Antiretroviral therapy

Standard antiretroviral therapy (ART) consists of the use of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Huge reductions have been seen in rates of death and suffering when use is made of a potent antiretroviral regimen.

In 2009, an estimated 33.3 million people were living with HIV, of whom more than 30 million were living in low- and middle-income countries.

WHO and UNAIDS estimate that at least 14.6 million people were in need of antiretroviral therapy in 2009. As of the end of 2009, 5.25 million people had access to antiretroviral therapy in low- and middle-income countries.

WHO is providing countries with ongoing guidance, tools and support in delivering and scaling up antiretroviral therapy within a public health approach.

Latest updates

Antiretroviral Therapy for HIV Infection in Adults and Adolescents - recommendations for a Public Health Approach - 2010 revision

• More information

Report of a consultation: preparing for pre-exposure prophylaxis (PrEP) results: from research to implementation.

• More information

HIV/AIDS

The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function. As the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to infections. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS). It can take 10-15 years for an HIV-infected person to develop AIDS; antiretroviral drugs can slow down the process even further.

HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of contaminated blood, sharing of contaminated needles, and between a mother and her infant during pregnancy, childbirth and breastfeeding.

How is HIV passed on?a

How is HIV passed on?

HIV is not a very infectious virus. It cannot pass through unbroken skin, or through the air like cold germs. It cannot be passed on through ordinary social contact. People with HIV and AIDS live and work with uninfected people without putting them at any risk.

There are three main ways in which HIV can pass from someone who has HIV to an uninfected person:

• through having sexual intercourse (sex where the penis enters the vagina or anus), without using a condom or Femidom (the female condom)
• through sharing drug injecting equipment
• from a mother to her baby during pregnancy or birth, or through breastfeeding.

It is very uncommon for HIV to be passed on in any other way. However a small number of people have been infected from giving oral sex to a man with HIV (sucking his penis), and there have been a few cases of health care workers (doctors, nurses etc) being infected through accidents with needles while caring for patients with HIV.

In the past, people who were given blood transfusions, blood factor treatments (for haemophilia) or organ transplants sometimes became infected because the donor had HIV. All blood and organ donations in the UK are now screened to prevent this happening, though it is still a risk in some parts of the world.

Stopping the epidemic

Stopping the epidemic

We could slow down the world-wide HIV epidemic if everyone had the information they need about preventing infection, and had society's support to help them act on it.

Young men growing up gay need access to good information about how to avoid becoming infected with HIV.

In countries (like the UK) with forward-thinking programmes for injecting drug users, including needle exchange schemes and methadone schemes, rates of HIV among drug users are relatively low. In other countries, like Spain, France and the USA, HIV has spread rapidly because of public reluctance to protect the health of drug users.

Religious, cultural or economic restrictions can make it hard for people to use condoms and protect themselves and their partners. A woman who is economically dependant on a man may find it impossible to ask for safer sex. World-wide,women are most commonly infected by their husbands or permanent partners.

Denial by national leaders that some behaviours happen, such as sex between men or drug injecting, can make it particularly difficult for people to avoid the risks. Some governments do not accept that HIV is an issue for them at all. As the former Director of the WHO Global Programme on AIDS has said: "Denial at personal, social, national and international level has been a constant problem and remains today a grave threat to public health."

People often react with prejudice and denial to things they do not understand. These reactions to HIV and AIDS hinder HIV prevention programmes, and they make life more difficult for people living with HIV and AIDS. Every one of us can make a difference to the AIDS epidemic by fighting prejudice, challenging denial and increasing understanding.

Even though there are now more effective anti-HIV

Living with HIV

Even though there are now more effective anti-HIV treatments, living with the knowledge of a serious and potentially life-threatening infection is likely to be stressful and difficult. Someone with HIV may remain in good physical health for several years but misunderstanding and fear about HIV and AIDS is still widespread in society. People living with the virus may encounter hostility or rejection even from friends and family and some people have lost jobs and homes due to their employers' or landlords' attitudes, and children with HIV have been banned from schools.

Many people with HIV have seen friends and partners become ill before them, and may have seen friends die. Some communities have been more affected by HIV than others: for example, gay men, people from sub-Saharan African communities and injecting drug-users. In some parts of the world, and among African families in the UK, it is not unusual for whole families to die with AIDS.

Many people with HIV choose to tell no one about their diagnosis except for a few trusted friends, and this burden of secrecy can be very hard to bear. Living with the knowledge that you could pass a serious infection to a someone else can also be very hard. A number of support groups have been set up round the country to help counter the isolation which HIV can cause.

Many people with HIV make changes in their lives to help them cope with their diagnosis. Some choose to work at keeping fit and healthy with good food and exercise; others may read up about HIV and become their own experts in drug treatments or complementary therapies. Some people with HIV have said that focusing on living and enjoying life to the full has helped them to cope with living with HIV.

Treatments for HIV and AIDS

Treatments for HIV and AIDS

Increasingly, it is possible to prevent or treat opportunistic infections using new drugs. For example, PCP was a frequent cause of death in people with AIDS in the early years of the epidemic. Doctors are now able to prevent PCP with drugs, or to treat it quickly if it occurs. Death from PCP is now rare among people with HIV in the UK.

Research studies show that the most effective way to attack HIV is with a combination of anti-HIV drugs. Combination therapy is a huge advance in the treatment of HIV, and many people have done very well on it.

Combination therapy is not easy to take (the various drugs have to be taken at different times according to a strict timetable), and there are side effects. It does not work for everyone, and where it does work we do not know how long that will last. Sometimes the drugs stop working because people develop resistance to them.

Research is continuing all the time to make combination therapies more effective and easier to take.

Some people with HIV and AIDS use complementary treatments to help with their symptoms. Examples are acupuncture, aromatherapy and homeopathy.

There is no vaccine or cure available yet, but scientists' understanding of how the virus works continues to improve. However, drug treatments and vaccines are expensive to develop, and it is not likely that people in some countries will be able to benefit from new discoveries for the foreseeable future.

What happens when someone has HIV?

What happens when someone has HIV?

Becoming HIV positive

Most people who become infected with HIV do not notice that they have been infected. A few weeks after infection, the body's immune system reacts to the virus by producing antibodies. Some people with HIV have a short 'seroconversion' illness at the time these antibodies are created. The likely symptoms are the normal response to many other infections, and may include a sore throat, a fever or a rash.

Asymptomatic infection

The infected person may have no further outward signs or symptoms for many months or years. This is called asymptomatic infection.

Some people with asymptomatic infection have swollen lymph nodes, but this is not a sign of immune system damage. Nor are colds or flu: people with HIV do not get colds more often than other people. People who have HIV and feel completely well may have signs of immune damage detectable in laboratory tests on their blood.

Symptomatic infection

In time, immune damage may become more severe, though the increasing use of combination therapy may result in more people with HIV remaining well for longer. We do not know whether every person with HIV will eventually become ill.

Not all opportunistic infections are part of the AIDS definition, so a person with HIV may be quite ill but not have AIDS.

An AIDS diagnosis

AIDS itself does not have symptoms and there is no test for AIDS. The doctor will look for the specific illness causing the person's symptoms. If they are caused by one of the AIDS-defining illnesses, and if the patient has HIV, then he or she is said to have AIDS.

