Introduction
AIDS is acquired immune deficiency syndrome; this is the final stage of the infection and it is caused by the virus called Human Immune Deficiency Virus (HIV), (World Health Organization (WHO), 1984). HIV is a member of the retrovirus family that causes Acquired Immune Deficiency Syndrome. The immune system begins to fail leading to life threatening conditions in which the immune system becomes exposed to life threatening opportunistic infection(WHO, 1985). HIV infection primarily affects vital cells in the human immune system such as T-cell (CD4+ Tcell) macrophages and dentrictic cell (Douglas, 1990).
HIV is found in the body fluid of an infected person. This virus canbe transmitted from one person to another through blood to blood sexual contact. In addition, infected pregnant women can transmit HIV to their babies through pregnancy, delivery and through breastfeeding(Fauci et al., 2005).
According to Munywoki (2008) mother to child transmission of HIV can occur before, during and after delivery. Transmission is rare in early pregnancy and relatively frequent in late pregnancy and breastfeeding also contributes substantially.The transmission of HIV from mother to child ranges from 15% – 40%.
He further postulated that post-natal transmission from mother to child through breastfeeding remain important cases where Antiretroviral prophylaxis reduces the risk of vertical transmission in late pregnancy and delivery, it was also stated that, the risk factors for vertical transmission include, maternal progression of infection premature infant are more likely to be infected than term infants and the risk increase with the duration of membrane rupture, elective caesarean section approximately half the risk of transmission. He also stated that effective intervention include the reduction of the maternal viral load through antiretroviral therapy, the avoidance of exposure to contaminated material /fluid, secretion and birth canal with antiseptic to reduce exposure to contaminated secretion.
In December 2003, United Nation Program on HIV/AIDS and world health organization [UNAIDS/WHO] worldwide statistics shows that 700,000 children under age 15 years were newly infected with (HIV/AIDS of which about 95% of all the infected people living in developing countries especially Africans. This causes about 95% of deaths to people in seven sub-Saharan Africa countries, also, mortality due to HIV/AIDS in children under age (5) has increased by 20% – 40% (National Institution of Allergy and InfectiousDisease(NIAID), 2004).
HIV probably originated from remote rural areas where it was endemic at low levels, but then spread amongst sexually active population in cities, initially in the early 1980, amongst homosexual men in developed countries of Europe, North America and Australia, (Gallo1984).
Conceptual framework
Genetic research indicates that HIV originated in west-central Africa during the early twentieth century. AIDS was first recognized by the Centre for Diseases Prevention and Control(CDC) in 1981 and the cause “HIV” infection was identified in the early part of the decade. Since its discovery, AIDS has caused an estimated 36 million death as of 2012.
As at 2012, approximately 35.3 million people were living with HIV globally (Graeme, 1997).AIDS is considered a pandemic. HIV/AIDS has had a great impact on society both as an illness and as a source of discrimination. This disease also has significant economic impact. There are many misconceptions about HIV/AIDS such as; the belief that it can be transmitted by casual non-sexual contacts (Gallo, 2006). The disease has become subject to many controversies involving religion. It has attracted international medical and political attention as well as large-scale funding since it was identified in the 1980’s (Kaiser, 2006).
Wambua (2007) gave a 99.7% certainly that HIV sub-type B originated in Haiti before passing to the United States, He also went further to say that HIV had entered the United State several times before sub type B took a firm hold which would explain the infection of the St.Luis teenager in early mid 1960s, but it was late 1960/70s transmission that is believed to be responsible for the wide spread of the epidemic seen in the United State of America today.
He went further to say that his data was not intended to place any blame on Haiti or on central Africans, he also stressed that none of the people who transmit HIV would have been aware that they were infected. His work still received strong protest from on Haitian who delegate at the Conference on Retrovirus and Opportunistic Infection (CROI)in 2007 demonstrating the extent to which tracing HIV’s origin remain a politically sensitive exercise. HIV is said to have originated from non-human primates in the sub- Saharan Africa and was transferred to human during the late 19th or early 20th century. Scientist identified a type of chimpanzee in West Africa as the source of HIV infection in human. It is believe that the chimpanzee versions of the immunodeficiency virus (SIV) “mostly was transmitted to human and mutated into HIV when human used these chimpanzees for meat and came into contacts with their infected blood. Over decades, the virus slowly spread across Africa and later into other parts of the world (Karutu, 2008).
