PCP HIV AIDS Toolkit/HIV Transmission

Purpose
To provide an understanding of how HIV is transmitted.

Rationale
Information about how HIV can and cannot be transmitted is necessary to develop prevention education and to help reduce the stigma and discrimination that people living with HIV/AIDS experience.

Target Audience
Peace Corps participants (trainees and/or Volunteers)

Duration
2 hours 5 minutes to 2 hours 15 minutes

Objectives
By the end of the session participants will be able to
 * 1) Explain how HIV is transmitted.
 * 2) Identify populations at higher risk for HIV.
 * 3) Identify factors that increase the risk of HIV.
 * 4) Explain how to prevent transmission of HIV.
 * 5) Explain the general characteristics of an HIV epidemic.

Session Outline

 * 1) Introduction (5 minutes)
 * 2) HIV Transmission (30 minutes)
 * 3) Biological Risk Factors of HIV Transmission (15 minutes)
 * 4) Prevention (50-60 minutes)
 * 5) Characteristics of an HIV Epidemic (20 minutes)
 * 6) Wrap Up (5 minutes)

Facilitators/Technical Expertise
It may be helpful to have someone with medical expertise available to assist with the session. Facilitator must be knowledgeable about the biology of HIV/AIDS.

Materials and Equipment

 * Flip charts, markers, tape or tacks
 * Copy of the Life Skills Manual [ICE No. M0063]
 * Prepared flip chart with session outline
 * Handouts
 * A. Biological Risk Factors of HIV Transmission
 * B. World Health Organization: Statement on Kenyan and Ugandan trial findings regarding male circumcision and HIV
 * C. The Female Condom (pdf)
 * D. Instructions for Male Condom Use
 * E. Persuading Your Partner to Use a Condom
 * F. The ABC Approach
 * G. Universal Precautions
 * H. Measures of Disease Frequency
 * I. Mother-to-Child Transmission (MTCT)
 * J. Centers for Disease Control Factsheet: HIV and Its Transmission (pdf)

Preparation Checklist

 * Read the entire session and plan the session according to the time you have available.


 * Make copies of handouts.


 * Make an extra copy of Handout A: "Biological Risk Factors of HIV Infection." Cut it into the three sections to be used for group work in Part III, Step 2.


 * Research country policy on needle exchange and drug user services for Part IV, Step 3.

I. Introduction (5 minutes)
Step 1: Reveal flip chart with session outline

Step 2: Explain
 * 1) This session will focus on how HIV is and is not transmitted. There are many myths and fears relateding to HIV transmission. Developing an accurate understanding of HIV transmission is key to a Volunteer’s role as a prevention educator, and in helping to reduce the stigma and discrimination against people living with HIV/AIDS.
 * 2) A study on stigma done by the International Center for the Research of Women (ICRW) showed that even though people had learned a little about transmission, it was not enough to really understand it, and their “what if” scenarios created great fear that lead to stigma and discrimination. The study showed that people need more than hearing messages; they need to talk about what they heard and to have their “what ifs” answered. (We will learn more specifically about the ICRW study in the Behavior Change module.)

II. HIV Transmission (30 minutes)
Step1: Body fluids (5 minutes)

Trainer's note: Handout J: "HIV and its Transmission" can be handed out before this segment so that participants can follow along.
 * 1) Explain: In order to become infected with HIV, a person must be in direct contact with one of four main body fluids that transmit HIV. Ask what the four fluids are and write on flip chart paper under a heading: “Fluids that transmit HIV.”
 * 2) * Blood
 * 3) * Semen
 * 4) * Vaginal fluid
 * 5) * Breast milk
 * 6) State that HIV has been found in saliva and tears in very low quantities from some AIDS patients, but it is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV.

Step 2: Portal of entry (5 minutes)
 * 1) To become infected, these fluids need a portal of entry into the body. Ask for a definition of “portal of entry.”
 * 2) A portal of entry is a cut, sore, or opening in the skin or through the mucous membranes (HIV enters the body through the mucous membranes of the vagina, penis, rectum, and mouth).