Examples of illnesses which will result in an AIDS diagnosis, if HIV is present:

• pneumocistis carinii pneumonia (PCP), a rare form of pneumonia common in people with HIV
• cytomegalovirus (CMV), a member of the herpes family which can cause blindness and serious gastrointestinal, brain and lung problems in people with HIV

Someone with AIDS is likely to enjoy periods of comparatively good health between bouts of serious illness. Some people have lived for several years with an AIDS diagnosis.

People taking combination therapy successfully will be less likely to develop AIDS-defining illnesses.

What is an HIV test?

What is an HIV test?

HIV is usually diagnosed by a blood test, known as an HIV antibody test or an HIV test. This test looks for antibodies formed by the immune system if HIV is present.

If HIV antibodies are found, the test is referred to as positive. The person is HIV antibody positive, often referred to as HIV-positive. If antibodies are not found, the test is negative and the person is HIV antibody negative or HIV-negative.

There is a gap, or 'window period', between infection and the formation of antibodies. This can last from a few weeks to three months. During this window period,the HIV antibody test will be negative even if HIV is present. That is why people who think they may have been infected need to wait for at least three months before they have a test. Some testing centres suggest a test after six months, to be absolutely sure.

HIV tests in the UK are highly accurate. A positive result is confirmed using a different technique. Negative tests are accurate so long as they are not done during the window period. Very occasionally the result may be unclear or 'equivocal'. When this happens a second test a few weeks later will give a clear result. See the booklet on the Terrence Higgin's website Testing Issues for further information about HIV tests.

Testing babies for HIV

Babies are born with their mothers' antibodies, which clear once the baby has developed its own immune system. Babies born to women with HIV have HIV antibodies in their blood from the mother for the first 18 months of life.An HIV antibody test on the baby's blood would show the mother's antibodies, and would not tell the doctor whether the baby had HIV. Some hospitals are now able to perform tests on much younger babies of HIV-positive women, to discover whether the baby itself is infected with HIV.

HIV and pregnancy

HIV and pregnancy

Mothers and babies

In the UK, the risk of HIV being transmitted from an HIV-infected woman to her baby before or during birth is about one in seven. In parts of the world where the standard of living and healthcare is not so high as here, the risk is greater.

HIV can also be passed to a baby during breastfeeding if the mother has HIV. In the UK, 423 babies born to women with HIV have had HIV themselves.

HIV and donated sperm

Just as a woman can be infected during sexual intercourse with a man who has HIV, she can also become infected through donated sperm if the donor has HIV.

Men who donate sperm to clinics are tested for HIV and their donations are guaranteed free from HIV.

HIV and bloodHG

HIV and blood

HIV and shared injection equipment

One in ten (3,106 out of 30,101**) infections in the UK were acquired through sharing drug injecting equipment with someone with HIV. But sharing injecting equipment is not less risky than having sex with someone who has HIV. In Scotland, and in Southern Europe and parts of the United States, shared drug injecting equipment is the most common route of infection.

People who inject drugs can avoid transmitting HIV, either to themselves or to others, if they use a new set of injecting equipment every time or sterilise equipment between users. However, there is evidence that unsafe drug injecting is on the increase in this country.

HIV and blood transfusions

In the UK, 168 men and women were infected with HIV through transfusions of blood which contained the virus.

All blood donations and organ donations in the UK have been tested for HIV since 1985. The test may not be accurate if a person was very recently infected, and so people at risk of HIV are asked not to give blood.

In 1997, 3 people in the UK were discovered to be HIV positive through receiving blood donated by someone who had themselves been very recently infected with HIV. These cases are the only ones to have occurred in many millions of donations since 1985.

In some countries, infection through blood transfusion is still a significant risk.

Blood factor treatments

Factor 8 is a product of donated blood used in the treatment of haemophilia. Before it was known that donated blood might contain HIV, 1,196 men and boys with haemophilia became infected in the UK. Haemophilia is rare in women, and only 11 women were infected in this way. All Factor 8 is now heat treated, which kills HIV.

HIV and sex

HIV and sex

HIV can be passed from one person to another during penetrative sexual intercourse, that is, sex where the penis enters the vagina or anus.

Using a condom with water-based lubricant, or a femidom, during vaginal or anal penetrative sex will prevent transmission of HIV and many other sexually transmitted diseases.

HIV and sexual intercourse between men

Seven out of every 10 men with HIV in the UK were infected through sexual intercourse with another man. In the UK, northern Europe and parts of the United States, the most serious impact of the virus has been felt by the gay community. A large number of gay and bisexual men in the UK are still being infected every year: 1,474 tested HIV positive in 1995 and 1,634 in 1996***

HIV and sexual intercourse between men and women

In the UK, fewer than 2 out of every 10 people with HIV were infected through sex with a member of the other sex who had HIV.

In 1995, 852 people were reported to have contracted HIV as a result of sexual intercourse with a person of the opposite sex who had HIV. In 1996 the number of people reported to have been infected in this way was 779***


In Asia and sub-Saharan Africa HIV is transmitted most frequently by sexual intercourse between men and women. In the UK, HIV has had a devastating effect on communities of people from parts of Africa where HIV has taken hold.

HIV and oral sex

There have been about 20 cases world-wide where someone has become infected by giving oral sex to a man with HIV (sucking his penis). Where this has happened, it was probably because infected semen was able to pass through a cut or abrasion in the other partner's mouth or throat.

There are no confirmed reports of someone becoming infected through giving oral sex to a woman with HIV (licking her labia or clitoris).

Someone whose genitals are sucked or licked by a person with HIV will not become infected, because saliva does not an contain sufficient HIV to infect another person.

See the booklet on the Terrence Higgins website Oral Sex: a briefing for workers for a detailed discussion of oral sex and HIV transmission.

HIV and other sexual activities

One sexual activity which may be risky if one partner has HIV is sharing a sex toy: inserting an object into the vagina or anus of more than one person without washing it carefully between users or putting a clean condom on it between users.

HIV cannot be passed from one person to another through other sexual activities, including deep kissing, mutual masturbation, or via fingers inserted into the vagina or anus.

How do people become infected with HIV?

How do people become infected with HIV?

In order for a person to become infected, a sufficient amount of HIV must enter their bloodstream. This sufficient amount is the amount of HIV found in some, but not all, of the body fluids of someone with HIV or AIDS.

In a person with HIV or AIDS, the body fluids which contain enough HIV to infect someone else are:

• blood
• sperm and seminal fluid
• vaginal fluids, including menstrual fluids
• breast milk

Other body fluids like saliva, sweat or urine do not contain enough virus to infect another person.

If HIV is present in body fluids, it still cannot enter another person's body easily. There are a limited number of routes:

• directly into the bloodstream; for example, via a puncture caused by injection equipment
• via an organ transplant or blood transfusion
• through the 'interior' skin (mucus membrane) of the rectum, vagina, cervix and urethra. The urethra is in front of the vagina in women and is the 'tube' in the penis in men
• very rarely, through the eyes, mouth or throat

HIV cannot pass through intact external skin. It cannot pass through the air like cold germs.

See the Trust's booklet Preventing HIV Infection for information on preventing HIV transmission.

How does HIV cause AIDS?

How does HIV cause AIDS?

HIV affects various parts of the body's immune system. The most important damage it causes is to certain white blood cells known as CD4 cells or T-helper cells. These cells are found in the lymph nodes as well as circulating round the body.

