Module 3 – HIV

This module discusses HIV and AIDS, defines key terms, and explores the prevention methods that are available for HIV negative people as well as discusses HIV treatment for young people living with HIV. HIV is a global epidemic which significantly affects young people. Sub-Saharan Africa has the highest burden of HIV globally and Zimbabwe is one of the 5 countries with the greatest burden of HIV, together with Eswatini, Botswana, South Africa, and Lesotho.

In 2018, around a third of all new HIV infections in people above the age of 15 in Zimbabwe were among young people (under the age of 24). Adolescent girls and young women have higher HIV infection rates compared to males – there were 9,000 new infections among young women, more than double the number of new infections among young men (4,200).

Topic objectives

• To educate young people on HIV and AIDS, the trends and impact, and the basic facts about including HIV transmission, prevention, and management of HIV infection.
• To develop HIV prevention and management skills among adolescents and young people in Zimbabwean tertiary institutions, in school and out of school.
• To have a critical mass of young people in tertiary institutions who are key HIV ambassadors and support other young people to make health choices.

What is HIV and AIDS?

HIV stands for human immunodeficiency virus. It works by attacking the immune system – the system that stops us from getting sick. HIV targets CD4 t-cells in the immune system – cells which usually coordinate our body’s immune response. The virus over these cells and uses them to make copies of itself. Over time, HIV kills more and more of the CD4 cells weakening the body’s immune system. If HIV is not controlled by treatment the body will eventually fail to fight infections and will be attacked by opportunistic infections like TB, leukemia pneumonia etc. It is these opportunistic that cause death.

AIDS is acquired immune deficiency syndrome. It is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus. Syndrome is a group of signs and symptoms that occur together in AIDS this can be weight loss, fever or night sweats, fatigue, and recurrent opportunistic infections. Most people with HIV do not develop AIDS because taking HIV medicine – antiretroviral medicines (ARVs) every day as prescribed stops the progression of the disease.

TRANSMISSION OF HIV

The three ways that HIV can be transmitted are:

1. During unprotected sex with someone who has HIV (vaginal or oral sexual intercourse). The most common means of transmission in Southern Africa and in Zimbabwe is unprotected heterosexual intercourse Sex between a man and a woman without a condom). Heterosexual people in stable unions account for around 55% of all new HIV infections.
2. From an HIV-positive woman to her baby during pregnancy, birth, or breastfeeding. In Zimbabwe, mother-to-child transmission is estimated to be 7%.
3. Exchange of blood with someone who has HIV (usually from a used needle or something sharp, like a razor). Anecdotal evidence suggests that more young people are now using drugs and some of them are injecting drug users therefore there may be a rise in the number of infections from injecting drug use that is yet to be detected and recorded.

The four body fluids that can transmit HIV are:

• Pre-ejaculate or pre-cum (the fluid that comes out of the penis when a man has an erection before he ejaculates),
• Vaginal fluids,
• Blood,
• Breast milk.

It is important for young people to know that HIV cannot be spread through casual contact and interaction in public places such as college campus or workplaces, kissing, hugging, toilet seats, mosquitoes, and other insect bites, sharing utensils, clothes, tears, and sweat.

HIV AMONG YOUNG PEOPLE IN ZIMBABWE INCLUDING TERTIARY INSTITUTIONS

What does the evidence say:

15. HIV prevalence in Zimbabwe has decreased from 15.2% in 2011 (ZDHS 2010–2011) to 13.4% (ZIMPHIA 2015–2016) among 15–49-year-olds.
16. According to 2018 HIV estimates (NAC, MoHCC and UNAIDS, 2019), the prevalence among adults 15-49 years declined from 13.79% in 2015 to 12.78% in 2018.

• A third of all new HIV infections in 2018 were among young people (under the age of 24).

6. The prevalence rate in females decreased from 6.29% in 2015 to 5.7% in 2018 but for the age group 15-24, prevalence among females is almost twice that of males (3.41% in 2015 to 3.2% in 2018 (ZNASP 2021 – 2025).
7. 59% of young people had tested for HIV, (52% males compared to 65% females). Among young people living with HIV, 60% were aware of their status.
8. 17% of young women (15-19) reported having had sex with a man 10 years older in the past 12 months.