Step 3: Mechanisms of transmitting HIV (10 minutes)
 * 1) Ask participants to form two groups, one by each flip chart paper hung on wall.
 * 2) Ask one group to define the most common mechanisms of transmitting HIV. Ask the other group to list mechanisms that do not transmit HIV. Give participants five minutes to make lists.
 * 3) Bring groups back together, share and discuss lists. Answers should include:
 * Most common ways of transmitting:
 * vaginal, anal, and oral sex
 * through exposure to non-sterile equipment and medical procedures (including needles and syringes)
 * through direct blood transfusions of untested blood
 * from mother to infant during pregnancy, delivery, or breast-feeding
 * Ways HIV is NOT transmitted:
 * through sweat, coughing, or sneezing
 * being near a person with HIV
 * sharing cups, eating utensils, or bathrooms
 * by hugging or kissing people with HIV when blood is not present
 * sharing toothbrushes (only if blood is not present on the brush)
 * by blood sucking insects (mosquitoes and bedbugs)

Step 4: High risk/low risk/no risk (10 minutes)
 * 1) Explore transmission further by thinking about other situations in which an individual can become infected with HIV.
 * 2) Call out different activities. If participants consider the activity:
 * 3) * no risk, participants should stay seated.
 * 4) * low risk, participants should stand.
 * 5) * high risk, participants should stand and stretch arms above their heads.
 * If there is no agreement about an activity, stop to talk about it.
 * 1) What is the risk of catching HIV from a person living with HIV/AIDS during each of the following activities? (Pause after each to allow them to stay seated, stand, or stand and stretch arms up. If there is disagreement, ask why.)
 * 2) * Hugging
 * 3) * Deep kissing
 * 4) * Having sex without a condom
 * 5) * Sleeping in the same room
 * 6) * Sharing cups, plates, or utensils
 * 7) * Using the same toilet
 * 8) * Cleaning up spilled blood
 * 9) * Eating food prepared by someone with HIV
 * 10) * Eating from the same plate as someone with HIV
 * 11) * Drinking from the same cup as someone with HIV
 * 12) * Birth to HIV-positive mother
 * 13) * HIV-positive mother breast-feeding her child
 * 14) * Being bitten by mosquitoes
 * 15) * Carrying someone who died of AIDS to the cemetery
 * 16) * Using unsterilized needles
 * 17) * Using someone else’s razor
 * 18) * Having sex with a condom
 * 19) * Receiving blood transfusion
 * 20) * Being spat on by someone with HIV
 * Trainer’s notes:
 * 1) * Hugging
 * No risk—no exchange of body fluids.
 * 1) * Deep kissing
 * Low risk (extremely low)—Deep or open-mouthed kissing is considered a very low-risk activity because HIV is present in saliva in only extremely minute quantities, insufficient to lead to HIV infection alone. Of the 65 million people infected with HIV/AIDS to date, there is only one documented case where HIV was transmitted by kissing, and both partners had serious gum disease. Investigators believe that the HIV was transmitted via blood present in their mouths, not by saliva.
 * 1) * Having sex without a condom
 * High risk—exchange of HIV containing body fluids.
 * 1) * Sleeping in the same room
 * No risk—no exchange of body fluids.
 * 1) * Sharing cups, plates, or utensils
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.
 * 1) * Using the same toilet
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.
 * 1) * Cleaning up spilled blood
 * Low risk— if universal precautions are not taken (see Handout G: “Universal Precautions”), there could be a risk of body fluid exchange if the person has open cuts or sores on his hands.
 * 1) * Eating food prepared by someone with HIV
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.
 * 1) * Eating from the same plate as someone with HIV
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.
 * 1) * Drinking from the same cup as someone with HIV
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.
 * 1) * Birth to HIV-positive mother
 * Depends. Low risk to high risk (see Part IV, Step 5)—depends on whether the mother was given ARV drugs during pregnancy and/or delivery.
 * 1) * HIV-positive mother breast-feeding her child
 * Depends. Low risk to high risk (see Pat IV, Step 5)—depends on whether the mother is breast-feeding the child exclusively (low risk), or giving the child other food (higher risk).
 * 1) * Being bitten by mosquitoes
 * No risk. Insects inject their own saliva into a person, not the blood of another person. Also, HIV cannot infect a mosquito’s cells, and cannot survive in a mosquito’s body.
 * 1) * Carrying someone who died of AIDS to the cemetery
 * No risk— no exchange of body fluids.
 * 1) * Using unsterilized needles
 * High risk— exchange of HIV-containing body fluids.
 * 1) * Using someone else’s razor
 * Low risk—if there are cuts on the person’s head, and the razor has blood on it (even if you can’t see it), then there could be an exchange of HIV-containing body fluids.
 * 1) * Having sex with a condom
 * Low risk—while condom use does not fully protect a person from HIV infection, it can drastically reduce the risk of infection if used properly.
 * 1) * Receiving blood transfusion
 * Depends. Low to high risk—if the blood has been properly screened and tested (very low risk), or if the blood has not been screened or tested (high risk).
 * 1) * Being spat on by someone with HIV
 * No risk—no exchange of the type of body fluids that contain enough HIV to be infectious.