The first cases of AIDS were reported in the United State in 1981, at that time, the average life expectancy for a person diagnosed with AIDS was six months, subsequent advances in treatment, particularly the use of combination Antiretroviral therapy have transformed HIV/AIDS into a chronic manageable condition. A 35 year old person diagnosed with HIV infection has an estimated life expectancy of 35 years depending on the CD4 cell. In the setting of these success however, patient with HIV infection still faces many challenges as treated patient live longer, illnesses typically associate with an aging population such as cardio vascular disease, osteoporosis and diabetes are being seen at increased frequency (Pallelaet al., 2003).
In 2007, a data was presented by a group of scientist based on complex genetic analysis of 122 early samples of HIV group M, sub type B, the most common strain was found in the USA and Haiti showing that the strain had probably been brought to Haiti from Africa by a single person in around 1996, time when many Haitians would have been returning from work in Congo (Moss, 1989).
HIV was first clinically observed in the United States. This fact is not enough to conclude that HIV is originated from United States. The origin of HIV still remains a political sensitive exercise to researchers (Gaem et al., 1997).
Signs and symptoms of HIV
The initial period following the contraction of HIV is called “Acute Retroviral Syndrome” (ARS) or primary HIV infection. Within 2-4 weeks many but not all people experience fill-like symptoms after post exposure often described as “worst flu ever”. It occurs in 40 – 90% of cases while in other people, the symptoms tends to be common as follows fever, swollen glands sore throat, rash, headache etc. these symptoms can last anywhere from a few days to several weeks. However, one should not assume that he/she has HIV if he/she exhibits these symptoms, because each of these symptoms can be caused by other illnesses. It is also important to note that, not everyone who is infected with HIV develops ARS, many people who have been infected with HIV do not have any symptoms at all for ten years or more. It is also important that someone cannot rely on symptoms to know whether he/she has HIV, the only way to know for sure is to get tested, by carrying out a proper laboratory count test of CD4 cells (Jason et al., 1997)
HIV signs and symptoms can also be split into stages, which are, the early signs and symptoms like tiredness, nausea, diarrhoea, enlarged lymph nodes in the neck, armpits or the groin, the late stage signs and symptoms of HIV are: rapid weight loss dry cough, re–occurring fever that leads to excessive night sweat, unexplained fatigue, swollen lymph node, diarrhoea lasting more than a week, pneumonia, unusual blemish on the tongue or throat, depression which can lead to memory loss and other neurological disorder.
Opportunistic infections(OIS)
Opportunistic infections are infections that are caused by micro-organisms. It is an infection that takes advantage of the body’s immune system when the body’s immune system is extremely weak and unable to fight against infections, thereby introducing pathogens into the body and exposing the body to various diseases.The phrase “opportunistic infections” is often shortened to “o/s”. When an individual with HIV infection” develops OIS, the individual might have AIDS. Treatment with HAART often improves current as well as decrease the risk of future opportunistic infections.
Opportunistic infection may be caused by bacteria, virus, fungi and parasitethat is normally controlled by the immune system. Some of these opportunistic infections are: tuberculosis, candidiasis thrush, white patches on the tongue, difficulty in swallowing, uncontrolled diarrhoea, cervical cancer for women, unexplained fever etc. (Gallo.,1984).
Different transmission route of HIV
HIV is transmitted or can be contracted through the following route by infectious body fluid. They are:
Sexual contact: This can be heterosexual
This is a sexual contact between a male to a female or a female to a male.
Homosexual: this is a sexual contact between a male to a male or a female to a female.
Oro–genital sex: this is a sexual intercourse or sexual activity involving stimulation of the genital of a person by another person using the mouth including lips, tongue or teeth to lick or suck his/her partner that is infected.
The most frequent route of HIV transmission is through unprotected sexual contact with an infected person. However, the pattern of transmission varies significantly between countries. In the United Statesas of 2009, most sexual transmission occurred in men who have sex with men (Kitahata, 1996).