CD4 cells set other parts of the immune system in motion when organisms which cause disease are present in the body. These organisms include viruses, bacteria, protozoa and fungi. They can cause disease if not controlled by the immune system.

The CD4 cells of an HIV-infected person mount a defence against the invading HIV, and it may be held at bay for many years. But the virus is not completely destroyed, and it continues to attack the CD4 cells. Eventually the number of CD4 cells declines and the virus numbers rise.



When the CD4 cells start to decline, the person with HIV becomes vulnerable to other infections. The organisms which cause disease in people with HIV are common organisms, easily kept under control by the healthy immune system. They are able to cause illness only when the immune system is severely damaged, so the illnesses they cause are known as opportunistic infections.

Similarly, cells of the body go out of control all the time, and the immune system keeps them under control. If the immune system is damaged, these cells can cause opportunistic tumours.

Government centres for epidemiology* in the United States have compiled a list of serious illnesses and tumours which may result from immune system breakdown in a person with HIV. Once a person with HIV has experienced one or more of the conditions on this list, they are said to have AIDS.

HIV can also have direct effects upon the body. For example, the virus can attack cells in the brain and impair its working. One result of this is HIV encephalopathy (brain disease), and it is an AIDS-defining condition.

Recent research has shown that taking a combination of anti-HIV drugs (combination therapy) can slow down the effect of HIV on the immune system. When combination therapy is successful, it can improve and sustain the health of a person with HIV and will mean they are less likely to develop AIDS-defining conditions.

What are HIV and AIDS?

What are HIV and AIDS?

HIV is a virus which attacks the human immune system, the body's defence against disease. A person with HIV may feel completely well and have no symptoms.

In time, a person with HIV may develop particular rare illnesses or cancers because their immune system is weakened. When this happens, the person is said to have AIDS.

Caesarean section

Caesarean section

There is evidence that delivery by Caesarean section will reduce the chance of infection during birth. More evidence is needed before this potentially hazardous procedure can be routinely recommended to pregnant women with HIV.

Breast feeding

The breast milk of a woman with HIV contains enough virus to infect a baby during breast feeding. In regions with a poor water supply, using substitutes for breast milk can be a greater risk to babies' health than HIV, and women with HIV are advised to breast feed. In parts of the world where the water supply is safe, women with HIV are recommended not to breast feed.



Talking to health care workers

Many doctors and midwives will be helpful and supportive to a woman with HIV who wants a child. A few are less so. It can be very hard for a woman with HIV to tell her health care workers she is pregnant or wants to be, if she suspects they will try to change her mind. Staff with experience of working with women who have HIV are likely to be the best informed and most supportive.



Towards the future

In time the development of a vaccine may prevent new HIV infections throughout the world. Until that happens we all need to know how to protect ourselves and each other. HIV infection is preventable, but we need to understand how. Often we need support to help us act on our knowledge.

Honest, sex-positive sex education will help prepare young people for adulthood, but it is not always available in this country. Particularly important is a sex education which will help young people to feel confident and good about their sexuality (and this includes young gay men, lesbians and bisexuals), and which gives them information about sexual health which is relevant to them. Confidence and self esteem help everyone achieve a healthy sex life.

Sticking to safer sex is not always easy, and the same can be true for safer drug use. We are all human after all. Even in the UK, people are becoming newly infected all the time.

If you are finding that safer sex or safer drug use is a struggle, why not call one of the Helplines to talk it through. They are there to give support, or just to listen. Many HIV organisations, including the Terrence Higgins Trust, also have counsellors you can talk to face-to-face

HIV AND HEALTH CARE WORKERS

HIV AND HEALTH CARE WORKERS

Health care workers are sometimes said to be at particular risk of getting HIV, either from sprays or spillage of infected blood, or injuries from needles. In fact, the standard infection control measures ("universal precautions") designed to protect against hepatitis B in health care settings will also protect against HIV transmission. Hepatitis B and HIV have similar modes of transmission with one key difference: HIV is much less infectious than hepatitis B.

Though many thousands of patients with HIV have been cared for in hospitals and clinics around the world, only a handful of health care workers have become infected. Where this has happened it has generally been because the standard safety procedures were not followed. These procedures are:

• wear gloves when mopping up body fluids and giving injections
• wear goggles if blood may spurt during surgery
• point needles away from your body
• do not resheath needles after use
• do not leave needles lying around
• dispose of used needles carefully in sharps containers and incinerate them

It is sometimes suggested that health care workers with HIV might be a risk to their patients. Extensive follow up of patients cared for by workers with HIV has revealed only one case in the world of a worker whose patients may have been infected. This was an American dentist, and it remains unclear whether he did actually infect his patients and, if he did, how this happened.



Reducing the risk of transmission during and after pregnancy

A woman living with HIV who wishes to become pregnant may have particular anxieties about the health of her baby. The chance of the virus being transmitted to the baby is about one in seven. It can happen before or during birth or through breast feeding. In parts of the world with lower standards of general health, transmission from a woman with HIV to her baby is more likely.



Viral load and mother-to-baby transmission before and during birth

Viral load is the amount of HIV in the blood. If a woman with HIV has low viral load it is less likely that the virus will be passed to her baby than if she has high viral load. However, even if viral load is very low, there is still a chance that HIV will be transmitted.

Among people with HIV who have not had anti-HIV treatments, viral load is highest during the weeks immediately after infection and when they start to become ill. So a woman with HIV might reduce the risk to her baby by becoming pregnant while she is healthy rather than delaying until she has become ill.

Viral load can often be reduced by taking anti-HIV drugs. Research has shown that if the anti-HIV drug AZT is taken by the mother during the last six months of her pregnancy and while giving birth, and given to the baby for a few weeks after birth, the baby's chances of infection will be reduced by up to two thirds. No significant side effects of exposing babies to AZT before and after birth have yet been reported, but the long-term effects are not known. Taking the drug in this way may also affect the mother's own future treatment options.

HIV AND DONATED BLOOD AND ORGANS

HIV AND DONATED BLOOD AND ORGANS

Before it was known that AIDS is caused by a virus carried in the blood, a number of people became infected through transfusions of blood donated by people with HIV.

The UK blood supply is now one of the safest in the world. All donations are tested for HIV antibodies (the test which shows whether HIV is present). People from population groups which have been severely affected by HIV are asked not to give blood, because there is a gap (the window period) between infection and an accurate test result. A newly infected person could unwittingly donate during this time. Blood used for blood transfusions must be used whole and untreated, and it must be used quite quickly, so these measures ensure the supply remains as safe as possible.

You cannot get HIV from donating blood.

In some countries of the world, infection through blood transfusion is still a significant risk, due to lack of resources to ensure the safety of the blood supply. Travellers can telephone MASTA at the London School of Hygiene and Tropical Medicine (0891-224100) or the Foreign and Commonwealth Office Consular Department's Travel Office (0171-270 3000) for up-to-date information and advice.

People with haemophilia are treated with blood products derived from donated blood. Before the link between HIV and AIDS was understood, many people with haemophilia became infected because they were given blood products derived from infected blood. Blood products for use in haemophilia treatment can be heated, and this kills HIV. Treatment with blood products is now safe from HIV in the UK.

All organ donors are now tested for HIV.

