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Developed by JHPIEGO’s Training in Reproductive Health Project with funding from USAID.

Lesson 1: Fundamentals of Reproductive Health and HIV/AIDS
Instructor: Jean Anderson

Objectives

This first e-mail lesson is entitled "Fundamentals of HIV/AIDS and Reproductive Health." It has the following objectives:

1. To develop an understanding of common terms and concepts used in the field of HIV/AIDS and in reproductive health
2. To review the health burden of the HIV/AIDS epidemic and reproductive health problems around the world
3. To review the special issues in reproductive health and family planning for HIV-positive women

Definitions

Before we get started with the “fundamentals” of HIV/AIDS and reproductive health, we need to start with the fundamentals of the fundamentals! What do we mean by certain terms that are used whenever we talk about HIV or reproductive health? Even though many of you may already understand a lot about this subject, it is important that when we use certain words we all mean the same thing. We will start with a few words or phrases that we will use over and over again. 

So here goes:

1. Human Immunodeficiency Virus (HIV): When someone has HIV infection they have been infected with this virus.
2. Acquired Immune Deficiency Syndrome (AIDS): AIDS is the end of the clinical spectrum of HIV infection. It occurs when the immune system of a person who is HIV-infected becomes so suppressed that they are vulnerable to a variety of illnesses. These are illnesses people who have normal immune systems do not have to worry about. 
3. CD4 cell counts: A specialized type of lymphocyte, the CD4 cell counts is an important component of the immune system. They are the most common “target” cells for the human immunodeficiency virus. HIV attacks these cells, infects them, and kills them. The primary way to determine the degree of immune damage from HIV is to measure the number and percentage of CD4 cells.
4. HIV-RNA level or viral load: A measure of the amount of virus present--usually measured in blood plasma-- using a sophisticated molecular technique known as polymerase chain reaction or PCR. The unit of measurement is number of copies per milliliter (ml). The measurement can range from undetectable levels (the most sensitive tests now available can measure down to a level of 50 copies per ml) to levels of over 1 million copies per ml! This test is used to monitor the effectiveness of antiretroviral regimens. It also reflects infectiousness. HIV-positive people with high viral loads are more infectious to their sexual partners and to their fetus or breastfeeding infant than those with low or undetectable viral loads. 
5. Opportunistic infections (OI): Different infections that have the “opportunity” to occur when the immune system is severely damaged by HIV. In most cases, people who have normal immune systems do not get these infections even when they are exposed.
6. Antiretroviral (ARV) therapy: Treatment with drugs that specifically attack the HIV virus. There are several different “classes” of ARV drugs that act in different ways and at different sites on or in the virus. 
7. Highly Active Antiretroviral Therapy (HAART): The abbreviation used for antiretroviral regimens that use effective combinations of agents from two or more drug classes in order to achieve the greatest suppression of viral load for the most sustained period of time.
8. Reproductive health: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes, including sexual health.
9. Family planning: Voluntary planning and action by individuals to have the number of children they want, when and if they want them. Family planning helps couples space births, prevent unwanted pregnancies and avoid sexually transmitted infections (STIs), including HIV.
10. Dual protection: Protection against both unwanted pregnancy and STIs/HIV.
11. Emergency contraception: The use of certain methods after unprotected intercourse to prevent pregnancy.
12. Risk assessment: The use of socioeconomic, demographic, clinical and behavioral indicators to predict who is at risk for STIs.

Health Burden of HIV/AIDS (1) and Reproductive Health Probems (2)

At the end of 2001, the total number of adults and children living with HIV/AIDS was 40 million, 28.5 million of who live in Sub-Saharan Africa. However, the regions of the world where the HIV epidemic is growing fastest include South East Asia, India, and Eastern Europe. Five million people were newly infected with HIV in 2001. About half of these people were women and about half were young people between the ages of 15 and 24. Furthermore, the HIV pandemic has fueled a resurgence of the tuberculosis (TB) epidemic, which is spread much more easily than HIV and affects both HIV-positive and –negative people alike.

There is a new global resolve to fight this pandemic. This resolve is not only because of the suffering and death it causes to individuals who are infected, but because it is reversing decades of progress in healthcare, education and economic growth and stability. It is believed that 14 million children who are not infected have been orphaned because one or both parents have died of AIDS. These children are at increased risk for illness and death, poverty and despair. Meanwhile, without access to antiretroviral drugs, about one-quarter of children born to women with HIV will also be infected. And these children and their parents and other adults--usually in the prime of their lives--will continue to sicken and die without the provision of care and support. HIV/AIDS seems to magnify all of the social problems of our time. Ignorance, intolerance, violence, and oppression worsen the situation for those already infected and help spread new infections.

And so, HIV affects all of us and as a global community we CAN make a difference. We know how to prevent HIV infection and, although we are still far from a cure, we have learned a lot about how to treat it. 