• Only 42% of young women and 47% of young men have comprehensive knowledge about HIV.
• Every week, 4000 adolescent girls and young women aged 15–24 years became infected with HIV globally in 2022. 3100 of these infections occurred in sub-Saharan Africa (UNAIDS Factsheet, 2023).

Key drivers in tertiary institutions – HIV Campus Barometer

• Age Mixing
• Multiple and Concurrent Partnerships
• High mobility
• Low levels of circumcision
• Peer pressure, drug, and substance abuse
• Incorrect and inconsistent
• Use of condoms
• Low health-seeking behavior e.g., HIV testing and VMMC

KNOW YOUR HIV STATUS!

It is important that everyone gets an HIV test and know their HIV status. Knowing one’s status is essential for you to take steps to manage your HIV infection if you are HIV positive or to prevent HIV infection if you are HIV negative. If you have a sexual partner, it is essential that you test for HIV together because you cannot find out one’s status by merely looking at them. A student or any other person living with HIV might not necessarily present AIDS-related symptoms.

The HIV Testing Journey

Decide to get an HIV Test – This is the first step each one should take. It must be a conscious decision to take an HIV test.

Find out where you can get an HIV test – HIV testing is available at most health clinics in Zimbabwe, you should find out if there are testing at your clinic campus. Other testing sites include NGOs like PSI and sometimes there are mobile testing campaigns at business centers or shopping malls. Some clinics, NGO sites and even peer educators of community health workers are also now distribution HIV self-test kits which one can use on their own with no health worker administering them. The kits are easy to use as they come with clear step by step easy to follow instructions.

Go for the HIV test – when you present for an HIV test they will do pretest-counseling and provide information about HIV and make sure you are ready for the test. They will tell you that the test is Voluntary and Confidential. Pretest counseling can be done in groups. Next you will be invited to a room where they will take blood from your finger. You might have to wait for some minutes (up to 30 minutes) before they call in you for posttest counseling and giving you your results.

Now you know your status – If you are HIV positive you will immediately be given a chance to start ARVs or you will be referred to another health facility if the facility you were tested at does not dispense ARVs.

If you are HIV negative, you will be told about the HIV prevention methods available for you. If you are HIV negative, you must repeat the HIV test every year or every time you think you have been exposed to HIV. You may be asked to get another HIV test after three months because the HIV tests may fail to detect recent HIV infections – this period is called a window period.

TYPES OF HIV TESTING AVAILABLE

HIV self-testing (HIVST)

• A person who wants to know their HIV status performs an HIV test themselves and interprets the result in private, using rapid test kits, such as fingerstick tests (on whole blood) or mouth swab tests (on oral fluid).
• HIVST does not provide a diagnosis. Non-reactive (negative) self-test results are considered negative, but all reactive (positive) self-test results need to be confirmed. If the test is “positive” then one must get a confirmatory test i.e., a rapid test or an antigen test.

Advantages – privacy and confidentiality concerns, fear of stigma and discrimination from health care providers, and limited access to HIV testing services. As a result, HIVST may increase people’s access to and frequency of testing.

Where to get HIVST– you can get HIVST from a peer educator, clinic or buy from a pharmacy.

Rapid antibody HIV test

They are called ‘rapid’ tests because the result can usually be given within a few minutes. It detects the presence of HIV antibodies in a person’s blood.

An HIV negative results can be due to two reasons:

1. That the person does not have the virus that causes AIDS in their body at all
2. That the person is currently within the window period – a time when an individual’s body has not made enough HIV antibodies for the standard HIV test to detect. The standard window period time ranges from 3 weeks to 3 months from the time of infection.

Advantages – Quick run time (15 minutes). The tests are portable; if performed at point -of-care, high likelihood that person will receive test result. Less sensitive near the time of infection than IgM/IgG or Ag/Ab tests performed on plasma. Quick run time when performed with whole blood (10 minutes).

FACT: It is important to note that a person on window period can test HIV negative because the antibodies are not enough to be detectable. However, such a person can pass on HIV – they are highly transmissive in this period because HIV will be multiplying faster, and the viral load is high.