GETTING USED TO CONDOMS

GETTING USED TO CONDOMS

Some people have said that stopping to put on a condom kills spontaneity and deadens sensation. It would be foolish to suggest that intercourse with a condom is exactly the same as intercourse without. But many people have made condoms an integral part of a satisfying sex life.

Getting out the condoms before any sexual activity has taken place can raise the sexual temperature: a hint of what is to follow. Rolling a condom down your partner's penis (or your partner rolling one down yours - whatever applies) can be a sexy experience for both of you.




RELATIONSHIPS

If you are in a relationship (or starting one), the prospect of always having safer sex may be daunting. Some people choose not to use condoms in this situation. However, this is only a reliable way of avoiding HIV infection if you know that neither of you has HIV, and you are confident that neither of you will have unsafe sex with anyone else.

Having an HIV test is the only way of being sure that this strategy will work. For more information, see the Terrence Higgins Trust's booklet Testing Issues



Safer Drug Use

Sharing any drug injecting equipment (works) can easily lead to HIV and other diseases carried in the blood (such as hepatitis B and C) being passed on. Works are not just the needle and syringe but include spoons, mixing dishes, filters, water and citric acid.

If you inject drugs, use a new needle and syringe each time and don't share any injecting equipment. New equipment can be bought from some chemists, or is available free from needle exchanges, most drug agencies and some chemists. Look out for this sign:

In most needle exchanges you do not have to literally exchange old needles for new ones. You should be able to get a supply of new, sterilised needles.

Get rid of your used works carefully. Needle exchange schemes provide sharps or 'cin' bins for safe disposal. If you do not have one, put the needle and syringe into a tin can, crush carefully to ensure they do not fall out, then place in a bin.

Cleaning works

It is best to go to a needle exchange and get a new set of works. But if sharing is impossible to avoid, works can be cleaned between users as a last resort. Cleaning works will kill HIV, but not hepatitis C. Hep C is more common among drug users than HIV and can have serious long-term effects.

This is what you should do to clean works:

draw fresh cold water through the needle into the syringe and flush x 3

draw household bleach through the needle into the syringe and flush x 3

draw fresh cold water through the needle into the syringe and flush x 3

The bleach should stay in the syringe for 30 seconds. Remember not to flush out into the clean water.

Do not use hot water: it will make the blood congeal so traces may be left behind. Boiling works may not remove all the blood for the same reason, and anyway disposable works usually buckle if boiled.

The Terrence Higgins Trust leaflet Reducing the Risks gives more information about keeping as healthy as you can if you are a drug user.



If you are concerned about your own or a friend or partner's drug use, you could contact the Terrence Higgins Trust for support and information about further help available.

OTHER SEXUAL ACTIVITIES

OTHER SEXUAL ACTIVITIES

Anal-oral contact

(rimming, licking a man or woman's anus). HIV is not transmitted in this way, though this is a route for transmission of other infections. If you have HIV it can be dangerous to lick your partner's anus as you could get an infection that could lead to serious illness. A dental dam (oral shield) or a piece of non-microwaveable clingfilm placed over the anus will prevent infections being passed during rimming.

Sharing sex toys

If a sex toy such as a vibrator or dildo is used to penetrate both partners, the virus could be passed on. A dildo should be washed between users, or a fresh condom put on it.




Cuts and injuries.

If sex results in cuts or broken skin, it is good basic hygiene to cover the wound with a waterproof plaster.

Other sexual activities like deep kissing, body rubbing, fingering and mutual masturbation will not transmit the virus.



SAFER SEX AND COMMUNICATION

Communication is important in all sex, but it is especially important if you want to have safer sex.

Try to be clear with your partner from the start that you want to have safer sex. This may mean that you need to talk about safer sex before you're in a situation together where sex could happen.

Don't risk being unprepared - the right moment for sex could arrive when neither of you has condoms with you. Don't rely on your partner to provide the condoms and lubricant. Remember also that you don't have to have intercourse to have good sex: you can explore ways of having fun together without intercourse.

Talking about sex sometimes feels awkward or embarrassing. It may seem easier to just let things take their course. But delaying the discussion until you are both sexually aroused could mean the discussion doesn't happen. Perhaps your partner was hoping you would raise the subject first.

Although talking about sex can be difficult, it can also be fun - some people find that discussing sex can be a great way of turning each other on.

SEXUAL INTERCOURSE WITH A CONDOM OR FEMIDOM

Condoms and Femidoms (the female condom) can make penetrative sexual intercourse - anal or vaginal - very much safer. Condoms and Femidoms will also protect from most other sexually transmitted infections.

The male condom

Condoms with the British Kitemark or the new European CEN mark are recommended for use in vaginal sexual intercourse. No condoms have been scientifically tested for anal sex, but extra strong condoms such as Durex Ultra Strong and Mates Super Strong are widely used.

Standard and extra strong condoms are available free from family planning clinics, genitourinary medicine clinics (known as GUM clinics or STD clinics) and some GPs. Extra strong condoms are sometimes available free from gay venues. Not all chemists stock extra strong condoms.

Most condoms are already lubricated, but extra lubricant should always be used for anal sex to help prevent damage to the rectum or the condom. Vaginal sex is safer and more pleasurable with extra lubricant, particularly when the vagina is dry. Put the lubricant on the condom when it is on the penis, or on the anus or the entrance to the vagina before penetration. To increase the penis's sensitivity, some people also like to put a dab of lubricant inside the tip of the condom before it is put on - don't use a lot, or the condom could come off. Water-based lubricants, such as KY jelly or Boots own brand, are safe to use with latex condoms (all recommended male condoms are made of latex). Oil-based lubricants, such as Vaseline or massage oils, will damage latex and make the condom unsafe.



Nonoxynol-9 is a chemical used on some ready-lubricated condoms and in spermicidal creams. As well as killing sperm it provides some protection against HIV and other STDs. But some men and women are allergic to it - it can cause abrasions (roughness) and this increases vulnerability to HIV. If you experience discomfort with a product containing nonoxynol-9, stop using it. Lubricants such as KY and Boots own have no spermicidal properties and will not cause irritation.

The female condom

Femidoms (female condoms) also carry the Kitemark. Like Kitemarked male condoms, they protect against HIV, other sexually transmitted diseases and pregnancy.They can be used with most lubricants because they are made of plastic, not latex. They sit inside the vagina instead of fitting onto the penis. If you are using lubricant with a Femidom, put it inside the Femidom or on the penis.

Although designed for use in the vagina, a Femidom can also be inserted into the anus for anal sex. It can be worn by a man as a baggy condom for vaginal or anal sex. Some people remove the Femidom's inner ring before using it for anal sex or as a baggy condom. If it is used for anal sex, lubricant should be put on the inside and outside of the Femidom. Femidoms have not been scientifically tested for use as a baggy male condom or for anal sex.

Condoms are sometimes criticised as being unreliable, based on their failure rate as a contraceptive. In fact, condom failure is usually due to incorrect use or not enough lubricant. It is important to follow the instructions carefully. Neither male nor female condoms should ever be reused.

HIV and sex

HIV and sex

If someone has HIV, it can be passed to another person through anal or vaginal sex. This can happen whether the person with HIV is doing the penetrating or being penetrated.

If either you or your partner has HIV (or could have HIV), the only way to protect each other when having sex is to have safer sex.