III. Biological Risk Factors of HIV Transmission (15 minutes)
Step 1: Explain that there are many factors (such as social, cultural, and behavioral) that can put an individual at a higher risk for contracting HIV. In this session, we will focus on the biological risk factors related to transmission.

In your group you will read and discuss the information provided on a particular biological risk factor. After discussion, each group will have one person present a summary of your information for the entire group. Groups will have 10 minutes to work.

Step 2: Ask participants to divide themselves into three groups. Provide each group the appropriate information from Handout A: “Biological Risk Factors of HIV Transmission”:
 * Presence of sexual transmitted infections
 * Type of sexual intercourse
 * Male circumcision

Step 3: Each group spends time learning and discussing key points from its information sheet.

Step 4: Ask one person from each group to provide key points about the topic to the large group. Ask for any questions after each presentation; clarify information if necessary. Step 5: Distribute Handouts A and B to everyone for future reference.

IV. Prevention (50-60 minutes)
Step 1: Introduction (5 minutes)

Explain: HIV/AIDS prevention is a topic that we will talk about from many perspectives. In this session, we will focus on the “biology” of HIV prevention.

Step 2: Prevention in medical settings/universal precautions (5 minutes)
 * 1) Ask participants: “Who knows what the term ‘universal precautions’ means?”
 * 2) “Universal precautions” is a term usually used by health-care professionals working in hospital and clinic settings. It means that people should always protect  themselves “universally” from diseases that are transmitted via blood and body fluids (such as HIV and hepatitis). You should not decide to use barriers for protection from infectious bodily fluids based on how sick a person may look or how at risk they appear to be.
 * 3) Volunteers should never be in situations where they are exposed to blood and bodily fluids. However, information on universal precautions can be shared with health-care professionals to ensure they have the knowledge to protect themselves.
 * 4) Refer participants to Handout G: “Universal Precautions.”

Step 3: Prevention for injection drug users (5 minutes)
 * 1) Sharing contaminated needles and drug equipment is a highly efficient means of HIV transmission, and is the primary driver of HIV epidemics in some countries and regions of the world. Prevention programs for injection drug users (IDUs)  focus on reducing individual risk, and reducing the risk environment.
 * 2) Some examples of prevention programs to reduce individual risk:
 * 3) * HIV-prevention education programs targeted to IDUs
 * 4) * Disinfection and needle-exchange programs
 * 5) * Risk-reduction counseling
 * 6) Some examples of prevention programs to reduce the risk environment:
 * 7) * Creating safe environments for IDUs to adopt healthier behavior
 * 8) * Mobilizing IDUs and their communities to take action and reduce risks
 * 9) * Ensuring members of the community have the necessary knowledge, skills, and capacity to respond to the IDU population.

Step 4: Prevention of sexual transmission of HIV: abstinence, faithfulness, and correct and consistent use of condoms (25 minutes, longer if there are demonstrations included)

Trainer’s note: Handouts C, D, E, and F can be distributed as this segment begins so that participants can follow along or add notes, or they can be distributed after the discussion below.


 * 1) Explain: Because sexual transmission remains the primary mode of HIV infection, sexual prevention should be a major component of any HIV/AIDS intervention strategy.
 * 2) Ask participants to name the three ways in which sexual transmission of HIV can be prevented or reduced (the ABCs: practicing abstinence, being faithful, and correct and consistent condom use). Write them on a flip chart entitled “Preventing Sexual Transmission.” Make the following points in your discussion:
 * 3) Abstinence
 * 4) * Abstaining from all sexual activities that can transmit HIV is the only certain way to protect from sexual exposure to HIV and other STIs.
 * 5) * Note that in the Life Skills Manual (in the newer version see page 174; in the older, three-ring binder version see Part V, pg. 13) there is a session on delaying sex.
 * 6) Being faithful (i.e., practicing monogamy)
 * 7) * Being faithful with a mutually faithful and uninfected partner reduces (but does not eliminate) the risk of sexual transmission of HIV.
 * 8) * An individual, even if faithful themselves, can still be at risk of becoming infected if his or her spouse or regular partner is not faithful.
 * 9) * The fewer lifetime sexual partners a person, the lower the risk of contracting or spreading HIV or another STI.
 * 10) Correct and consistent condom use
 * 11) * Reduces, but does not eliminate, the risk of HIV infection.
 * 12) * Condoms protect by forming a barrier to prevent contact with semen, vaginal fluids, and open sores.
 * 13) * To achieve the protective effect of condoms, people must use them correctly and consistently, at every sexual encounter. Failure to do so diminishes the protective effect and increases the risk of acquiring an STI because transmission can occur with even a single sexual encounter.
 * 14) Distribute Handout G: “The ABC Approach” and ask participants to read it.
 * 15) Check to see if they have questions. Remind them about or show them a copy of the Life Skills Manual. They will be introduced to the manual in another session; they should all have a copy.
 * Optional demonstration: If not yet covered, demonstrate the appropriate use of the male condom and, if available in the country, the female condom.
 * Male condoms: (Handout D: “Instructions for Male Condom Use”)
 * The male condom covers the penis to create a barrier against STIs, HIV, and sperm.
 * Check the expiration date before use.
 * Keep condoms in cool areas—do not store condoms in sunlight, glove compartments, or wallets for long periods of time.
 * Check that the condom has not been left too long in the sun by feeling for an air pocket in the wrapper.
 * Walk participants through the appropriate steps of condom use
 * Female condoms: (Handout C: “The Female Condom”)
 * The female condom lines the vagina to create a barrier against STIs, HIV, and sperm.
 * The condom is a pre-lubricated sheath with flexible rings at either end. The inner ring is used for insertion and it holds the condom in place. The outer ring stays on the outside of the vagina.
 * Female condoms are made of polyurethane (not latex), therefore they are not susceptible to damage from heat or humidity.
 * 1) Explain that we will talk about sexual prevention of HIV transmission in more detail in other sessions (Behavior Change, Capacity Building).