Estimates show that the risk of HIV transmission through unprotected heterosexual activities per sexual act appears to be 4–10 times higher in low–income countries than in high–income countries. The risk of female to male transmission is estimated as 0.8% per act for male to female and 0.08% per act for female to male transmission (Douglas, 1990).
Exposure to infected body fluid: this is the second most frequent mode of HIV transmission. It is via blood and blood products. Blood borne transmission can be transmitted through needle-sharing, during intravenous drug use, needle stick injuring or medical infection with unsterilized equipment. The risk from needle infection is between 0.63 and 2.4% per act with an average of 0.8% (Morwoki, 2008).
The act of acquiring HIV from a needle stick from an infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucus membrane exposure to infected blood as 0.9% (about 1 in 1000) per act, (Moss, 1989).
Unsafe medical infection plays a significant role in sub-Saharan Africa. In 2007 between 12 and 17% of infection in this region attributed to medical syringe use (Pellelaet al., 2003).
From infected mother to child: the transmission of the virus from mother to child occur in utero (during pregnancy), intrapratum (at child birth), or via breastfeeding. In the absence of treatment, the transmission rate up to birth between the mother and child is around 25%. However, where combination of antiretroviral drug are available, this risk can be reduced to as low as one percent. Postnatal mother to child transmission may be largely prevented by complete avoidance of breastfeeding: however, this was significantly associated with morbidity; exclusive breast feeding and the provision of extended antiretroviral prophylaxis to the infant are also efficacious avoiding transmission. It is also important to note that mother to child transmission is also known as vertical transmission, (Centre for Disease Control and Prevention, 2003).
Blood transfusion:Blood transfusion with infected blood result in transmission of HIV infection in about 93% of cases in developed countries, the risk of acquiring HIV from a blood transmission is extremely low (less than one in half a million) where improved donor selection and HIV screening is performed in the United Kingdom, the risk is reported at one in five million, (United State Agency for International Development, 2011).
However, in low income countries, only half of the blood use for transmission may be appropriately screened. It is estimated that up to 15% of HIV infection in these areas comes from transfusion of infected blood and global infection (WHO, 2001).
Some other transmission route of HIV include:
Sharing of infected sharp objects like blades, clipper, knives and domestic needles.
Classification of HIV
HIV is classified into two types, HIV 1 and HIV 2.
HIV 1: is more virulent, it is easily transmitted and it is caused by most majority of HIV infections.
HIV 2: is less transmittable (Fauciet al., 2005).
Generally two types of HIV has been characterized which are HIV 1 and HIV 2.
HIV 1: this is the most prevalent human retro-virus, there are 3 distinct groups M, N and O.sub type M is the predominant group and consists of Evelen Clades (A – K).
HIV 2:is primarily localized to Africa, especially West Africa. There are six sub types of HIV -2 (A – F). A person can be as infected with HIV 1 and HIV 2 as well as different sub-types (Douglas, 1990).
There are two species of HIV known to be in existence; HIV-1 and HIV 2.
HIV 1: is the virus that was initially discovered and termed LAV. It is more infective and it is the cause of majority of HIV infections globally. The lower infectivity of HIV infectivity of HIV 2 compared to HIV 1 implies that fewer of those exposed to HIV 2 will be infected per exposure.
HIV 2: Because of its relatively poor capacity for transmission, it is largely confined to West Africa (Douglas, 1990).
Stages of HIV
Stages of HIV is based on clinical findings that guide the diagnosis, evaluations and management of HIV/AIDs, and it does not require a CD4 cell count, these staging system is used in many countries to determines eligibility for antiretroviral therapy, particularly in settings in which CD4 testing is not available. Clinical stages are categorized as follows:
- Through progressing from primary HIV infection to advanced HIV/AIDS.
- These stages are defined by specific clinical condition and symptoms for the purpose of World Health Organization staging system (WHO,2006).
The signs and symptoms of HIV/AIDS are described under four stages.
- Stage one
- Stage two
- Stage three
- Stage four
Stage one:(Asymptomatic Stage): these disease is characterized by generalized lymphadenopathy.