Where to get an HIV Rapid test– at a clinic, hospital, or doctor’s room. It can also be done at NGOs or at mobile clinics.

How can I manage an HIV infection and live a good and long life?

If you test HIV positive do not despair, now people living with HIV live long, healthy, productive, and reproductive lives. You may feel overwhelmed, fearful, and alone, but you are far from alone there are people and resources available to help you. More than 1million people in Zimbabwe are living with HIV and most of them are living happy and healthy lives on HIV Antiretroviral treatment.

HIV antiretroviral treatment

Antiretroviral treatment is the main and commonly known type of treatment for HIV positive individuals. Although it’s not a cure, it can stop people from becoming ill for many years if they take their medicines religiously as prescribed – this called treatment adherence. The treatment consists of drugs that must be taken every day for the rest of a person’s life. These drugs are known as antiretrovirals (ARVs).

ARVs inhibit the replication of HIV. When taking ARVs, HIV replication and immune deterioration can be delayed, and survival and quality of life is improved. If one takes their ARVs consistently and as prescribed by their doctor the levels of the virus in their bodies may be lowered significantly that the virus is undetectable by an antibody or antigen test (less than 200 copies/ml). This is also known as virally suppressed. When the virus is undetectable it is also untransmutable that is the chances of an HIV positive person with undetectable viral load to transmit HIV during sex is extremely low and insignificant.

HIV positive people who have undetectable viral load therefore protect their partners from getting HIV. It should however be noted that an undetectable viral load cannot protect against other STIs, and it may change over time and therefore needs to be confirmed by a viral load test regularly.

How can you protect yourself from HIV infection?

If you test HIV negative it is critical that you take charge of your behavior and your life to prevent an HIV infection. In Zimbabwe most HIV infections are through sexual intercourse hence it is important to adopt safe sexual behaviors.

To prevent HIV infections, we encourage adopting the ABCD model of prevention:

Abstaining from sex – if you are not sexually active there is no chance for you to get an HIV infection from sex.

Be faithful to one faithful sexual partner who is HIV negative –go for an HIV test with your partner regularly.

Condomize – use female or male condoms correctly and consistently.

Delaying sexual debut – research shows that individuals who indulge in sexual intercourse at an older age (above 23) are most likely to make better informed safer sexual choices.

In addition to the ABCD model of prevention we can also add a E and an F as below

Early treatment of STIs – because STIs increases one’s vulnerability to HIV. If you have cuts, bruises, tears and swollen genital parts then they present an easy entry of HIV into your system if you have sex with an HIV positive person.

Free and frank discussions on HIV. If you discuss about HIV, you learn was to protect yourself and your partner. You can also agree on HIV prevention methods that work best for you.

There are other HIV prevention strategies that you can use as indicated below. It is important that you understand the strategy, you understand if this is a good fit for you and where you can access the intervention.

BIOMEDICAL HIV PREVENTION OPTIONS

1. PEP (Post Exposure prophylaxis)

PEP is a form of emergency treatment taken after possible exposure to HIV, to prevent HIV infection. It is Antiretroviral medicines taken in prescribed doses and is most effective at preventing HIV infection if you take it within 24 hours of exposure and continued for 4 weeks at the same time every day. It can’t be taken more than 72 hours after exposure and It’s important not to miss any doses or your treatment may not work.

PEP is used after: –

• sexual exposure this includes rape or sexual assault,
• sharing needles,
• occupational exposure e.g., exposure to another person’s blood.

PEP is not taken: –

• If you already have HIV,
• to prevent pregnancy or other STIs,
• as a regular form of HIV prevention.

PEP can be 80% effective in preventing HIV transmission if administered 72 hours or soon after exposure. PEP is a right to anyone who has been sexually assaulted, and it does not require a police report to get PEP at Public hospital or clinics, NGO points where that have the response centers e.g., adult rape clinic, One stop GBV centers or any district hospital and some private clinics or pharmacies.

