About HIV:
A Teaching Tool
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
■ Section 1
Understanding HIV Infection
■ Section 2
Understanding HIV Treatment
The “About HIV” teaching tool is designed to provide a pocket-sized resource for teaching
families and community members. The illustrated content and pocket size will make teaching
easier and increase learners’ understanding about HIV infection and its treatment.
n
For those using this tool, please feel free to send comments or questions to:
[email protected] — Director, PACTG International Training Program
FXB Center, UMDNJ 65 Bergen St., GA 36, Newark, NJ 07101-1709
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
Section 1
Understanding
HIV Infection
Section 1
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Learning goals
This information helps people understand
the body’s immune (infection-fighting)
system, HIV infection, and AIDS.
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
Learn about:
■ HIV
■ The immune system
■ CD4 cells
■ Checking how the immune
system is working
Section 1
■ Viral load
■ Why some people
with HIV are well and
others are very sick
■ How you get HIV
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Our immune system
■ The immune system is the body’s infection fighter.
■ It helps the body fight all kinds of illnesses
including colds, flu, pneumonia, and HIV.
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
HIV
COLDS
A
I
N
O
M
U
E
PN
Section 1
FLU
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
■ HIV is a virus (germ) that makes you sick. This
is a picture of HIV under a microscope.
■ While it looks big in this picture, it is very,
very tiny. HIV is so tiny it can only be seen
with a microscope. The letters stand for
H: Human
I: Immunodeficiency
V: Virus
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
HIV is a virus.
■ The virus attacks the
immune system.
■ Over time, the immune
system weakens, and the
body loses its protection
against diseases.
©2002 Boehringer Ingelheim GmbH
Section 1
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
CD4 cell
■ Every part of the body is made up of tiny cells that
can only be seen when looking under a microscope.
■ A very important part of the immune system
is a CD4 cell.
■ HIV specifically attacks CD4 cells.
■ HIV gets inside and “takes over” the CD4 cell.
10
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ HIV uses
the CD4 cell
like a factory
to produce
more and
more copies
of the virus.
■ These new
HIV copies
are released
into the body.
©2002 Boehringer Ingelheim GmbH
Section 1
11
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
■ CD4 cells are
destroyed after
HIV uses them to
make more HIV.
■ The body’s immune
system works
hard making more
CD4 cells.
©2002 Boehringer Ingelheim GmbH
12
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
CD4 cell
■ Over time, HIV destroys the CD4 cells faster than
the immune system can make new ones.
■ Without treatment, HIV infection causes the
number of CD4 cells to fall lower and lower,
which weakens the immune system.
■ This process can take several months to several years.
■ The length of time it takes to do this is different for everyone.
Section 1
13
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
When CD4 cells get very low
■ Not having enough CD4 cells makes
the immune system weak.
■ The immune system becomes so weak it
can’t protect the body from infections.
■ Eventually, HIV destroys the immune system.
14
Section 1
François-Xavier Bagnoud Center
I NF E C
About HIV: A Teaching Tool
TIO
N
HIV
IMMUNE
SYSTEM
Section 1
15
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Measuring CD4 cells
16
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ It is possible to tell how much HIV has
damaged the immune system by measuring
the number of CD4 cells in the blood.
■ This requires taking about a teaspoon of
blood to test in the laboratory.
Section 1
17
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
AIDS
■ AIDS is when a person’s immune system is very
weak. We will talk more about this later.
18
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
Healthy Adults
Normal adult CD4 counts
Adults: normal is over 500
AIDS: <200 cells
0
Section 1
300
600
900
CD4 Counts
1200
1500
19
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Normal CD4
measurements in children
<12 months >35%
1–5 years >25%
5 years and up >500 cells
20
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ Normal CD4 counts in children vary
widely by age.
■ In children less than 5 years of age, instead
of measuring the number of CD4 cells, CD4
percentage (%) is used to determine how much
damage has been done to the immune system.
■ CD4 % indicates the proportion of immune
system cells that are CD4 cells.
Section 1
21
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Viral load test
22
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ The amount of HIV in an infected patient’s blood can
be measured. It is called the viral load.
