Issue Contents    Manuals What have you heard about sexually transmitted diseases? Preventing STDs - and AIDS How common are STDs ? Time to act Treating HIV infection like a Sexually Transmitted Disease What are the main aims of STD control programmes? Why are STD programmes important for AIDS prevention and control? Do STDs facilitate transmission of HIV? Does HIV infection affect the clinical symptoms of other STDs? Treatment guidelines General guidelines on diagnosis, treatment and prevention of genital ulcer disease Chancroid Signs and symptoms Treatment Syphilis, Signs and symptoms Primary syphilis: Secondary syphilis: Latent syphilis: Late syphilis: Laboratory diagnosis Non-specific tests: Specific tests: Treatment Genital herpes Signs and symptoms Treatment Treatment protocol for genital ulcers Health promotion A day in the life of Gente Joven Sexuality in school Five themes San Bernabe and the puppet show Meeting the promoters Street talks Readers' Comments Resources Colour slide sets Manuals WHO Report - AIDS: a worldwide effort will stop it World AIDS Day - a special embrace Putting the pieces together Consultation on Sexually Transmitted Diseases (STDs) as a Risk-factor for HIV Transmission Introduction STDs as a risk-factor for HIV transmission Research Priorities Strategic and programmatic implications WHO Publications International Conference

Imagine a young man who has recently found a new lover. Three or four days after making love, he develops a burning sensation when he urinates and a bad-smelling, whitish discharge from his penis (the signs of gonorrhoea). After ten days, the symptoms are no better and he goes to the local health centre. He is examined carefully by a nurse and given an intramuscular injection (a single, 2g dose of Kanamycin). 'This will cure your infection,' she tells him, 'but you must tell your girlfriend to come in for treatment as well-even if she has no obvious symptoms - otherwise she will re-infect you, and may become very ill herself and never be able to have children.' The nurse also tells him about the serious consequences of other sexually transmitted diseases (STDs) if they are not treated early enough, and about the newest and deadliest one - HIV infection and AIDS. 'This disease kills and there is no cure. I am going to tell you how to protect yourself and your sexual partner from AIDS.'

Some time later the young man leaves the clinic with a free pocket of condoms and sets off to discuss all this with his lover. For the first time, he recognises that he may be at risk from AIDS. 'But I needn't be,' he thinks, remembering all the advice about condoms, and keeping to one partner. 

Now imagine the outcome of this story if there had been no free medical treatment, no kanamycin or co-trimoxazole (the other drug used to treat gonorrhoea)(1), and no trained nurse who could explain the dangers of STDs and how to prevent them. Unfortunately, this is the situation in much of the developing world.

Preventing STDs - and AIDS
AIDS is essentially an STD, since the most common method of HIV transmission is through penetrative sex.(2) However, AIDS is rarely considered in the context of other STDs, even though the methods for the primary prevention of AIDS are the same as those for STDs i.e. promoting safer sexual behaviour, including the use of condoms and having fewer sexual partners. Resources are often channelled into single focus AIDS initiatives without integrating these into STD prevention and control. There are a number of benefits to establishing an integrated approach (see pp. 2-3):
 

Treating and counselling people with STDs gives health care workers a valuable opportunity to counsel people at particularly high risk of acquiring or transmitting HIV infection.

Clinical studies suggest some STDs may facilitate the sexual spread of HIV infection (i.e. act as risk-factors) by increasing both the infectivity of a person with HIV and/or increasing the sexual partner's susceptibility to HIV infection. The type of STD that appears to act as a risk-factor is genital ulcer disease (GUD), including chancroid, syphilis and genital herpes. Chlamydial infection is also a potential risk-factor.

How common are STDs? 
Every year, over 200 million cases of gonorrhoea are reported worldwide, and over 50 million cases of syphilis. The real figures are unknown - in large parts of the world STDs go unreported and untreated. The most common of the serious STDs (excluding HIV infection) are gonorrhoea, syphilis, chancroid (common in parts of Africa, although rare in most developed countries) chlamydial infections and herpes. In Africa, chancroid and syphilis cause around 80 per cent of genital ulceration, and herpes around 10 per cent. Genital ulcer disease is mare common in Africa than in developed countries (which tend to have a higher incidence of other STDs, such as genital warts); since GUD may facilitate the spread of HIV this could explain the more rapid spread of heterosexually acquired HIV infection in some parts of Africa. Widespread STD control could have a significant impact on the spread of HIV in areas where GUD is prevalent.