Stage two: (Mild symptoms Stage): the features includes;
- Moderate unexplained weight loss
- Recurrent respiratory infection (sinusitis, tronsillitis, otitis, media and pharyngitis).
- Herpes Zoster.
- Angular cheillitis
- Recurrent oral ulceration
- Papular pruritic eruption
- Seborrhoic dermatitis
- Fungal nail infection.
Stage three: (Advanced symptoms Stages): the features are:
- Unexplained severe weight loss
- Unexplained chronic diarrhoea greater than one month
- Unexplained persistent fever (continuous or intermitted for longer than one month above 37.6oC)
- Persistent oral candidasis (thrush).
- Pulmonary tuberculosis (current).
- Severe presumed bacterial infections, such as, pneumonia, phyomositis, borne or joint infections, meningitis etc.
- Acute necrotizing ulcerative stomatitis, gingivitis and periodontitis.
- Unexplained anaemia (haemoglobin 8g/dl).
- Neutropenia (neutrophis L 500 cells /ml).
- Chronic thrombocytoperia (plates L 500,000 cells/mi).
Stage four: (severe symptoms stage): the features are:
- HIV wasting syndrome
- Prieume – cystis
- Recurrent severe bacteria pneumonia
- Chronic herpes simplex infection (more than one month).
- Kapasi sarcoma.
- HIV encephapathy (brain involvement).
- Disseminated mycosis e.g. histoplasmosis.
- Candida of the bronchi, trachea or lungs.
- Progressive multiple leuco – encephalopathy (PML).
- Disseminated endemic fungal infections e.g. general mycosis.
- Central nervous system toxoplasmosis.
At stage 1: the patient performs his/her normal duty or daily social activities, he/she is not sure whether he/she is sick or not. Therefore the individual does not seek for treatment.
Stage 2: though symptomatic, but normal activities are still being performed.
Stage 3: the patient is bed-ridden less than 50% of the day during the last one month.
Stage 4: the patient is bedridden more than 50% of the day during the last one month.
Mother to child transmission of HIV (MTCT)
The transmission of HIV from an HIV positive mother to the child during pregnancy, delivery or breastfeeding is called mother to child transmission. In the absence of and intervention transmission range from 15 – 45%, this rate can be reduced to level below 5% with effective intervention, the global community has committed itself to accelerate progress for the prevention of mother to child transmission (PMTCT) through an initiative with the goal to eliminate new paediatric HIV infection by improving maternal, newborn and child survival and health in the context of HIV. WHO works together with partners on setting global norms and standard for HIV prevention, care and treatment of pregnant women, mother and their children, developing evidence – based strategies, defining global target, baselines and indicators, promoting the integration of PMTCT. Newborn-child health services and strengthening health system (Douglas,1990).
About 900 children were newly infected with HIV per day, over 90% occurring in sub Saharan Africa, 57% of pregnant women living with HIV received antiretroviral drugs to prevent them from transmitting the virus to their babies, globally, only 35% of infants born to mothers living with HIV in low and middle income countries received an HIV test within the firsttwo months of life. Only 28% of children under 15 years living with HIV in low middle income countries received antiretroviral treatment for the virus, as compared with 54% for adults, (UNICEF,2011).
Ensuring that no baby is born with HIV is essential step towards achieving an AIDS free generation, an intervention known as “prevention of mother to child transmission of HIV or PMTCT provide drugs, counselling and psychological support to help mother safe guard their infants against virus. PMTCT is provided to all women that need it. It is a most effective way to eliminate HIV infections among children and keeping their mother alive. As increasingly more pregnant women living with HIV receives access to antiretroviral treatment, fewer children are being newly infected with HIV. Whether HIV infected or not, children born to women living with HIV have increased risk of morbidity and mortality, and poverty, isolation and distance from health care facilities can place them beyond the reach of life saving care, partners must also work together so that HIV exposed children are identified early provided with follow up treatment, care and support throughout childhood, adolescence and adulthood (WHO, 2011).