Step 5: Prevention of Mother-to-Child Transmission (PMTCT) (10 minutes)

Trainer’s note: Handout I: “Mother-to-Child-Transmission (MTCT)” can be handed out as this segment begins so that participants can follow along or add notes, or it can be handed out after the discussion below.


 * 1) Explain: Mother-to-child HIV transmission (MTCT) is responsible for the greater majority of the estimated 700,000 new annual HIV infections in children worldwide. Without intervention, approximately one-third of infants born to HIV-positive mothers will become infected with HIV.
 * 2) There are three ways that mothers can transmit HIV to their children. Ask participants if they can name the three ways and write them on a flip chart entitled “Modes of MTCT”:
 * 3) During pregnancy
 * 4) During labor and delivery
 * 5) Through breast-feeding
 * 6) Explain: While it is impossible to completely prevent MTCT, the risk can be significantly reduced.
 * 7) Refer back to your flip chart entitled “Modes of MTCT” ask participants how the risk of MTCT can be reduced during each of these steps. Key points:
 * 8) 	During pregnancy
 * 9) * HIV can cross over from the mother to the baby’s bloodstream.
 * 10) * The risk can be reduced by the mother taking ARV drugs during pregnancy.
 * 11) During labor and delivery
 * 12) * HIV infection can occur when blood or other infected maternal fluids present during delivery pass into the baby’s body.
 * 13) * The risk can be reduced through delivery by cesarean section, and through administering ARV drugs during labor and delivery.
 * 14) Through breast-feeding:
 * 15) * If it is economically feasible, it is best for an HIV-positive mother not to breast-feed her baby.
 * 16) * However, in resource-poor settings where access to clean water and adequate replacement food is limited, the increased risk of disease, malnutrition, and death from not breast-feeding must be weighed against the risk of HIV transmission.
 * 17) * In these cases, it is recommended that an HIV-positive mother breast-feed exclusively (infant is given breast milk only, with no other food or liquids) for the first few months of life, and wean the baby as soon as possible. Exclusive breast-feeding may reduce the risk of HIV transmission because unclean food/water can cause gastrointestinal illness in the infant, which creates an environment where HIV infection is more likely.

V. Characteristics of an HIV Epidemic (20 minutes)
Step 1: Definitions of incidence and prevalence

Distribute Handout H: “Measures of Disease Frequency” and explain the difference between incidence and prevalence.
 * 1) In the context of HIV/AIDS:
 * 2) * Incidence: the rate at which new cases of HIV are occurring in a population during a given time (usually a year).
 * 3) * Prevalence: the percentage of the population that is infected with HIV; includes both new cases and existing cases.
 * 4) * For example, in a population of 1,000 people:
 * 5) *# If 100 people are infected with HIV, the prevalence will be 10 percent.
 * 6) *# If 30 of the 100 cases are new infections (in a given time period), the incidence will be 3 percent.
 * 7)  What incidence and prevalence tell us
 * 8) * Incidence tells us more about how a disease is spreading in a population. Changes in HIV incidence can be an indicator of whether prevention efforts are successfully reducing the number of new infections.
 * 9) * In a population, the availability of life-extending treatments like ARV therapy can lead to an increase in HIV prevalence. This is because fewer people are dying, which contributes to overall percentage of the HIV-positive population.