The international newsletter for information exchange on AIDS prevention and control

Why are STD programmes important for AIDS prevention and control?
Many experts believe that to launch AIDS control initiatives without integrating them within broader STD control programmes may well be ineffective and certainly uneconomical. The reasons for this are:
 

	STD treatment centres have direct contact with patients at high risk of acquiring HIV infection. All patients with symptoms of a common STD have in theory been at risk of acquiring HIV infection, since their sexual behaviour has already led to them getting a sexually transmitted disease. The disease they caught could have been HIV infection/AIDS. Patients may continue to put themselves at risk, unless convinced otherwise through appropriate health education. This should be provided at all STD treatment centres as well as through public education campaigns. In addition, studies have shown that HIV infected individuals are more likely to have a greater number of other STDs than individuals not infected with HIV. A person with HIV infection is likely to present with at least one other STD long before symptoms of AIDS develop (HIV infection has a longer incubation period than most other STDs) therefore providing an early opportunity for health education.
	Health workers already trained in STD management and control can offer some of the best expertise needed in an AIDS control programme. STD clinics often have extensive experience in providing specialised counselling on sexual behaviour and the use of condoms, for example.
	Since some STDs could actually facilitate the spread of HIV infection (see below), developing more extensive STD control programmes within primary health care could slow the current rapid spread of HIV in many parts of the world.
	Infection with STD activates the immune system, stimulating the replication of HIV in infected cells, which could speed up the progression to full-blown AIDS. Early treatment of STDs could therefore help prolong the life of an HIV-infected patient.
	Monitoring the occurrence of STDs with short incubation periods - and those easier to diagnose than HIV - can provide useful indicators of the effectiveness, or ineffectiveness, of AIDS control programmes and/or significant changes in sexual behaviour. The incidence of STDs in a given population reflects the degree of unsafe sexual behaviour and hence the risk of HIV transmission. For example, the reduction in the incidence of syphilis and gonorrhoea amongst the male homosexual community in the USA and Europe indicates wide-spread change in sexual behaviour.

Do STDs facilitate transmission of HIV?
There are strong theoretical reasons, as well as clinical evidence, to suggest that certain STDs are a potential risk-factor in the transmission of HIV i.e. they might help the virus to pass from one infected person to their partner during sexual intercourse. It has been suggested that the high prevalence of some STDs reported in most urban centres in tropical Africa, could be a major factor contributing to the rapid spread of heterosexually acquired HIV in the region.

Several small-scale clinical studies have suggested that genital ulcer disease (GUD) in particular is a potential risk-factor in HIV transmission. GUD is a term which includes a number of ulcer-producing STDs, including chancroid, syphilis and herpes. At the STD clinic in Dar-es-Salaam, Tanzania, HIV seropositivity among patients presenting with GUD is currently four times that for all other patients attending STD clinics.

GUD could increase the risk of HIV transmission by increasing the infectivity of an HIV infected person (e.g. as a result of passage of HIV through the ulcer) and/or increasing the susceptibility of a person to HIV infection (e. g. by facilitating entry of the virus through genital ulcers, or through broken skin or mucous membranes). 

Most STDs cause inflammation and/or genital ulceration of the skin or mucous membranes. Broken skin or mucous membranes allow easier entry or exit of HIV.

In addition, inflammed skin or mucous membranes and ulcers contain increased numbers of the cells that HIV attacks - the lymphocytes and macrophages which contain receptors for HIV on their surfaces (see AIDS Action, issue 3, for an explanation of how HIV attacks the body's defence system). Thus, any STD which increases the number of these cells in the genital area could facilitate the transmission of HIV.