■ The viral load test shows how much virus is present
to damage the immune system.
■ Viral load is measured by taking about a teaspoon
of blood.
Section 1
23
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Understanding viral load
■ A high viral load means the virus is very
active and will damage the immune system more quickly.
■ A low viral load indicates that the virus is less active, which
may damage the immune system more slowly.
■ Successful treatment with HIV medications can bring the
viral load down to less than 50 copies.
24
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ LOW viral load is less
than 10,000 copies.
■ HIGH viral load is more
than 10,000 copies.
Section 1
25
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Antibodies signal infection.
■ Antibodies are special proteins in the blood made by the
immune system to fight a specific infection.
■ People with HIV usually develop HIV antibodies 4–6 weeks
after being infected. Or it may take as long as 3 months for
antibodies to develop.
■ To find out if a person has been infected with the virus,
an HIV test is done that finds and measures antibodies in
blood.
26
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ A person whose
blood test result
shows HIV infection
is HIV-positive. A
person whose blood
test result does not
show HIV infection
is HIV-negative.
Section 1
27
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Photos: ©2002 Boehringer Ingelheim GmbH
Early stages of HIV infection
■ HIV enters the cell.
28
■ HIV uses parts of the CD4 cell to
make more virus (replicate). During
this process the CD4 cell is destroyed.
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ During the early stages of HIV, the immune system is
still able to make enough CD4 cells to replace the ones
destroyed by HIV during replication.
■
The person will have no symptoms (asymptomatic).
This stage can last months to several years.
■
Not knowing they carry the virus, HIV-infected people
with no HIV symptoms can still infect others.
■
Many people do not know they are infected until they
develop symptoms.
Section 1
29
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
Viral load and
CD4 cells
CD4
viral
load
30
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ Eventually, the immune system is unable to make
enough CD4 cells to replace the ones killed by HIV.
■ The immune system gets weaker and disease
symptoms may develop (symptomatic HIV infection).
■ As the viral load goes up, the number
of CD4 cells goes down.
Section 1
31
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
WHO HIV clinical stages
Stage 1
Stage 2
Asymptomatic Mild symptoms
(No symptoms
of HIV disease)
32
Stage 3
Advanced symptoms
Stage 4
Severe symptoms
(AIDS)
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ HIV infection progresses through stages.
The World Health Organization (WHO) has developed a
system to describe the different stages of HIV infection.
■ Sometimes people wonder about the differences between
HIV infection and AIDS. As stages 1–3 show, a person may
be HIV-infected and not have AIDS.
■ A more detailed table of the stages includes the specific
illnesses seen at each stage.
Section 1
33
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
AIDS
A Acquired—not inherited
I Immuno—attacks the
immune system
D Deficiency—destroys
CD4 cells
S Syndrome—a group of
symptoms or illnesses
34
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
AIDS
■ AIDS stands for acquired immunodeficiency syndrome. It is
the most advanced stage of HIV infection. AIDS develops when
the immune system is weakest.
■ AIDS is a group of serious illnesses and opportunistic infections
that affect many different parts of the body, including the eyes,
brain, lungs, and kidneys.
■ An opportunistic infection is caused by a germ that would not
usually cause illness in a healthy person, but will cause illness
in a person who has a weak immune system. Having HIV infection creates the “opportunity” for the germ to cause the illness.
Section 1
35
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
HIV can be transmitted from
one person to another by:
36
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
■ Sexual contact, such as unprotected (without a condom)
vaginal, anal, or oral sex with a partner who is HIV-infected
Unprotected sex is the most common route of HIV
infection. Women are at particularly high risk for
acquiring HIV through sex.
