecting with cleaned needles
Tattooing with non-professional equipment
Taking blood in the mouth
Occupational Exposure
Negligible/Theoretical Risk
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Receiving fellatio/cunnilingus
Performing fellatio/cunnilingus with barrier
Anilingus
Fingering, fisting
Vulva-vulva rubbing
Docking
Taking breast milk into the mouth
Using drugs with shared pipe or straw
Sharing toothbrushes/razors
Fighting
No Risk
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Kissing (no visible blood)
Non-insertive masturbation
Receiving unshared sex toys
Injecting with new needles
WARNING: Spermicide and
Condoms
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Spermicidally-lubricated condoms should not be used*.
They provide no extra (statistically significant)
protection against pregnancy than regularly-lubed
condoms.
The N-9 (spermicide) inflames the vaginal and rectal
mucosa and can increase the chance of acquiring HIV
should the person be exposed to HIV after using N-9
The WHO and CONRAD have called for the removal
of these products, and all but Trojan volunteered to
stop making these products
HIV and the Criminal Code
HIV & the Criminal Law:
An Introduction
 R.v.Currier
(1998)
 People living with HIV can be found guilty
of a criminal offence if they fail to disclose
their HIV status before engaging in
behaviours that pose a “significant risk” of
HIV transmission to another person.
 Aggravated
Sexual Assault (max. life
imprisonment)
 Transmission not required (“Attempted”)
HIV & the Criminal Law:
An Introduction
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“Significant risk” is where things get hazy. It
definitely includes unprotected anal or vaginal sex
(the details of the case). It MAY mean lower risk
activities like unprotected oral sex, or protected anal
or vaginal sex.
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The supreme court in 1998 said that “the consistent use of
condoms may so reduce the risk that the duty to disclose
would not arise”
They also hinted that if a person feared violence upon
disclosing their status, the duty may not arise
Each case would need to be examined on its own merits
HIV & the Criminal Law:
An Introduction
 An
assault charge requires no consent
 The majority opinion stated that not
disclosing a significant risk of transmission
was fraud and therefore vitiated consent
 Some
justices were very concerned about the
use of a “broad” statement (like significant risk)
rather than a clear line as it could trivialize the
charge of assault
 If
someone doesn’t disclose they are married or lies
about birth control, does that mean the consent is
vitiated and the act is assault? They argued for a
clear line in the sand. Condoms? We won’t prosecute
Criminal charges laid (1989 –
2007)
Canadian HIV/AIDS Legal Network, 2008.
Sex of accused and complainant
women charged for sex
with men
men charged for sex with
someone whose gender is
unspecified
men charged for
sex with men and women
men charged for
sex with women
men charged for sex with
men
Canadian HIV/AIDS Legal Network, 2008.
Changes in HIV Science since
1998
 We
better understand the realities/risks
of transmission:
 Viral
Load / Treatment
 How effective condoms really are (hint: very)
Recent scenarios in case law
 An
appeals court acquitted an HIV+ gay
man who had unprotected anal sex (he
received/bottomed).
 The
judge found the science showed a risk for
that particular activity and with his particulars
a risk of 0.12% chance of transmission
 Judge found that was NOT significant risk
 Case is being appealed to SCC
Recent scenarios in case law
 Condom
Use
 Most
cases/judges/appeals courts have
concluded that condom use reduces the risk to
such an extent that the duty to disclose does
not arise (not sufficient to convict)
 Oral
Sex
 Fewer
cases; one case found that unprotected
oral sex on an HIV+ man low risk and therefore
not enough for the duty to disclose
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Aziga case (Hamilton) jury did convict; however, not the best
case to differentiate as there was other egregious behaviour
that they were distracted by
Why this is a problem
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Unfair/Inconsistent treatment across Canada
Misuse of the charge (Mabior)
Will do nothing to prevent further HIV
transmissions; criminalizing only makes society
less safe
Drives people away from being tested
 Ignores the responsibility we all have to protect our
own sexual/reproductive health
 Creates a false sense of safety
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