Does HIV infection affect the clinical symptoms of other STDs? 
Since HIV infection destroys the body's ability to fight off other diseases, the clinical picture of common diseases in HIV infected individuals is often atypical and treatment may be more difficult. Many STD clinics in East and Central Africa are now having to cope with increasing numbers of HIV infected patients with GUD symptoms which persist for several weeks, sometimes months, despite the provision of normal medical treatment. Chancroid ulcers in HIV infected patients, for example, tend to be larger, more numerous, and persist for longer than usual. Response to the recommended single oral dose of Trimethoprim sulphametrole (640mg/3200mg - i.e. eight standard tablets each containing 80mg trimethoprim/400mg sulphametrole) is sometimes disappointing (note: this drug is not as widely available as co-trimoxazole - see following treatment guidelines). 

Herpes simplex infections of the skin and/or mucous membranes are common in patients with AIDS and can cause severe genital, peri-anal and rectal ulcers. Extensive genital ulceration due to Herpes Simplex Virus type 2, may be the first indication of underlying immunodeficiency (damage to the immune system caused by AIDS).

In HIV infected patients, it also appears that late syphilis (see pp. 4-5) may develop within an unusually short period of time (less than five years) after initial infection with Treponema pallidum (the bacterium which causes syphilis). However, most HIV infected patients with early syphilis respond well to doses of Benzathine benzyl penicillin G (2,4 million units).

Genital viral warts, candidosis and trichomoniasis are also STDs more commonly found in HIV infected patients than in non-HIV infected individuals in Dar-es-Salaam; symptoms tend to be more serious in patients suffering from immunodeficiency. There is certainly sufficient evidence to suggest that HIV infection may alter both the clinical presentation and the natural history of STDs, and that some STDs may facilitate the spread of HIV and affect the clinical picture of AIDS. Strengthened STD programmes are urgently needed: in Tanzania, for example, reports to the Ministry of Health between 1973 and 1978 showed gonorrhoea to be the ninth most frequent cause of hospital out-patient attendance in the country.

Since HIV infection/AIDS is predominantly an STD, it should be treated as such in integrated prevention and control strategies. Attempts to control the spread of HIV in the absence of STD prevention and control activities are less likely to succeed.

Dr K J Pallangyo, Consultant Physician and Senior Lecturer, Muhimbili Medical Centre, PO Box 65066, Dar-es-Salaam, Tanzania.

General guidelines on diagnosis, treatment and prevention of genital ulcer disease

The following guidelines deal with the most common causes of genital ulcer disease.
 

The management of all sexually transmitted diseases should include counselling on safer sex, information on HIV infection and AIDS and the use of condoms for the prevention of STDs. Remember to call in sexual partners of patients for treatment and counselling, whether or not they have symptoms. Above all, try to be welcoming and emotionally supportive to patients - many of whom feel embarrassed or worried by their infection.

Chancroid
This is the leading cause of genital ulcers in many developing countries, but is less common in developed countries. Chancroid is caused by a bacterium known as Haemophilus ducreyi.

Signs and symptoms
Both males and females with chancroid develop painful, dirty-grey, genital ulcers. In males, ulcers are commonly found on the edge of the glans penis, but can appear anywhere on the external genitalia. In females, ulcers may be found anywhere on the external genitalia, including around the vulva, clitoris and anus, or inside the vagina and on the cervix. Chancroid ulcers are painful and the syphilis one is not. 

Patients often develop enlarged lymph nodes in the groin, called bubos.

Treatment
Co-trimoxazole, two tablets (each tablet 80mg trimethoprim, 400mg sulphamethoxazole) orally twice a day for seven

days, or Erythromycin 500mg six hourly for seven days. See also treatment protocol page five.

Note: there is considerable geographical variation in the sensitivity of H. ducreyi to antimicrobials; in some parts of the world this bacterium is resistant to sulphonamides and possibly also to trimethoprim (including co-trimoxazole), tetracycline and streptomycin. Nevertheless, co-trimoxazole is still highly effective in many areas, but not in Thailand.

An appropriate choice can be made from the above, or: 640mg Trimethoprim/3200mg sulphametrole (i.e. eight tablets where each contains 80mg/400mg), orally in a single dose.