■ Using contaminated needles or other sharp instruments,
or receiving a transfusion of HIV-infected blood products
■ From a mother who is HIV-infected to her child during
pregnancy, childbirth, and breastfeeding
Section 1
37
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
The risk of HIV transmission
through sex can be reduced by:
A
38
B
ABCs
A = abstinence
B = be faithful
C = condoms
C
Section 1
About HIV: A Teaching Tool
François-Xavier Bagnoud Center
Following the “ABCs”
of HIV prevention
■ Abstaining from sex (not having sex)
■ Being faithful to one uninfected partner
(having sex with one uninfected partner and no one else)
■ Condoms: Using male and/or female condoms
correctly every time you have sex
Section 1
39
François-Xavier Bagnoud Center
About HIV: A Teaching Tool
HIV is NOT transmitted by:
40
Section 1
About HIV: A Teaching Tool
■ Coughing or sneezing
■ Kissing
■ Shaking hands
■ Drinking from a public
water fountain
■ Being bitten by an insect
■ Going to a public
bath or pool
François-Xavier Bagnoud Center
■ Working or going to
school with a person
who is HIV-infected
■ Eating food prepared by a
person who is HIV-infected
■ Sharing cups, glasses,
plates, or other utensils
■ Touching or hugging
■ Using a public toilet
■ Using a telephone
Section 1
41
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Section 2
Understanding
Antiretroviral Therapy
Section 2
43
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
Learn about:
■ Highly active antiretroviral therapy (HAART)
■ How HAART works
■ Adherence
■ Resistance
■ Side effects
■ Why HAART sometimes doesn’t work well
44
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Learning goals
This information helps people understand how
treatment for HIV works, and some of the problems
that can occur with antiretroviral (ARV) therapy.
Section 2
45
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
What is antiretroviral therapy?
■ Medicine that fights HIV is called antiretroviral
medicine or antiretroviral therapy (ART).
■ These medicines cannot kill all of the HIV in
the body, but they can decrease the amount
of virus in the blood to very low levels.
■ Taken according to the instructions, ARV medicines
control HIV infection but do not cure HIV.
46
Section 2
About HIV: A Teaching Guide for Families and Communities Section 2
François-Xavier Bagnoud Center
47
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
CD4
Goals of ARV therapy
viral
load
48
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
■ Lower the amount of HIV in the blood (reduce viral load).
■ Preserve CD4 cells and allow immune system
to recover (increase CD4 cell count).
■ Restore health and reduce the number of infections.
■ Improve quality of life.
■ Prolong life.
■ Reduce the chance that a mother will pass HIV
to her baby during pregnancy or childbirth.
■ Restore hope.
Section 2
49
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
Classes of ARV therapy
There are different types (classes) of antiretroviral
medicines that attack HIV at different points
in the life cycle of the virus. They are
■ Nucleoside reverse transcriptase inhibitors
■ Non-nucleoside reverse transcriptase inhibitors
■ Protease inhibitors
■ Fusion inhibitors
50
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
■ NRTIs
■ NNRTIs
■ PIs
■ FIs
Section 2
51
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
HAART
■ HAART is a combination of antiretroviral medicines.
Taking a combination of different ARV medicines is
much more effective than taking only one medicine.
■ This is because each class of medicine works at a different
place, as the picture shows.
■ HAART usually includes 3 medicines of at least two different
types—like 2 NRTIs with either an NNRTI or a PI. HAART
is like a boxer that hits HIV three times, using both hands!
■ HAART can reduce HIV to very low levels in the blood.
52
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Protease
inhibitors
Fusion inhibitors
Nucleus
Protease
HIV
RNA
New HIV
Reverse
transcriptase
DNA
New HIV
CD4 cell
NRTI: nucleoside reverse transcriptase inhibitors
and
NNRTI: non-nucleoside reverse transcriptase inhibitors
= Flow of HIV replication
= Where medications work to slow HIV replication
Adapted from: New York/New Jersey AETC and Albany Medical College, Division of HIV Medicine 2004
Section 2
53
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
When to
start ARVs
54
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
■ Guidelines for starting ARV therapy vary from one
country to another and are based on recommendations
from WHO and other organizations.
■ Countries develop their own guidelines for when and
how to use ARV therapy using available resources.
■ When considering therapy, clinicians evaluate each
patient’s stage of illness, damage to the immune system,
and ability to adhere to (follow) a medicine schedule.
Section 2
55
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
■ Taking ARV medicines lowers viral load. The medicines
stop HIV from reproducing and from destroying CD4 cells.