2. PrEP (Pre-Exposure Prophylaxis)

PrEP is a course of HIV drugs taken by HIV-negative people to protect them against HIV infection. Truvada is the name of the pill used for PrEP. PrEP is different from PEP. PrEP does not prevent unwanted pregnancy or other STIs. First, you should get an HIV test and the results must be negative. PReP is taken as one tablet per day. You will need to take PrEP for 7 days before you are protected, and then every day for as long as you want protection.

PrEP may be a good option if:

• Your sexual partner is living with HIV.
• You have multiple sexual partners, and you do not always use condoms.
• You do not know your sexual partner’s HIV status and do not always use condoms.

The anti-HIV drugs in PrEP stop the virus replicating in your body. If you are exposed to HIV, but have been taking PrEP correctly, there will be high enough levels of the drugs to prevent you from getting HIV. Any public hospital near you, other NGOs and private clinics that offer PrEP include PSI clinics, Wilkins Clinic, CeSHHAR Clinics.

3. Condoms

A condom is a thin piece of material that fits over the penis (male condom) or inside the vagina (female condom) during sex. It creates a barrier to stop these fluids (semen and vaginal fluid) from entering the body. Condoms are usually made of latex, and a few are also made from Polyurethane or polyisoprene. Condoms are worn over the penis or inserted into the vagina before sexual intercourse. A new condom must be used each time you have sex. Condoms should be used by anyone who is sexually active but would like to prevent: HIV transmission, STI infection and Unwanted pregnancy. If used correctly and consistently condoms help prevent HIV for higher risk sexual activities like vaginal sex, oral sex and sharing sex toys. Condoms can be found in public toilets and bathroom, clinics including campus clinic, shops, health outlets, NGOs, hospitals, pharmacies, and bars.

4. PMTCT (Prevention of Mother to Child Transmission)

Mother-to-child transmission of HIV is the spread of HIV from an HIV positive mother to her child during pregnancy, childbirth, or breastfeeding.  PMTCT is the use of HIV medicine ARVs and other strategies when there are chances of mother-to-child transmission of HIV If the mother is HIV positive. Automatically the mother is prescribed ARVs for their own health and to prevent mother-to-child transmission of HIV. ARVs prevent HIV from multiplying, and reduces the amount of HIV in the body and reduces the chances of the mother to transmit HIV to their baby HIV positive women who are: –

• planning to have a baby.
• pregnant or
• breastfeeding their baby.

If ARVs are taken consistently and as prescribed the HIV in a woman’s body can be low that it cannot be detected. This is called undetectable viral load. This reduces the chances of HIV transmission to baby significantly. PMTCT can be found at any public clinic or hospital near you.

5. Voluntary Medical Male circumcision

Male circumcision removes a fold of skin that covers the head of the penis –the foreskin. It is voluntary and should be done by a medical practitioner for it to be safe and effective. It reduces but does not eliminate the risk of HIV infection. Other forms of protection like condoms or PrEP should continue to be used. It removes an HIV entry point – the inner foreskin contains cells that HIV targets to enter the body. Small tears or genital ulcers on the foreskin can increase the risk of HIV infection. It does NOT reduce the risk of sexual transmission of HIV on to a female partner. VMMC can be done by any male who is sexually active or intend to be sexually active in the future. It can also be done on male babies or boys with the consent of their parents or guardians. VMMC reduces HIV infection risk for a circumcised man by 60%. It is a quick, safe procedure with no long-term side effects. It reduces the chances of getting other STIs. Circumcision has been shown to help prevent cancer of the penis as well as increase good hygiene among men. Any public clinic or hospital near you offers VMMC services.

6. PrEP Ring/ Dapivirine vaginal ring

It is a silicone rings that can be inserted in the vagina for long-acting, topical, and localized protection against HIV at the site of infection. To properly use the ring, it must be worn inside the vagina for a period of 28 days, after which it should be replaced by a new ring. The ring is made of silicone and is easy to bend and insert. The ring works by releasing the antiretroviral drug dapivirine from the ring into the vagina slowly over 28 days. The PrEp ring can be used by women who are HIV negative and sexually active. The Ring study demonstrated an HIV reduction of 35% among women using the Prep ring, and the ASPIRE study a 27% reduction in risk. The PrEP ring can be found at any public local clinics and hospitals.