Amoxycillin 500mg with clavulanic acid 250mg orally every eight hours for three days. Enlarged lymph nodes (bubos) should be aspirated with wide-bore needle every two days if necessary. When a bubo is ready for aspiration, the overlying skin is shiny and the area underneath is soft. Take a sterile 5ml syringe and a wide-bore needle. Clean the skin over the bubo with methylated spirit on a cotton wool swab. Pierce the shiny skin entering only 2mm and suck out as much pus as possible into the syringe.

Syphilis
This Is caused by a bacterium known as Treponema pallidum. This disease can affect all organs of the body. It occurs in two forms - early (primary and secondary stages) and late syphilis. During early syphilis, the patient is infectious to his/her sexual partner. During fate syphilis, the patient is not infectious to sexual partners. Between early and late syphilis, the disease enters a latent phase which may continue for many years, when there are no symptoms or signs.

Signs and symptoms
 
Primary syphilis: Three weeks after contact with an infected partner an ulcer develops at the site of infection. This ulcer is the 'primary chancre'. It may be found anywhere on the penis in males, or in females on the external genitalia, the vaginal opening, inside the vagina or on the cervix. In both cases, it is a painless, single, firm ulcer with a 'punched out' (i.e. raised lump) appearance. It may heal without treatment. The inguinal (pelvic) lymph nodes become enlarged and feel rubbery.

Secondary syphilis:
Between two and four months following initial infection, patients may develop secondary syphilis. The first sign is a non-itchy rash all over the body which may become popular (round, solid raised lesion of skin), pustular (infected pimples), or may develop into flat warts (condylomata lata). There may be whitish lines on the tongue and mucous membrane of the mouth called 'snailtrack' ulcers. There may be generalised lymph node enlargement.

Latent syphilis:
During this stage, there are no signs or symptoms but a blood test is positive and the patient should be treated.

Late syphilis: 
Untreated syphilis may progress. After between two and 15 years, the heart and brain may be affected. At this time the disease cannot be passed to other people.

Laboratory diagnosis 
Many Third World countries lack the necessary equipment for laboratory diagnosis of syphilis - STD programmes should be supplied with testing equipment as a matter of urgency. There are two types of blood tests for syphilis: non-specific and specific tests.

Non-specific tests: These are the VDRL and Rapid Plasma Reagin (RPR) tests. These tests are cheap and quick to perform but may give a false positive result i.e. sometimes the test is positive when the patient is not infected. Treat all patients whose blood gives a positive result. These tests will give a positive result about five weeks after initial infection, and should revert to negative within six months of successful treatment. If the result does not become negative, the patient should be retreated.

Specific tests: These tests are only for syphilis but are expensive. Tests may remain positive for life despite adequate treatment. The Absorbed Fluorescent Treponemal Antibody (FTA-Abs) test is highly specific for syphilis and becomes positive three weeks after initial infection. The Treponema Pallidum Haemagglutination Assay (TPHA) is also a specific test which becomes positive five weeks after infection.

Treatment
 

Educate your patient about syphilis: this is a serious disease that causes permanent disability, and may affect the unborn child (see previous article). All sexual partners should be traced, examined and treated even if they have no symptoms or signs. For primary and secondary syphilis, give a single dose of Benzathine penicillin by intramuscular injection of 2,4 million units (1,2m units in each buttock).  For patients without signs or symptoms, but who have had a positive blood test for syphilis, give Benzathine penicillin 2,4 m units, weekly for three weeks. For late syphilis, patients should be treated in a hospital. For patients allergic to penicillin, give tetracycline 500mg orally, every six hours for 14 days EXCEPT to pregnant or breastfeeding women - in which case, treat with erythromycin instead, 500mg orally every six hours for 14 days. Following treatment, review the patient after a month. Have the symptoms disappeared ? If the sore persists, treat as chancroid. Has the partner been treated?

Genital herpes
This is caused by the herpes simplex virus and is the major cause of genital ulcers in the developed world. The incubation period is short.