■ To keep the medicines working, it is important to
follow all of the instructions from the clinician (doctor,
nurse, or healthcare worker) about which medicines
to take, how much to take, and when to take them.
■ Taking medicine exactly as instructed is called “adherence.”
56
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Take all doses.
ARV
Section 2
Lower
viral load
57
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
■ Missing doses is called “nonadherence” to
therapy. With ARV medicines, even missing a few
doses can stop the medicines from working.
■ Viral load increases if doses are missed.
■ Missing doses also causes a person to
develop resistance to ARV therapy.
■ If resistance develops, the medicines will not work. Viral
load will increase and the CD4 cell count will fall.
58
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Missing doses
HIGHER
viral load
■ If doses are missed,
medicines may no
longer be effective.
ARV
Section 2
59
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
There are a number of steps to take that can make
it easier to take every dose of ARV therapy.
■ Remembering to take medicines becomes easier when
taking medicines is part of the daily schedule.
■ Receiving support from others can also make
adherence easier—a friend, your spouse or partner,
another family member, your religious leader, clinician,
church group, or another type of support group.
■ Talking about problems taking the medicines with the
clinician may help.
60
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Adherence
■ Doctors, nurses,
counselors, family,
and friends provide
support for taking
medicines.
Section 2
61
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
Monitoring treatment
62
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
■ The healthcare team and the patient want to
ensure that ARV therapy is effective and safe.
■ That is why it is important to return to the clinic for every
appointment so the team can see how the therapy is
working.
■ At these visits clinicians will ask if there are any
problems with taking the medicines and will check:
■
general health
■
viral load (if available)
■
side effects
■
CD4 count (if available)
Section 2
63
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
■ Like any medicines, ARV therapy can cause
side effects (bad effects of the medicine).
■ Side effects are more common when medicines are
first started. Most are mild and get better over time.
■ More severe side effects are less common but may be
harmful. It is important for patients and families to recognize
side effects and report them to the clinician right away.
■ Sometimes people stop taking their medicines when
they have side effects. Instead of stopping the medicine,
it is best to notify the clinician. The clinician may
suggest ways to manage the problem or will decide
if medicines need to be stopped or changed.
64
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Side effects
■ All medications can
cause side effects.
■ Side effects are rare.
■ If they occur, talk to
your clinician.
Section 2
65
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
ARV therapy does not always work well if:
■ The person forgets to take the medicines or stops taking
the medicines (nonadherence). Nonadherence is the
most common reason medicines fail to work well.
■ Other medicines or home remedies interfere with
the ARV therapy. This should be discussed with
the clinician before starting ARV therapy.
■ HIV disease is too advanced. The medicines work
best when taken before a person becomes very ill.
66
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
Treatment failure
■ Missed doses
■ Viral resistance
■ Medicines not taken due to side effects
■ Other medicines interfere
■ Advanced HIV disease
Section 2
67
François-Xavier Bagnoud Center
About HIV: A Teaching Guide for Families and Communities
For antiretroviral therapy
to succeed…
■ Keep all clinic appointments so clinicians can
check your health.
■ In between appointments, report any changes
in health right away.
■ If a dose of an ARV medicine is missed, take the missed
dose as soon as possible. But if it’s close to the time when
the next dose will be taken, don’t take the dose you missed.
Two doses should never be taken at the same time.
68
Section 2
About HIV: A Teaching Guide for Families and Communities François-Xavier Bagnoud Center
■ If vomiting occurs fewer than 30 minutes after
taking a dose, repeat the dose. If the repeat
dose is vomited, contact the clinician.
■ If side effects occur, discuss them with the clinician.
■ Do not stop taking ARV medicines, and do not
start any new medicine or home remedy without
first discussing changes with the clinician.
Section 2
69
About HIV: A Teaching Tool
This tool was developed by the François-Xavier Bagnoud Center at
the University of Medicine and Dentistry of New Jersey (UMDNJ),
with the support of the Pediatric AIDS Clinical Trials Group.
Excerpts from this publication may be freely reproduced or
adapted with acknowledgement of the source, provided the
material reproduced is for not-for-profit educational purposes only.
Send any comments or questions to [email protected].
© 2nd edition 2006