SAFER SEX

Safer sex principally means using condoms or Femidoms (the female condom) and lubricant if you have penetrative sex, or having sex where the penis does not penetrate the vagina or anus.

It is "safer" not safe sex, because there will always be a tiny risk (for example, condoms can break), but the risk can be made so small that it does not interfere with enjoyment of sex.



As well as preventing HIV transmission, safer sex protects against most other sexually transmitted infections (STDs). Some STDs can do serious long-term damage if they are not treated promptly.

Safer sex will also prevent pregnancy.

This section gives a general overview of safer sex. Other Terrence Higgins Trust publications provide information about safer sex for particular groups of people:
Safer sex for gay men
HIV and AIDS - information for women
Reducing the risks (for drug users)
HIV and AIDS - information for lesbians

DO I HAVE HIV?

DO I HAVE HIV?

Many people feel they have some idea of whether they have HIV or not. Perhaps you suspect that you could have, based on things you have done in the past. You can never really be sure unless you have an HIV test, and deciding to have a test can be difficult - there is a big difference between thinking you may have a serious medical condition and finding out that you definitely have. Some people choose to delay having an HIV test until the time feels right. Others decide that there are advantages to knowing, such as access to anti-HIV treatments, which make it worthwhile.

If you are thinking about having an HIV test, see the Terrence Higgins Trust's booklet Testing Issues for more information to help you decide.

It can sometimes be tempting to make guesses about sexual partners too: "this person could never have HIV" or "I know this person so well now, I just know they have not got HIV." But there is no easy way to tell if someone has HIV or not, and they may not know themselves. Many people with HIV are healthy and well after several years of living with the virus, so you cannot tell from how someone looks, or how well you know them, whether or not they have HIV.



IF YOU HAVE HIV

Whether you think you have HIV, or know that you do, safer sex and safer drug use will not only prevent you infecting other people. They will also help you stay healthy:

• you will avoid getting infected with other strains of the virus which may be resistant to treatments which could benefit you
• you will avoid getting other infections which could be difficult to treat if your immune system is damaged by HIV (although many of these are more infectious than HIV and may be avoided only with even 'safer' sex than what is described below).

For more information about sex and living with HIV, see the Terrence Higgins Trust's leaflet Sex Positive (for gay men) or Living with HIV & AIDS (available from NAM Publications, 0171-627 3200).



PREVENTING INFECTION The rest of this booklet gives detailed information about the ways in which you can avoid getting HIV from other people or giving it to them. These are:

• safer sex - using condoms or Femidoms if you have penetrative sex, or avoiding penetration
• safer drug use - making sure that you always use new drug injecting equipment if you inject drugs
• reducing the risk of transmission during and after pregnancy.

WHO HAS BEEN MOST AFFECTED BY HIV?

WHO HAS BEEN MOST AFFECTED BY HIV?

Although anyone may become infected with HIV, some UK communities have been affected more than others:

• HIV is most common amongst gay men in the UK. Up to one in five gay men in London and up to one in twenty outside London have HIV
  
  
• Men and women who inject drugs (and their sexual partners) have been affected because of HIV being passed through sharing drug injecting equipment. Of those who have tested for HIV, about one in forty have HIV. This figure may be nearer one in fifteen in London
  
  
• HIV has spread rapidly by sex between men and women in parts of Africa. Many of the men and women in the UK who were infected through sex with the opposite sex are people who have lived in or visited Africa.

People who have unsafe sex within these groups are at increased risk of meeting a partner who has HIV.

In addition, numbers of people (almost all men or boys) with haemophilia were infected with HIV through blood products used in haemophilia therapy. Sexual partners of some of the men infected in this way were also infected. Haemophilia treatments used in the UK are now safe from HIV.

Levels of HIV infection remain highest within these population groups. At the moment it is very uncommon in the UK amongst people who have had no sexual contact with them. However, HIV and safer sex is an issue for everyone, and increasingly so:

• there is a slow but real spread of HIV in the UK amongst women, and amongst men who have never had sex with men, including men and women with no links to the communities described above
  
  
• people in the UK have been infected by sexual partners who they never dreamt could have HIV
  
  
• HIV is more common in the general population of some parts of the world than it is in the UK. There are higher rates of infection in parts of the US, Africa and Asia, and in some European countries including Spain and Italy. So for both men and women, sex without a condom while travelling abroad could be a bigger risk than sex at home.

IS IT A RISK?

IS IT A RISK?


Remember that for someone to be infected with HIV, three things must all be present. They can be summed up as source, quantity and route:

• source: HIV can only by transmitted in certain body fluids of someone with HIV
• quantity: only blood, seminal fluid, vaginal fluids and breast milk of someone with HIV contain enough HIV to infect another person
• route: there has to be a route for the HIV into the blood stream in order for a person to become infected

If you are worried that you could have been at risk or you are not sure whether a particular activity is risky, you could talk it through with someone on a Helpline. There are phone numbers at the end of this booklet.

What are HIV and AIDS?

HIV stands for Human Immunodeficiency Virus. This virus attacks the human immune system, the body's defence against disease.

A person with HIV may feel completely well and have no symptoms. However over a long period of time the virus may damage the immune system. As a result the body may not be able to fight off certain rare illnesses and cancers. When this happens the person is said to have AIDS.

AIDS stands for Acquired Immune Deficiency Syndrome. The 'syndrome' is a collection of rare illnesses which people with HIV can get if their immune system is weakened by the virus.





How is HIV passed on?

HIV is not a very infectious virus. It cannot pass through unbroken skin, or through the air like cold germs. It cannot be passed on through ordinary social contact. People with HIV and AIDS live and work with uninfected people without putting them at any risk.

There are three main ways in which HIV can pass from someone who has HIV to an uninfected person:

• through having sexual intercourse (sex where the penis enters the vagina or anus), without using a condom or Femidom (the female condom)
• through sharing drug injecting equipment
• from a mother to her baby during pregnancy or birth, or through breastfeeding.

It is very uncommon for HIV to be passed on in any other way. However a small number of people have been infected from giving oral sex to a man with HIV (sucking his penis), and there have been a few cases of health care workers (doctors, nurses etc) being infected through accidents with needles while caring for patients with HIV.

In the past, people who were given blood transfusions, blood factor treatments (for haemophilia) or organ transplants sometimes became infected because the donor had HIV. All blood and organ donations in the UK are now screened to prevent this happening, though it is still a risk in some parts of the world.

We could slow down the world-wide HIV epidemic

We could slow down the world-wide HIV epidemic if everyone had the information they need about preventing infection, and had society's support to help them act on it.

Young men growing up gay need access to good information about how to avoid becoming infected with HIV.

In countries (like the UK) with forward-thinking programmes for injecting drug users, including needle exchange schemes and methadone schemes, rates of HIV among drug users are relatively low. In other countries, like Spain, France and the USA, HIV has spread rapidly because of public reluctance to protect the health of drug users.

Religious, cultural or economic restrictions can make it hard for people to use condoms and protect themselves and their partners. A woman who is economically dependant on a man may find it impossible to ask for safer sex. World-wide,women are most commonly infected by their husbands or permanent partners.

Denial by national leaders that some behaviours happen, such as sex between men or drug injecting, can make it particularly difficult for people to avoid the risks. Some governments do not accept that HIV is an issue for them at all. As the former Director of the WHO Global Programme on AIDS has said: "Denial at personal, social, national and international level has been a constant problem and remains today a grave threat to public health."