Signs and symptoms
In males, the patient develops itchiness at the site of infection. This may be on the foreskin, the shaft of the penis or the glans penis. A small area of redness appears which develops into small blisters. These may break down to reveal painful, shallow ulcers. In the first attack lesions are more extensive and cause severe pain. The lesions heal after about two to three weeks. In females, the lesions are on the cervix, the labia, the vagina, or around the anus. During the first attack there may be quite extensive inflammation of the cervix, the vulva and vagina.

Recurrence of lesions occur in about 50% of patients, and lesions are usually less extensive and heal within five to seven days. Recurrences in both males and females may follow sexual contact, stress and, in females, the menstrual period.

Treatment There is no effective cure. Patients should be reassured but warned that a recurrence of ulceration is a possibility and he/she should not have sexual intercourse while lesions are present, as the Herpes Simplex Virus can be passed on during this stage. Tell the patient to keep the lesions clean and dry and wash with soap and water.


Treatment protocol for genital ulcers

Frequently, in an ulcer that looks like chancroid, the bacterium causing syphilis can also be found. It is safe to assume that all large genital ulcers could be double infections of both chancroid and syphilis. Where there are no diagnostic tests far syphilis, and the patient is not likely to be seen again, the following treatment protocol is particularly useful:

In cases of possible double infection with chancroid and syphilis in areas where H. ducreyi is known to inactivate penicillin, treat and cure chancroid before treating syphilis. Otherwise, penicillin given to treat syphilis may be destroyed by H. ducreyi.

1. If patient allergic to penicillin, give tetracycline 500mg orally, six hourly for 14 days, EXCEPT where pregnant or breastfeeding, in which case give erytnromycin (same dose and regimen) instead. If after one week the ulcer is not healing, REFER to nearest hospital or clinic.
2. Where each tablet contains 80mg trimethoprim/400 mg sulphamethoxazole.

Adapted from Sexually Transmitted Diseases produced by the Zimbabwe Essential Drugs Action Programme, Training Unit, Ministry of Health.

A day in the life of Gente Joven

In Spanish Gente Joven means 'young people' - and is the name given to a pioneering Mexican youth movement. Focusing on issues of sexuality, the organisation is dedicated to promoting a better understanding of the problems faced by adolescents and to finding some answers. Hilary Hughes, from AIDS Action, spent a day with Gente Joven's community promoters in the northern city of Monterrey - a local group which has attracted nearly 26,000 members.

'I'm going to show you our Sex Education Week' exclaimed Itziar Rocha - the dynamic, 27 year-old director of Monterrey's Gente Joven. It was 8.30 in the morning, and she had arrived to take me to the city's largest state technical college for the launch of Sex Education Week. The college has around 8,000 students attending part-time courses, mainly in mechanical engineering, social work or tourism. Every month, Gente Joven (GJ) organises a week of educational activities on sexuality for a few hundred students at a time.

Sexuality in school 
On arrival, we entered a hall in semi-darkness where over 200 students aged between 16 and 19 years were watching a film. It was a moving and well-acted story about a young boy and his relationship with his drug-addict brother and his father. It explored difficulties in family communication and personal identity. When the film had finished, Geraldo Hemandez Sosa, a trained psychologist working as a volunteer for GJ, guided students into a discussion and invited comments from the audience. Students had the opportunity of writing down personal questions anonymously and putting them in a 'discussion box' which was passed around. 

'Most emotional problems faced by teenagers are rooted in difficulties in talking to parents and feeling accepted and understood - this is why family communication is covered in our activities' Itziar, also a trained psychologist, explains. 'Problems at home may lead to drug-taking, for example. Marijuana is cheap and popular in the shanty towns and in some, areas, marijuana and cocaine are sold in schools!' 

'Another problem some youngsters face at home is incest (usually where fathers sexually abuse their daughters). This is very difficult to deal with, especially when tolerated by the mother.' Some women think "Well, it's better than him going off with another woman..." But all the while, the poor girl has feelings she cannot deal with - she often feels "dirty" and guilty.'

Since communication is a two-way process, parents are invited to take part in a special introductory session at the start of Sex Education Week. Here, they are also told what their children will be learning.