 * (Trainer’s note: referring to Handout H, explain that this scenario is analogous to less water leaving the basin.)

Step 2: Different countries and areas of the world have different types of HIV epidemics.
 * 1) Explain: There are many types of HIV epidemics around the world. Behavioral, cultural, and biological risk factors all contribute to the type of epidemic a country will experience. We are going to discuss the three general types of HIV epidemics, and some characteristics of each. (On a flip chart, write the three types of HIV epidemics—low level, concentrated, and general— and discuss the following points.)
 * 2) Low-level epidemic
 * 3) * HIV prevalence is less than one percent in the general population and in all sub-populations practicing high risk behavior.
 * 4) * HIV infection may have existed for many years, but it has never spread to significant levels in any groups with high risk behavior.
 * 5) * Infection largely occurs among persons with higher risk behavior, such as commercial sex workers (CSWs), injection drug users (IDUs), and men who have sex with men (MSM).
 * 6) Concentrated epidemic
 * 7) * HIV prevalence is less than one percent in the general population, but more than five percent in any sub-population practicing high risk behavior.
 * 8) * HIV has spread in one or more groups with high risk behavior (CSWs, IDUs, MSMs, etc.) but has not become well established in the general population.
 * 9) * The future of the epidemic is determined by the frequency and nature of links between the highly infected subpopulations and the general public.
 * 10) * Note: Some of the most heavily populated countries in the world currently report a low prevalence in the population. However, an overall low prevalence can mask significant sub-epidemics in certain regions of the country or groups with high risk behavior, for example.
 * 11) Generalized epidemic
 * 12) * HIV prevalence is more than one percent in the general population.
 * 13) * HIV is firmly established in the general population.
 * 14) * Although some high-risk groups may continue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain the epidemic.

VI. Wrap Up (5 minutes)
Step 1: Ask a few people to share their feelings at this point about HIV/AIDS.

Step 2: Remind participants about the important role of Volunteers in educating others about HIV transmission and prevention. The major source of stigma and discrimination comes from incorrect beliefs or incomplete information about transmission. If these can be reduced, the number of people who will be tested and treated will increase.

Step 3: Be sure to end on a note of hope.
 * You can protect yourself if you are aware and careful.
 * Learn the percentage of your population that is not infected. Remember that prevention is the only vaccine against HIV!

Resources

 * HIV/AIDS in Eastern Europe and the Commonwealth of Independent States: Reversing the Epidemic: Facts and Policy Options, UNDP, Bratislava, 2004.
 * Life Skills Manual, Peace Corps: Washington, DC, 2001. Part III, “Facing Facts about HIV/AIDS and STDs.” [ICE No. M0063]
 * National Institute for Allergy and Infectious Diseases. “Questions and Answers NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda,” December 13, 2006. http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm (accessed March 26, 2007).
 * PEPFAR. “Ambassador Mark Dybul's Statement on Findings of Adult Medical Male Circumcision Trials,” December 13, 2006. http://www.pepfar.gov/press/77790.htm (accessed March 26, 2007).
 * PEPFAR. “HIV Prevention among Drug Users Guidance #1: Injection Heroin Use,” March 2006. Available for download at: http://www.state.gov/documents/organization/64140.pdf, (accessed March 26, 2007).
 * PEPFAR. ABC Guidance #1 For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach To Preventing Sexually Transmitted HIV Infections Within The President’s Emergency Plan for AIDS Relief, Final. Available for download at: http://www.state.gov/documents/organization/57241.pdf, (accessed March 26, 2007).
 * PEPFAR. Guidance for United States Government In-Country Staff and Implementing Partners for a Preventive Care Package for Children Aged 0-14 Years Old Born to HIV-Infected Mothers - #1, April 2006. Available for download at: http://www.pepfar.gov/documents/organization/77005.pdf (accessed March 26, 2007).
 * PEPFAR. Report on Blood Safety and HIV/AIDS, June 2006. Available for download at: http://www.pepfar.gov/progress/76858.htm (accessed March 26, 2007).
 * PEPFAR. “Issue Brief: Prevention of Mother to Child Transmission,” January 2007. http://www.pepfar.gov/pepfar/press/79674.htm (accessed March 26, 2007).
 * The Female Condom, The Female Health Company, www.femalehealth.com (accessed March 26, 2007).
 * World Health Organization. “HIV and Infant Feeding Resources.” http://www.who.int/child-adolescent-health/NUTRITION/HIV_infant.htm (accessed March 26, 2007).
 * UNAIDS. www.unaids.org, (accessed March 26, 2007).