People often react with prejudice and denial to things they do not understand. These reactions to HIV and AIDS hinder HIV prevention programmes, and they make life more difficult for people living with HIV and AIDS. Every one of us can make a difference to the AIDS epidemic by fighting prejudice, challenging denial and increasing understanding.

HIV in the world

HIV in the world

The World Health Organisation (WHO) estimated that, by the end of 1996 approximately 8.4 million cases of AIDS had occurred world-wide amongst adults and children****

Some areas of the world are particularly badly affected: eleven million infections have occurred in sub-Saharan Africa. The epidemic is spreading fastest in South and South-East Asia, with the estimated number of infections doubling in two years (from 1.5 million in mid-1993 to 3 million in mid-1995). Throughout the world, the numbers of men and women infected are roughly equal.

HIV mainly affects young adults and people in early middle age. These are the people who raise the children, support the elderly and build the country's economy. The many lives lost in this age group has had a serious effect on the economy of some countries in sub-Saharan Africa.

The world-wide, cumulative total of HIV infections for men, women and children could reach 30 million by the year 2000, of which 9 out of every 10 are likely to be in the non-industrialised world. WHO estimates that 5-10 million children may have lost their mother or both parents to AIDS by this date.

What are HIV and AIDS?

What are HIV and AIDS?

HIV is a virus which attacks the human immune system, the body's defence against disease. A person with HIV may feel completely well and have no symptoms.

In time, a person with HIV may develop particular rare illnesses or cancers because their immune system is weakened. When this happens, the person is said to have AIDS.

How does HIV cause AIDS?

HIV affects various parts of the body's immune system. The most important damage it causes is to certain white blood cells known as CD4 cells or T-helper cells. These cells are found in the lymph nodes as well as circulating round the body.

CD4 cells set other parts of the immune system in motion when organisms which cause disease are present in the body. These organisms include viruses, bacteria, protozoa and fungi. They can cause disease if not controlled by the immune system.

The CD4 cells of an HIV-infected person mount a defence against the invading HIV, and it may be held at bay for many years. But the virus is not completely destroyed, and it continues to attack the CD4 cells. Eventually the number of CD4 cells declines and the virus numbers rise.

As the HIV and AIDS Programme Manager,

As the HIV and AIDS Programme Manager, the incumbent will be responsible for the overall HIV and AIDS strategy, policy and practice to Increase capacity of staff, civil society organizations, government and other stakeholders for improved HIV and AIDS programme delivery country-wide. This will include the leading the effective implementation of the planned objectives for HIV and AIDS in the strategy, the provision of technical guidance to ongoing programmes, carrying out fundraising efforts and proposal development activities to mobilize of new resources, guidance and advice to Senior Management and Extended Senior Management Teams on HIV and AIDS issues, and external representa¬tion of the country portfolio.

The national HIV and AIDS Programme Manager will line manage the HIV and AIDS Project/Partnership Managers and be accountable for the overall operational and technical programme management and implementation throughout the Child Rights Programming Cycle. This will include programme development and planning, baseline data col¬lection, monitoring and evaluation, budgetary monitoring, donor report¬ing and learning.

Children left behind

Children left behind

In wealthy countries, successful measures to prevent mother-to-child transmission mean that only a small number of children are infected with HIV. Paediatric HIV/AIDS is therefore largely a problem in poor countries only – this is a major factor explaining why diagnostics and treatments for children lag behind. As there is little financial incentive for pharmaceutical companies to develop products specifically to treat children, it has taken much longer for paediatric versions of antiretroviral drugs to be made available than adult formulations. Even when paediatric versions do exist they are considerably more expensive than the drugs designed for adults.

MSF’s experience with paediatric HIV

MSF started providing antiretroviral therapy to children in December 2000. Over the last five years, nearly 10,000 children under the age of 15 have started antiretroviral therapy in our programmes worldwide, of which 4,000 are children under five years of age. Our experience has shown that children respond very well to treatment and can improve quickly. MSF’s largest paediatric project in Bulawayo, Zimbabwe has been very successful in reducing the mortality rates amongst the 1,800 children on antiretroviral therapy there.

Children and HIV/AIDS

© Francesco Zizola / Noor

“Our results in treating children are very good, but it’s an uphill battle. With better diagnostic tools, treatments that kids will swallow and that their bodies will respond to, many more young children could lead relatively normal lives.” Dr. Rachel Thomas, MSF, Kibera, Kenya

Too many children with HIV/AIDS still waiting

There are an estimated 2.1 million children living with HIV/AIDS, 90% of whom are from sub-Saharan Africa. Only 10% receive any treatment for the disease.

The vast majority of these children become infected with HIV through transmission from the mother during pregnancy, childbirth or breastfeeding. It is therefore imperative to continue to work towards the prevention of this transmission, something that has almost been fully achieved in industrialised countries.

But recognising the importance of prevention programmes must not mean ignoring the treatment needs of the more than two million children currently living with HIV/AIDS. In Sub-Saharan Africa, without treatment, a third of the children with HIV will have died before their first birthday, and a half of them will die before their second birthday.

Management of children in families affected by HIV/AIDS: community issues.

Management of children in families affected by HIV/AIDS: community issues.

Mbaye I, Mbaye N; International Conference on AIDS.

Int Conf AIDS. 1998; 12: 710 (abstract no. 34119).

University Cheikh Anta Diop, Thiaroye, Senegal.

ISSUES: Management of children affected by HIV/AIDS is becoming one of the most crucial social problems in Subsaharan Africa. Within the framework of a prospective study on "the psycho-social situation of children in families affected by HIV/AIDS in SENEGAL", we aimed to know how to improve the community involvement. PROJECT: Since January 1996 we are following-up 16 families where at least one parent is HIV positive and had received proper counselling. Every 3 months, the study team visits each family and collects informations by observation and parent interviews about the intra-family relations, the economical impact of HIV/AIDS on the household and the health situation of the children; special attention was given to the community implication in the coping mechanisms of the family management of the children. RESULTS: Ours findings confirms that the community involvement is the best culturally acceptable and affordable way four our societies to cope with the increasing number infected or affected children. But they revealed also the decline of the traditionnalnetworks of solidarity and the unawareness of the needs of the children affected by HIV/AIDS. LESSONS LEARNED: It raises the issues of the "shared confidentiality" the necessity of training the community to improve its perception of HIV/AIDS and to identify the specific needs of children affected by HIV/AIDS, and the external support for the caregivers.

Living with HIV

Living with HIV

Even though there are now more effective anti-HIV treatments, living with the knowledge of a serious and potentially life-threatening infection is likely to be stressful and difficult. Someone with HIV may remain in good physical health for several years but misunderstanding and fear about HIV and AIDS is still widespread in society. People living with the virus may encounter hostility or rejection even from friends and family and some people have lost jobs and homes due to their employers' or landlords' attitudes, and children with HIV have been banned from schools.

Many people with HIV have seen friends and partners become ill before them, and may have seen friends die. Some communities have been more affected by HIV than others: for example, gay men, people from sub-Saharan African communities and injecting drug-users. In some parts of the world, and among African families in the UK, it is not unusual for whole families to die with AIDS.