Five themes 
The Gente Joven ten - hour course is divided into five sessions, each two hours long, covering:
 

	family communication;
	human development - including the process of fertilisation, birth and the responsibility of parenthood;
	sexuality and youth - including the topics of masturbation, prostitution, premarital sex, marriage and chastity;
	sexually transmitted diseases - including symptoms, methods of transmission and prevention of common STDs, as well as HIV infection and AIDS;
	unwanted pregnancy and contraception - including physical and social consequences of teenage pregnancy, different contraceptive methods and the advantages and disadvantages of each.

At the end of the course, youngsters are given a multiple choice questionnaire to test their knowledge, and invited to join GJ as members. In addition to being part of an active social and educational movement, members receive free medical, family planning and counselling services. 

'Some schools have objected to Sex Education Week,' states Itziar, 'but most recognise the urgent need to give young people information that allows them to develop their sexuality in a healthy and responsible manner.' In Mexico, there are about 20 million youngsters aged between 11 and 19 years; a significant proportion have their first sexual experience before the age of 16, and 70 per cent have an active sex life before the age of 19. In its efforts to reach as wide a range of youngsters as possible, GJ does not confine its activities to schools, but organises educational and social events in the workplace and among street kids. The local Catholic church has also invited GJ to work with teenagers in the parish. 'At first we thought it would be difficult talking about sex and condoms in front of a priest! But because of AIDS the priest knows everyone has a right to health education.'

San Bernabe and the puppet show

By midday it was time to move on to San Bernabe - a large and very poor shanty town on the outskirts of Monterrey, where eight trained health promoters organise regular activities. Here, houses are built of corrugated metal and breeze blocks, spread over miles of dusty wasteland, where there is limited water supply and little or no electricity. 

At the crossroads between two wide, dusty streets, we discovered a group of adults and children watching a puppet show. As I arrived, the glove-puppet housewife was beating her unfaithful husband. It was part of a story of community life, told with hand-made glove puppets representing a variety of characters - a single mother, a young street child, a homosexual man, a factory worker...But the story was not just for entertainment, it clearly showed the dangers of having unprotected sex with many partners.  Working in the shantytowns had not been easy. 'On one of our first visits here, the promoters stayed too late - as they prepared to leave (it was around 8.00pm) local gangs tried to break into the car and attack them,' Itziar recalls. 'There is a lot of violence, and alcoholism. Men can be abusive towards the female promoters. Every month there are 2,000 robberies and around 20 deaths due to violent crime. It's therefore very important to gain the confidence and cooperation of community leaders. Here, for example, we work with Maria Elena, the municipal president responsible for coordinating the provision of low-cost, state-owned land to homeless families. She is a powerful community activist and has recently offered us free land to set up a community clinic and advice centre.'

 
Meeting the promoters 
Early afternoon we returned to the small Gente Joven office for a meeting with the community promoters. Many are young women or men attending social work courses, or on six-month attachments from courses at the School of Psychology and Media Communications. 'All the promoters receive over 100 hours of training and are tested on their knowledge before starting voluntary work...' explains Patti, a 22-year-old promoter, who works more than ten hours a day coordinating activities in San Bernabe. The organisation has built up an impressive team of professional volunteers. Thirty-six community promoters now work in nearly as many districts, recruiting up to 4,000 new students every month. Most promoters are at least 18 years old: 'This is because we found that older-promoters have more respect from the community - they should be quite smartly dressed, for the same reason.' Promoters have regular meetings to evaluate activities and keep detailed diaries of the courses they run, including the age and numbers of new students reached.

'One of our promoters, Pancho, is an ex-street leader,' Itziar remembers, 'He was part of a group of youngsters we wanted to work with - the street gangs or chicos bandas as they are known here - but he was very unfriendly towards us to start with. But then I said: "OK. So what do you want to do ? What is it you want ?" He told me "I'm interested in body-building." So that's what we helped some of the chicos bandas to do - we set up body-building sessions in a gym.' Once these activities are organised, it is easier to motivate youngsters to take part in other educational activities.