Reproductive health also affects each of us. Among women between the ages of 15 and 44 years in developing countries, the burden of poor reproductive health is far greater than that from tuberculosis, respiratory infections, motor vehicle injuries, homicide and violence, or from war. Poor reproductive health accounts for 36% of women’s total disease burden. Poor reproductive health is evident in the following statistics:

• 585,000 maternal deaths each year 
• 20 million cases of severe maternal morbidity
• 20 million unsafe abortions performed annually
• 166 million cases of curable STIs annually
• 450 thousand new cases of cervical cancer. 
• 85 to 110 million female genital mutilations 

Women suffer the greatest burden because of the risks of pregnancy, childbirth, and unsafe abortion because they are more vulnerable to reproductive tract infections and STIs, including HIV/AIDS. They also experience most domestic violence and sexual abuse. However, men also suffer from poor reproductive health, especially with STIs and HIV/AIDS, which account for 12% of their total burden of illness. The reproductive health of men and women is critical not only to their own health and happiness but also for the health and prosperity of the next generation.

Issues in Reproductive Health and Family Planning for HIV-Positive Clients

There are several reproductive health issues that are important to consider when caring for clients with HIV infection. Each of these will be introduced now, but we will discuss them in more detail in subsequent lessons.

Identification

In order to provide appropriate care for the woman or man with HIV, it is first important to know who is HIV-positive. In areas where HIV testing resources are scarce, healthcare providers may suggest HIV testing because of signs or symptoms suggestive of HIV disease or because of high-risk characteristics noted by doing a risk assessment. However, in areas where HIV is common, risk assessment is not very useful and all people who are sexually active should be considered “at risk”.

Pregnant women are a priority for counseling and voluntary testing in both high- and low-HIV prevalence areas because of greater availability of effective short-term antiretroviral therapies to reduce the risk of mother-to-child (MTCT) transmission. However, a diagnosis of HIV remains the cause of significant stigma and discrimination.

Prevention of Sexual Transmission

An important part of the comprehensive care of the individual with HIV infection is prevention of further transmission to others. Globally, sexual transmission (primarily heterosexual) is the major way HIV is transmitted. The magnitude of risk varies with different types of sexual activity and other factors that affect either the infectiousness of the infected person or the susceptibility of an uninfected individual. The major focus in prevention of transmission and acquisition of HIV has been on: the correct and consistent use of condoms, low-risk behavior, and prevention and treatment of STIs. 

Sexually active adolescents have special needs in terms of protection against HIV. Young women are starting to menstruate earlier and, in some countries, marrying later. Therefore, they are more likely to become sexually active outside of marriage. A recent study of 14 countries around the world found that in young people who had never been married, particularly men, sexual activity tends to be sporadic and often involves a number of different partners over time.(3) Since unmarried young women are less likely to be sexually active, young men may be more likely to initiate sexual intercourse with high-risk partners, such as prostitutes. Biologically, adolescent women are also more vulnerable to STIs, including HIV.

Family Planning

The decisions about if and when to become pregnant belongs to the individual woman, including those who are HIV-infected. However, a major goal should be to prevent unintended pregnancies with safe and effective methods of contraception. The types of contraception available to HIV-positive women are the same as those for women without HIV. These types of contraception include hormonal methods, the IUD, barrier methods, lactational amenorrhea, fertility awareness methods, and female and male voluntary surgical contraception. However, in addition to considerations of safety and effectiveness, a very important consideration is the effect of contraceptive methods on HIV and STI transmission or acquisition. Regardless of use of other contraceptive methods, the use of male or female condoms is recommended for men and women who are HIV-positive or at risk for HIV.

Reproductive Health Problems

There are several reproductive health problems that are common in the setting of HIV infection and these often occur when the woman with HIV has no other symptoms. In one study almost one-half of HIV-infected women developed a gynecologic problem over the course of follow-up.(4) And, another study of hospitalized AIDS patients found that 83% of women had coexisting gynecologic disease.(5) These disease include menstrual disorders, genital ulcer disease, abnormal vaginal discharge, pelvic inflammatory disease, and human papillomavirus infections and lower genital tract dysplasia and cancers. Several of these conditions are more frequent or more severe with declining immune function. Others may be associated indirectly with HIV because of common risk behaviors, weight loss or other factors. In particular, STIs and HIV are closely interrelated. The clinical findings of certain STIs are changed in the presence of HIV. Furthermore, STIs, both ulcerative and nonulcerative, increase the risk of HIV transmission 2-5 times.

Prevention of Mother-to-Child Transmission (MTCT)

Women with HIV want to have children for the same reasons other women want to have children. Many women first learn they are HIV-positive during pregnancy. Without intervention, approximately 30-45% of children born to women with HIV will be HIV-infected themselves from transmission during pregnancy, during labor and delivery or through breastfeeding. 