Many people with HIV choose to tell no one about their diagnosis except for a few trusted friends, and this burden of secrecy can be very hard to bear. Living with the knowledge that you could pass a serious infection to a someone else can also be very hard. A number of support groups have been set up round the country to help counter the isolation which HIV can cause.

Many people with HIV make changes in their lives to help them cope with their diagnosis. Some choose to work at keeping fit and healthy with good food and exercise; others may read up about HIV and become their own experts in drug treatments or complementary therapies. Some people with HIV have said that focusing on living and enjoying life to the full has helped them to cope with living with HIV.

An AIDS diagnosis

An AIDS diagnosis

AIDS itself does not have symptoms and there is no test for AIDS. The doctor will look for the specific illness causing the person's symptoms. If they are caused by one of the AIDS-defining illnesses, and if the patient has HIV, then he or she is said to have AIDS.

Examples of illnesses which will result in an AIDS diagnosis, if HIV is present:

• pneumocistis carinii pneumonia (PCP), a rare form of pneumonia common in people with HIV
• cytomegalovirus (CMV), a member of the herpes family which can cause blindness and serious gastrointestinal, brain and lung problemGs in people with HIV

Someone with AIDS is likely to enjoy periods of comparatively good health between bouts of serious illness. Some people have lived for several years with an AIDS diagnosis.

People taking combination therapy successfully will be less likely to develop AIDS-defining illnesses.

Treatments for HIV and AIDS

Increasingly, it is possible to prevent or treat opportunistic infections using new drugs. For example, PCP was a frequent cause of death in people with AIDS in the early years of the epidemic. Doctors are now able to prevent PCP with drugs, or to treat it quickly if it occurs. Death from PCP is now rare among people with HIV in the UK.

Research studies show that the most effective way to attack HIV is with a combination of anti-HIV drugs. Combination therapy is a huge advance in the treatment of HIV, and many people have done very well on it.

Combination therapy is not easy to take (the various drugs have to be taken at different times according to a strict timetable), and there are side effects. It does not work for everyone, and where it does work we do not know how long that will last. Sometimes the drugs stop working because people develop resistance to them.

Research is continuing all the time to make combination therapies more effective and easier to take.

Some people with HIV and AIDS use complementary treatments to help with their symptoms. Examples are acupuncture, aromatherapy and homeopathy.

There is no vaccine or cure available yet, but scientists' understanding of how the virus works continues to improve. However, drug treatments and vaccines are expensive to develop, and it is not likely that people in some countries will be able to benefit from new discoveries for the foreseeable future.

What happens when someone has HIV?

What happens when someone has HIV?

Becoming HIV positive

Most people who become infected with HIV do not notice that they have been infected. A few weeks after infection, the body's immune system reacts to the virus by producing antibodies. Some people with HIV have a short 'seroconversion' illness at the time these antibodies are created. The likely symptoms are the normal response to many other infections, and may include a sore throat, a fever or a rash.

Asymptomatic infection

The infected person may have no further outward signs or symptoms for many months or years. This is called asymptomatic infection.

Some people with asymptomatic infection have swollen lymph nodes, but this is not a sign of immune system damage. Nor are colds or flu: people with HIV do not get colds more often than other people. People who have HIV and feel completely well may have signs of immune damage detectable in laboratory tests on their blood.

Symptomatic infection

In time, immune damage may become more severe, though the increasing use of combination therapy may result in more people with HIV remaining well for longer. We do not know whether every person with HIV will eventually become ill.

Not all opportunistic infections are part of the AIDS definition, so a person with HIV may be quite ill but not have AIDS.

HIV and pregnancy

HIV and pregnancy

Mothers and babies

In the UK, the risk of HIV being transmitted from an HIV-infected woman to her baby before or during birth is about one in seven. In parts of the world where the standard of living and healthcare is not so high as here, the risk is greater.

HIV can also be passed to a baby during breastfeeding if the mother has HIV. In the UK, 423 babies born to women with HIV have had HIV themselves.

HIV and donated sperm

Just as a woman can be infected during sexual intercourse with a man who has HIV, she can also become infected through donated sperm if the donor has HIV.

Men who donate sperm to clinics are tested for HIV and their donations are guaranteed free from HIV.

What is an HIV test?

HIV is usually diagnosed by a blood test, known as an HIV antibody test or an HIV test. This test looks for antibodies formed by the immune system if HIV is present.

If HIV antibodies are found, the test is referred to as positive. The person is HIV antibody positive, often referred to as HIV-positive. If antibodies are not found, the test is negative and the person is HIV antibody negative or HIV-negative.

There is a gap, or 'window period', between infection and the formation of antibodies. This can last from a few weeks to three months. During this window period,the HIV antibody test will be negative even if HIV is present. That is why people who think they may have been infected need to wait for at least three months before they have a test. Some testing centres suggest a test after six months, to be absolutely sure.

HIV tests in the UK are highly accurate. A positive result is confirmed using a different technique. Negative tests are accurate so long as they are not done during the window period. Very occasionally the result may be unclear or 'equivocal'. When this happens a second test a few weeks later will give a clear result. See the booklet on the Terrence Higgin's website Testing Issues for further information about HIV tests.

Testing babies for HIV

Babies are born with their mothers' antibodies, which clear once the baby has developed its own immune system. Babies born to women with HIV have HIV antibodies in their blood from the mother for the first 18 months of life.An HIV antibody test on the baby's blood would show the mother's antibodies, and would not tell the doctor whether the baby had HIV. Some hospitals are now able to perform tests on much younger babies of HIV-positive women, to discover whether the baby itself is infected with HIV.

HIV and blood

HIV and blood

HIV and shared injection equipment

One in ten (3,106 out of 30,101**) infections in the UK were acquired through sharing drug injecting equipment with someone with HIV. But sharing injecting equipment is not less risky than having sex with someone who has HIV. In Scotland, and in Southern Europe and parts of the United States, shared drug injecting equipment is the most common route of infection.

People who inject drugs can avoid transmitting HIV, either to themselves or to others, if they use a new set of injecting equipment every time or sterilise equipment between users. However, there is evidence that unsafe drug injecting is on the increase in this country.

HIV and blood transfusions

In the UK, 168 men and women were infected with HIV through transfusions of blood which contained the virus.

All blood donations and organ donations in the UK have been tested for HIV since 1985. The test may not be accurate if a person was very recently infected, and so people at risk of HIV are asked not to give blood.

In 1997, 3 people in the UK were discovered to be HIV positive through receiving blood donated by someone who had themselves been very recently infected with HIV. These cases are the only ones to have occurred in many millions of donations since 1985.

In some countries, infection through blood transfusion is still a significant risk.

Blood factor treatments

Factor 8 is a product of donated blood used in the treatment of haemophilia. Before it was known that donated blood might contain HIV, 1,196 men and boys with haemophilia became infected in the UK. Haemophilia is rare in women, and only 11 women were infected in this way. All Factor 8 is now heat treated, which kills HIV.

HIV and sex

HIV and sex

HIV can be passed from one person to another during penetrative sexual intercourse, that is, sex where the penis enters the vagina or anus.

Using a condom with water-based lubricant, or a femidom, during vaginal or anal penetrative sex will prevent transmission of HIV and many other sexually transmitted diseases.