Street talks
By early evening we were on our way to the last visit of the day. Itziar and three promoters set off to a shanty town at the request of Maria Teresa, who coordinates local income-generating and social projects for young people. Tonight, Itziar was to recruit a new crowd of youngsters for the ten-hour sexuality course. As soon as the car entered the street, children were running round, banging in friendly excitement on the windows and doors. Within half an hour, teen-agers and children alike had made seats out of old planks of wood and building bricks for an informal, open-air gathering. Some of the older teenagers stood at a distance, leaning casually against the car and neighboring houses, as Itziar stood  up and explained why she, had come and what Gente Joven had to offer. 'For those of you who want to join in - we'll be meeting over in the building on the comer next Tuesday evening. All of you older ones are invited - especially those with girlfriends and boyfriends.' 

'I have a girlfriend!' shouted an eight-year-old. The older ones all laughed: 'You're too young.'

Gente Joven would like to hear from similar youth movements worldwide. Please write to: Itziar Rocha Guzman, Gente Joven, Rio Magallanes 225, Colonia Mitras Norte, 64320, Monterrey, Mexico D. F., Mexico.

Readers' Comments

Dear AIDS action, 
We are writing in response to your very useful item on the simple blood testing equipment developed by DuPont - HIV chek. However, we wish to draw your readers' attention to the following: 
 

	The assay is ideally performed by trained staff in blood banks and clinical laboratories for screening of blood for transfusion purposes. Where individuals receive their results, adequate pre-and post-test counselling must be given. The test should not be used by personnel with little or no knowledge of serological assays.
	Frozen blood samples should not be used as these may give false positive results.
	Each reagent in the assay requires a clean bulb pipette supplied in the kit. Bulb pipettes MUST NOT be reused in a desire to economise - contamination of one reagent with another affects the result.
	As with other assays, positive results should be confirmed by repeat test, or by using another recognised testing method, except where blood is being screened for supplies, when positive batches are automatically discarded.

Mike Bailey and Kwesi Tsiquaye, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine

(UK).


Dear AIDS action,
In issue four of your newsletter I read an article on safer sex counselling. My worry is that I do not know how to have sexual relationships without penetration. Kindly print additional articles on safer alternatives to penetrative sex, and if possible further information on how to use the condom.

Your assistance would be highly appreciated. 

GS, Zambia


Dear AIDS action,
I am pleased to write to you in appreciation of the AIDS action newsletters which have reached me. Many people appreciate your efforts to give others worldwide an idea of what AIDS is, how it can be prevented and how counselling HIV infected people can be approached. So many people want to read the newsletter, that the ten copies you sent me have disappeared without me keeping a copy for myself.

Please send me additional copies in both English and French.

N E Ndzi, Subdivisional Hospital, N. W. Province, Cameroon.

New Resources

Colour slide sets 
From Teaching Aids at Low Cost (TALC, UK):
HIV infection - virology and transmission
A set of 24 slides for teaching doctors, medical students, and health workers about HIV infection and AIDS. Includes teaching notes and questions and answers for discussion. Could be used as a complete talk, or individual slides can be selected out to illustrate other lectures. Covers epidemiology, virology, immunology and transmission of HIV infection.

HIV infection - clinical manifestations
Second in the colour slide set series: aimed at doctors and nurses caring for people with AIDS and those who are responsible for teaching others about HIV infection/AIDS. This set is best used with students who have seen the above set on virology and transmission.

Both slide sets mentioned above are available from: Teaching Aids at Low Cost, PO Box 49, St. Albans, Herts. AL1 4AX, UK. Price: set of 24 colour slides, self-mount, with instructions, £2.75 (for developing countries) including p&p. Mounted slides £4.40. Add 60p for airmail.

Manuals 
From the International Planned Parent hood Federation:

'Talking AIDS' -community workers A guide for community workers 
A practical handbook for all community workers and teachers involved in AIDS education. Provides basic information on AIDS/HIV infection, including transmission; prevention and care in social and economic contexts; approaches to counselling and how prejudices can hinder positive action. The book is well illustrated with cartoons and diagrams, stimulating thought on how readers should approach problems posed by HIV/AIDS in their own communities.
ISBN 0-333-49781-3 Price: free to IPPF network, or £1.25, (excluding p&p).

