Care and support for people living with HIV/AIDS

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Prevention: daunting challenges aheadFigure 26. HIV prevalence rate and frequency of sexually transmittedinfection (STI) episodes, Carletonville miners, South Africa,901991-1998807060HIV-infected (%)504030201001 2-4 5-9 10+number of STI episodesSource: Ballard R, 2000 (unpublished data)If effective prevention measures were directed at men presenting with their firstepisode of sexually transmitted infection, many would be able to prevent subsequentepisodes and avoid becoming infected with HIV. Standard guidelines for themanagement of such patients do call for counselling patients about prevention,including the use of condoms and the referral of sex partners for treatment. But serviceproviders regularly score very poorly on this part of patient management. Referralfor HIV testing has rarely if ever been assessed, but anecdotal evidence suggeststhat it is rare.Fortunately, good training can make a big difference in performance in the area ofprevention. A recent study in Zambia found that 61% of trained health-careproviders – but only 35% of those who had not been trained – performed adequatelyin providing prevention advice to patients with a sexually transmitted infection. TheZambian study found that training did not make much difference to already goodperformance in other aspects of patient care, such as history-taking and physicalexamination. Depressingly, however, only one-fifth of the cases were correctlytreated – probably because the correct drugs were rarely available. Almost all theservice providers reported serious shortages of drugs in the past year, and almostall were out of stock of at least one essential drug at the time of the study. A studyin India showed that only 10% of all men and women presenting with urethritis weresatisfactorily managed in public and private health facilities. Thus, while a greateremphasis on prevention is desperately needed, much also remains to be done toensure the proper diagnosis and treatment of curable infections such as syphilis andgonorrhoea.73
Report on the global HIV/AIDS epidemic – June 2000Injecting drug use: the other HIV epidemicGlobally, sex between men and women is by far the most common way of passingon HIV. But a second epidemic drives the virus in many, if not most, countries outsideof Africa. That is the epidemic among men and women who inject drugs. Overhalf of all AIDS cases are attributed to injecting drug use in countries includingBahrain, Georgia, Italy, Kazakhstan, Portugal, Spain and Yugoslavia, and over twofifthsin Argentina and the Islamic Republic of Iran. Figure 27 shows the proportionof HIV infections attributable to drug use in a number of countries. In total, 114 countriesand territories had reported HIV transmission between injecting drug users bymid-1999, up from just 52 seven years earlier.Figure 27. Proportion of all new HIV infections that are in injecting drugusers, selected countries, 1998-1999%1009080706050403020100Canada China Latvia Malaysia Moldova RussianFederationUkraineViet NamSource: National AIDS ProgrammesInjection of any sort is an even more efficient way of spreading HIV than sexual intercourse.Since injecting drug users are often linked in tight networks and commonlyshare injecting equipment with other people without cleaning it, HIV can spread veryrapidly in these populations. Because injecting drug use is illegal in most countries,it is hard to know exactly how many people inject drugs and how many share theirequipment; it is harder still to gauge how many are infected with HIV. Many of theestimates of HIV infection rates among injecting drug users come from tests of drugusers who have been arrested or who are registered at treatment centres. However,information collected by outreach services – which take HIV prevention and other74
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