HIV and sexual intercourse between men

Seven out of every 10 men with HIV in the UK were infected through sexual intercourse with another man. In the UK, northern Europe and parts of the United States, the most serious impact of the virus has been felt by the gay community. A large number of gay and bisexual men in the UK are still being infected every year: 1,474 tested HIV positive in 1995 and 1,634 in 1996***

HIV and sexual intercourse between men and women

In the UK, fewer than 2 out of every 10 people with HIV were infected through sex with a member of the other sex who had HIV.

In 1995, 852 people were reported to have contracted HIV as a result of sexual intercourse with a person of the opposite sex who had HIV. In 1996 the number of people reported to have been infected in this way was 779***


In Asia and sub-Saharan Africa HIV is transmitted most frequently by sexual intercourse between men and women. In the UK, HIV has had a devastating effect on communities of people from parts of Africa where HIV has taken hold.

HIV and oral sex

There have been about 20 cases world-wide where someone has become infected by giving oral sex to a man with HIV (sucking his penis). Where this has happened, it was probably because infected semen was able to pass through a cut or abrasion in the other partner's mouth or throat.

There are no confirmed reports of someone becoming infected through giving oral sex to a woman with HIV (licking her labia or clitoris).

Someone whose genitals are sucked or licked by a person with HIV will not become infected, because saliva does not an contain sufficient HIV to infect another person.

See the booklet on the Terrence Higgins website Oral Sex: a briefing for workers for a detailed discussion of oral sex and HIV transmission.

HIV and other sexual activities

One sexual activity which may be risky if one partner has HIV is sharing a sex toy: inserting an object into the vagina or anus of more than one person without washing it carefully between users or putting a clean condom on it between users.

HIV cannot be passed from one person to another through other sexual activities, including deep kissing, mutual masturbation, or via fingers inserted into the vagina or anus.

How do people become infected with HIV?

How do people become infected with HIV?

In order for a person to become infected, a sufficient amount of HIV must enter their bloodstream. This sufficient amount is the amount of HIV found in some, but not all, of the body fluids of someone with HIV or AIDS.

In a person with HIV or AIDS, the body fluids which contain enough HIV to infect someone else are:

• blood
• sperm and seminal fluid
• vaginal fluids, including menstrual fluids
• breast milk

Other body fluids like saliva, sweat or urine do not contain enough virus to infect another person.

If HIV is present in body fluids, it still cannot enter another person's body easily. There are a limited number of routes:

• directly into the bloodstream; for example, via a puncture caused by injection equipment
• via an organ transplant or blood transfusion
• through the 'interior' skin (mucus membrane) of the rectum, vagina, cervix and urethra. The urethra is in front of the vagina in women and is the 'tube' in the penis in men
• very rarely, through the eyes, mouth or throat

HIV cannot pass through intact external skin. It cannot pass through the air like cold germs.

See the Trust's booklet Preventing HIV Infection for information on preventing HIV transmission.

CHILDREN AND ADHERENCE

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CHILDREN AND ADHERENCE

Adherence (see fact sheet 405) is a major challenge for children and infants. Both the child and the parents may need extra help. Many children do not understand why they should put up with medication side effects.

Their parents are usually HIV-positive. They may have their own difficulties with adherence. Their children may take different medications, on a different schedule. Many ARVs taste bad or have a strange texture. A feeding tube directly into the stomach may be necessary if an infant refuses to swallow medications.

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THE BOTTOM LINE

Where ARVs and good medical care for pregnant women are available, new infections of children are rare.

Treatment of HIV-infected children is complicated. Not all ARVs are approved for use by children. The correct dosing is not always known. Children may have a difficult time tolerating medications and taking every dose as scheduled.

However, because children’s immune systems are still developing, they might have a better chance of fully recovering from damage caused by HIV.

Children with HIV should be treated by a pediatrician with experience in HIV.

TREATMENT FOR CHILDREN

TREATMENT FOR CHILDREN

HIV-infected children should be treated by a pediatrician who knows about HIV.

US Guidelines for ART in children were last updated in August 2010. They can be found on the Internet at http://www.aidsinfo.nih.gov/Guidelines/

Antiretroviral therapy (ART) works very well for children. The death rate of children with AIDS has dropped as much as for adults. However, manufacturers were not required to study their products in children until very recently in the US. Still, 17 ARVs are approved for use by children.

The best doses are not always known. Children’s doses are sometimes based on their weight. Another method is body surface area. This formula considers both height and weight. Sometimes, doses are recommended based on a child's development (Tanner stage.) As mentioned above, several factors affect drug levels in children. Dosing may have to be adjusted several times as a child develops.

The doses of some medications for infants and very young children can be individualized. They come in liquid or powder form. Others come in a granular form. Some pills can be crushed and added to food or liquids. Some clinics teach children how to swallow pills. Children who can swallow pills have more medication options.

Doctors sometimes try to cut adult tablets into smaller pieces for children. However, this can result in doses that are too low. Some tablets are difficult to cut. Also, the medication may be unevenly distributed in the tablet

It is difficult to know when to start treatment for children. Immediate treatment might prevent immune system damage. Delayed treatment may provide better quality of life for several years. However, HIV-related diseases show up much faster in untreated children than in adults. Without treatment, about 20% of children die or develop AIDS within one year.

HOW ARE CHILDREN DIFFERENT?

HOW ARE CHILDREN DIFFERENT?

Children’s immune systems are still developing. They have a different response to HIV infection. CD4 cell counts (see fact sheet 124) and viral load counts (see fact sheet 125) are higher than in adults. An infant’s viral load usually declines after birth until age 4 or 5. Then it stabilizes.

Children also respond differently to ARVs. They have larger increases in CD4 cell counts and more diverse CD4 cells. They seem to recover more of their immune response than adults.

Infants have more fat and water in their bodies. This affects the amount of medication available. Children have a very high rate of metabolism. This gradually slows as they mature.

The liver processes drugs and removes them from the body. It takes several years to mature. As it matures, drug levels in children can change a lot. Many drugs have special dosage instructions for children.

Bones develop quickly during the early years of life. ARVs can weaken bones in adults. This was also seen in children. See Fact Sheet 557 for more information on bone problems in HIV.

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RESEARCH ON CHILDREN

It is very difficult to recruit children into HIV clinical trials. In the US, many children with HIV have already been in more than one research study. With falling infection rates, there are very few new cases of pediatric HIV. The US has considered ending support for its pediatric trials network. Important research questions may be studied in adults.

A recent study found that children born to HIV-positive mothers have high rates of psychiatric disorders.

HOW SERIOUS IS HIV FOR CHILDREN?

HOW SERIOUS IS HIV FOR CHILDREN?

Where antiretroviral medications (ARVs) and good medical care for pregnant women are available, new infections of children are rare. There were about 2 million children around the world living with HIV in 2007.

Anyone age 13 or younger is counted as a child in US health statistics. In 1992, almost 1,000 children were infected in the US. By 2008, there were 182 new infections and 41 new diagnoses of AIDS. African-American newborns are much more likely to be infected than children of other races.

Most children with HIV were born to mothers with HIV. Others got a transfusion of infected blood. In the developed world, blood for transfusions is screened and most pregnant women are taking ARVs. See fact sheet 611 for more information on pregnancy and HIV.

Infected mothers can pass HIV to their newborns. This happens where mothers do not get good medical care while they are pregnant. It also happens where ARVs are not available, where new mothers feed their babies breast milk, or where blood for transfusions is not always screened.