MTCT of HIV is when an HIV positive mother passes the virus to her child through pregnancy, delivery or breastfeeding. Each year around 1.5 million women living with HIV become pregnant and without antiretroviral drugs (ARVs), there is a 25 -45% chance that their children will also become infected, however, among mother that take a resign of ARVS for the PMTCT, the risk of HIV transmission is less than 5% in 2011, around 330,000 children under the age of 15 became infected with HIV and estimated 230, 000 died from AIDS, almost all these infections as a results of MTCT and among children living in sub-Saharan Africa.
However, MTCT can be averted and in high income countries MTCT has been almost completely eliminated as a result of effective voluntary testing and counselling services, access to antiretroviral therapy, safe delivery practices and the wide spread availability and safe use of breast milk substitutes. Globally since 1995, more than 350,000 children have avoided HIV infection due to these interventions if these were available and accessible to women worldwide, the infectioncould be prevented for thousands of years (UNAIDS, 2012).
Prevention of mother to child transmission (PMTCT) of HIV
Programme to prevent the vertical transmission of HIV (MTCT) can be reduced to the rate of 92 – 99%, this primarily involves the use of a combination of antiretroviral medication during pregnancy and after birth of the infants and potentially includes bottle feeding rather than breast feeding if replacement feeding is acceptable, feasible, affordable, sustainable and safe. Mother should avoid breastfeeding their infants, however, exclusive breastfeeding is recommended during the first month of life if this is not the case. If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decrease the risk of transmission (Wambua, 2007).
Keeping women of reproductive age and their partners HIV negative through reproductive health and HIV prevention among HIV infected women and women at risk of HIV through family planning and HIV testing and counselling services.
Ensuring HIV testing of pregnant women and timely access to effective antiretroviral therapy, both for the health of HIV infected mothers and PMTCT during pregnancy, delivery and breastfeeding. Better integration of HIV care, treatment and support for HIV infected women and their families (UNAIDS,2012).
Management of MTCT of HIV
In 1987, a drug called “Zidovudine” (AZT) became the first approved treatment for HIV disease, since then approximately 30 drugs have been approved to treat people living with HIV/AIDS and more are under development (Jasonet al., 1989).
Pregnant women with HIV receive antiretroviral drugs during childbirth and delivery to reduce the risk of MTCT of HIV, Recommendations on the use of ARV drugs childbirth into account whether a woman is already taking ARV drugs when she goes into labour and the level of HIV in her blood (HIV viral load).Women already taking ARV drugs as much as possible during child birth. In addition to taking their ARV drugs, women who have a high viral load near delivery may also receive Zidovudine (brand name Retroir) by intravenous injection. Women who did not take ARV drugs during pregnancy may also receive Zidovudine during child birth. In some situation pregnant women with HIV may have a scheduled a pregnant women with HIV may have a scheduled Caesarean delivery (caesarean section) at 38 weeks of pregnant (two week before a woman’s expected date of delivery. A scheduled C S delivery is planned ahead of time (Gallo, 1984)
Child birth is a process of giving birth by a pregnant woman. A woman with HIV passes HIV to her baby at anytime during pregnancy and child birth. The risk of MTCT of HIV is greats during delivery when a baby passes through the birth canal and is exposed to any HIV in an HIV infected mother’s blood or other fluids (UNICEF, 2011).
The six weeks neonatal component of the Zidovudine chemoprophylaxis regimen is recommended for all HIV exposed neonatal to reduce perinatal transmission of HIV. Zidovudine at gestational age, appropriate doses should be initiated as close to the time of birth as possible, preferable within 6 – 12 hours of delivery. Infant born by a HIV infected woman who have not received ante-partum ARV drugs should receive prophylaxis with Zidovudinegiven for six weeks combined with three doses of Nevirapine in the first week of life (at birth, 48 hours later, and 96 hours after the second doses), began as soon after birth is possible. On the other hand, the decision to combine other drugs with the six-weeks Zidovudine regimen should be made in consultation with a paediatric HIV specialist, preferably before delivery and should be accompanied by counselling of the mother on the potential risk and benefit of the approach (McCarthy et al., 1995).
In the United States, the use of ARV drugs other than Zidovudine and Nevirapine cannot be recommended in premature infant because of lack of dosing and safety data (WHO,2010)
References
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