Tuesday, 21 September 2010

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Prevention in high-risk groups

It is possible to prevent or lessen the risk of HIV infection even in high risk groups. Mariette Correa describes the practices that can reduce one’s risk of HIV infection

Prevention of HIV infection depends on a number of factors – knowledge of how the virus spreads, power equations between sexual partners, the actions of health care professionals and institutions, and so on. While there are practices that can reduce the risk of HIV infection, some of these may not be within an individual’s control.

Preventing heterosexual transmission

To avoid getting HIV infection from sex workers and other non-regular partners, one can follow the ABC approach - Abstain or Be faithful to one partner, if not, use a Condom. Further, treating any sexually transmitted diseases reduces the risk of contracting HIV through unprotected sex. To reduce the risk of HIV transmission through heterosexual sex, it is best to avoid penetrative sex with people known to be HIV-positive or who have a high risk of being HIV-positive. If this is not possible, use condoms when having penetrative sex with partners of unknown HIV status, particularly in casual relationships.

Negotiating for safe sex is an important way to protect oneself from HIV. This is true for heterosexual as well as homosexual sex. While there is a lot of emphasis on training sex workers to negotiate for safe sex with their clients, negotiating within marriage or in short or long term relationships is often difficult. In cases where it may be difficult to negotiate for safe sex, and you have doubts about your partner’s HIV status, you should consider seeking help from a counsellor. This might involve reconsidering continuation of the relationship.

Many serodiscordant couples (where one partner has HIV and not the other) have fathered and birthed HIV-negative children. Serodiscordant couples should have unprotected sex only when they plan to conceive and/or take antiretroviral (ARV) treatment at the time of conception. This will further reduce the risk of transmission through sex. In the future, other options may be available to prevent HIV transmission between long-term partners, such as microbicides, antiretroviral treatment to lower viral load, and prophylactic antiretroviral treatment in the HIV-negative partner. It is very probable that some options will improve with time, enabling serodiscordant couples to live with HIV as a chronic, manageable disease but no longer a threat for transmission to spouses or children.

Preventing infection among MSMs

Strategies to prevent HIV infection for men having sex with other men (MSM) include knowing a partner’s HIV status (so that one can decide what precautions to take); being mutually faithful; using a condom, especially for anal sex; and avoiding penetrative sex. Receptive anal intercourse carries by far the greatest risk of acquiring HIV, but significant risk also exists with insertive anal sex.

Preventing mother-to-child HIV transmission

Most mother-to-child HIV transmission can be prevented. In 2001, the National Aids Control Organisation (NACO) and state health departments began testing pregnant women and offering medical interventions to protect children from HIV infection. To date, the government’s Programme for the Prevention of Parent to Child Transmission (PPTCT), which is available in many public hospitals, tests pregnant women to find those who are HIV-positive, counsels them, and provides antiretroviral drugs for HIV-positive mothers and infants to prevent HIV transmission. These drugs reduce HIV transmission to 10% (down from 33% otherwise). This rate can be further lowered to less than 2% with better combinations of antiretroviral drugs, which are available through the private sector, along with caesarean delivery and avoiding breastfeeding.

Since HIV can be transmitted through breastfeeding, one option is to avoid it and use bottled milk. However, those who do not have access to clean water, or who are unable to ensure sterility of the bottles, spoons, cups etc that are used to feed babies, may need to weigh the relative risks to their child’s health from unclean water and/or inadequate feeds, and breastfeeding. Other infant feeding options that may be available to babies of HIV-positive mothers include wet-nursing by known HIV-negative mothers, expressing and heat-treating breast milk, and breast-milk banks.

Technology and public programmes to prevent mother-to-child transmission have been changing rapidly. The best and latest advice to prevent mother-to-child transmission would be available from public hospitals, and State AIDS Control Societies (SACS). Services to prevent mother-to-child transmission are also available at some private health facilities, but care should be taken when accessing the private sector as there are many private doctors who give mixed messages and irrational treatment.

Pregnant women who test positive for HIV should also ask their doctor whether the drugs that they would be given to prevent mother-to-child transmission would affect their own treatment options when they need medication for AIDS.

Preventing HIV from injecting drug use

For those who cannot or will not stop injecting drugs, there are various ways to prevent infection with HIV and other blood-borne viruses. You could avoid sharing needles, syringes, water, or drug preparation equipment, and only use syringes obtained from a reliable source. If new or sterile syringes and other drug preparation and injection equipment are not available, then previously used equipment should be boiled in water or disinfected with bleach before reuse. Injection drug users and their sex partners also should take precautions, such as using condoms consistently and correctly to reduce risks of sexual transmission of HIV.

Other harm reduction methods are to switch to oral substitutes. Buprenorphine and methadone are commonly used opiod substitutes (an opiod is any compound resembling cocaine and morphine in its addictive properties and physiological effects) given under medical supervision to injecting drug users. The former is being increasingly used among NGOs working with injecting drug users (IDUs) in different parts of the country. Opioid substitution therapy is also a part of the next phase of the National AIDS Control Programme (NACP III). For those who are willing to give up drugs altogether, detoxification, rehabilitation and other therapies are available in many parts of the country.

Preventing HIV from other blood exposures

Unsterile practices are common in India, and could result in HIV infection. Blood for transfusions should be taken only from registered blood banks as these are now all tested to ensure that they are free from HIV. Ideally, to the extent possible, avoid skin piercing procedures like tattooing, piercing, and unnecessary injections and infusions. When you have to be exposed to skin piercing, use new disposable instruments. For instruments that have to be reused, like dental equipment, be sure they have been sterilised. Express your concerns to your health care providers and ask them to change their practices where necessary. If you are not sure about the sterility of equipment and cannot negotiate for safe care, consider changing your provider.

Health care providers protect themselves from HIV by assuming that all patients are potentially infectious. They should treat all patients in the same way that they would when treating a person known to be infected with the virus. The fact that HIV survives for a long time outside the human body is a risk faced by both health care workers and patients.

Because of the risks that health care providers face in administering care, the government has a programme where health providers are given medication after a possible risky exposure to HIV (post-exposure prophylaxis) to prevent them from getting infected.

(Mariette Correa is an independent consultant who has been involved in HIV/AIDS programming for NGOs in Goa and South Asia)

Infochange News & Features, February 2008

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