There are several maternal and obstetrical risk factors that have been identified as potentially increasing, or in some cases, decreasing the likelihood of MTCT. Factors relating to HIV infection itself that increase the risk of MTCT include: more advanced clinical disease, lower CD4 cell count, and perhaps most significantly, higher HIV-RNA levels, both in the blood and in the genital tract. Certain maternal behavioral or physiologic factors may also increase risk of transmission, including the presence of STIs or other coinfections. Most transmission appears to occur around the time of labor and delivery and obstetrical complications such as preterm delivery, prolonged rupture of membranes, or placental disruption may also increase risk of MTCT. However, there is new hope for preventing a significant proportion of MTCT with the use of different antiretroviral regimens, many beginning late in pregnancy or at the onset of labor. In certain situations, scheduled Cesarean section performed prior to the onset of labor or rupture of membranes can reduce the risk of MTCT. But, the risk transmission must be balanced against maternal risk from operative delivery. 

Breastfeeding is estimated to be responsible for over one-third of new pediatric HIV cases globally each year. Alternatives to breastfeeding should be offered and encouraged when they are available, affordable, sustainable and acceptable. However, even when breastfeeding is chosen or when there are no good alternatives, there is evidence that exclusive breastfeeding (without any supplemental foods or liquids) for a relatively limited period of time (approximately 6 months) can minimize MTCT through breastfeeding while preserving the benefits of breast milk for infant health and nutrition. 

Gender, Stigma and Violence

A constant theme in the care and support of individuals with HIV and those at risk for HIV is the issue of stigma and violence. This is particularly an issue for women who often have little or no control over their sexual lives and decisions about fertility, have fewer educational opportunities, may have poor nutrition, and generally have lower status socially and economically. The low status of women accelerates the HIV epidemic because women are often unable to negotiate condom use and have no control over their partner’s behavior. Women may become infected through repeated unprotected sexual exposures while trying to get pregnant because often having a large family is expected and not having children may lead to divorce or abandonment. 

Adolescent girls are especially vulnerable because they are often pressured into having sex at a young age. Adolescent girls also may be targets for rape because older men feel they are “safe” sexual partners because of their youth or due to the mistaken belief that having sex with a virgin can cleanse them of AIDS. Young girls may be at risk for HIV and other infections through genital cutting using nonsterile instruments. 

Men are also at risk of stigma and violence. Men who have sex with men are at increased risk of HIV and often experience stigma and violence. In some countries, HIV-positive men are often assumed to be gay and many have been attacked and even killed. Once a man or woman is determined to be HIV-positive they may be reluctant to disclose their status to their partner, family or friends for fear of rejection or abandonment. Reported violence among young women in Tanzania was 10 times higher among HIV-positive women than in HIV-negative women!(6) 

Stigma and violence can increase the risk of becoming HIV-infected. And, the incidence of stigma and violence is higher among individuals with HIV. Fear of stigma and violence can make HIV-infected individuals reluctant to seek care and leads to ongoing transmission. 

Infection Prevention

There is a lot of stigma and fear associated with HIV even among healthcare workers. It is important for healthcare workers to better understand what their risks are and what they are not. The highest risks for HIV transmission are associated with exposure to blood, semen, vaginal secretions, and sputum. Risk of transmission from a single needlestick from a person with HIV is approximately 0.04%. There are standard precautions that should be taken for infection prevention related to HIV (and other infections) in the healthcare setting:

• Handwashing
• Use of gloves, gowns and eye protection
• Careful handling and disposal of needles and other sharp instruments
• Appropriate disinfection of instruments 

These are all important to help protect healthcare workers from HIV and hepatitis B and C. These should be used with ALL patients, not just those known to be HIV-positive.

Summary

In summary, the burden of disease, disability and death from HIV/AIDS and from poor reproductive health and other reproductive and sexual issues is large and is greatest in the areas with the fewest resources. Reproductive issues of special importance in caring for individuals who are HIV-positive include:

• Identification of HIV
• Prevention of transmission of HIV to sexual partners
• Prevention of undesired pregnancy and when pregnancy occurs, prevention of mother-to-child transmission of HIV
• Identification and management of reproductive health problems that may be more common or more severe in women with HIV
• Stigma and violence related to gender, sexuality, and/or to HIV/AIDS
• Infection prevention for healthcare workers

So this is a preview of things to come! We hope you will learn from these lessons and we look forward to your thoughts, questions, and personal experiences.

Next Week's Lesson: 
Risk Assessment / Identification

References

1. UNAIDS. Report on the global HIV/AIDS epidemic, 2002.
2. World Health Organization. WHO’s work in reproductive health: the role of the Special Programme. Progress in Reproductive Health Research newsletter, 2002. www.who.int/reproductive-health/hrp/progress/42/news42_1.en.html
3. Singh S, et al. Gender differences in the timing of first intercourse: data from 14 countries. International Family Planning Perspectives, 2000; 26:21
4. Minkoff HL, et al. Prevalence and incidence of gynecologic disorders among women infected with human immunodeficiency virus. American Journal of Obstetrics and Gynecology, 1999; 180:824-36.
5. Frankel RE, et al. High prevalence of gynecologic disease among hospitalized women with human immunodeficiency virus infection. Clinical Infectious Diseases, 1997; 25:706-12.
6. Horizons Report, Spring 2001.