Preventing a crisis  - AIDS and family planning work
A larger resource manual aimed at family planning associations, teachers and youth leaders. Includes ideas and approaches to training, education and service delivery. Can be used to develop training materials and guidelines for workers
ISBN 0-86089-081-3 Price: free to IPPF network, or £6.00 (excluding p&p).

Both manuals available from: Macmillan Distribution Ltd, Houndsmills, Basingstoke, Hampshire RG21 2XS, UK

Apology  Please note: the Counselling Hints item on the use of condoms in issue 5 was produced by AHRTAG. It was not the responsibility in any way of Sister Maura O' Donohue who supplied the guidelines on the safe disposal of placenta in the adjacent Health Precautions feature. We apologise for any confusion caused by the misleading page layout.

WHO Report - Global Programme on AIDS

World AIDS Day - a special embrace

 

It was probably the first occasion in history when the world united - on one particular day - around a single health issue. The day was December 1 1988, and the message was one of hope and international solidarity: organisations across the world presented imaginative new ideas to educate populations about AIDS. At the WHO coordinating centre in Geneva, health educator Richard Rector - a man with AIDS - stood up and gave fellow health educators worldwide the most important message of all: 'We must recognise that people with AIDS or HIV infection...can offer expertise that cannot be learned in the laboratory. We must reach out to include their expertise in AIDS education and discussions on the provision of care.' Beyond Geneva, people from every country joined in response to WHO's call to 'Tell the world what you are doing about AIDS'. The following is a selection of the more high-profile activities - hundreds of other groups not listed here were also busy with work-shops, lectures, discussions and cultural events.

Benin: AIDS messages in churches, temples and mosques. Botswana: music festival; song contests for local bands; poster competition for secondary schools; football match. Brazil: photographic exhibition on the theme of non-discrimination; art exhibition by artists with AIDS; and opening of a special care centre for AIDS patients. Bulgaria: special brochures; talks in schools and factories; TV programmes, films, round-tables; AIDS week. Burkina Faso: inauguration of a documentation centre; AIDS week; posters and banners displayed in the street; cycling race. CAREC (Caribbean Epidemiology Centre): newsletter initiated. China: AIDS quiz; concert; special radio programmes on health and hygiene. Democratic Yemen: first laboratory on AIDS inaugurated. Federal Republic of Germany: painting of a 2,000 metre long cotton banner with expressions of hope for those with AIDS. Guinea Bissau: speech by President; anti-AIDS propaganda in bars and nightclubs; AIDS week; parades in the main street of the capital. Israel: hotline for questions at central blood bank; AIDS materials and discussions for prison warders and inmates, soldiers, schools, medical staff. Kuwait: all five national newspapers distributed WHO pamphlets on AIDS. Malawi: World AIDS Day message on postal franking machines; USAID to ship one million condoms to arrive by World AIDS Day. Mauritius: health newsletter on AIDS launched; 800 balloons released; T-shirt distribution to cycle rally and mountain climbing participants. Sweden: gala benefit performance at the Opera House followed by fund raising appeals broadcast throughout the day on radio and television. Thailand: massive education campaign; anti-AIDS week; concerts, 'walkathon', and celebrity fundraising drive; parades, dances, drama. Tonga: address by the King; special religious services; seminars and workshops; song competition. United Kingdom: conference on 'AIDS needs for the 1990s'.

Putting the pieces together
One project in particular symbolised growing international solidarity. It is known as The Names Project and began in 1987 when a man from San Francisco died of AIDS. friends and relatives made the first cloth panel of what was to become a giant patch-work quilt, commemorating the lives of those who have died of AIDS. The quilt - now made with over 10,000 panels - is displayed in California, commemorating men, women and children from different countries. On World AIDS Day, sections of the quilt were sent to Switzerland, Belgium, Brazil, Canada, Germany, Norway and the United Kingdom for exhibition.

The Names Project gives artistic expression to one of the major themes of World AIDS Day: the human face of AIDS. It reminds us all of the need to do our best to care for people with AIDS, to end discrimination and to find effective ways of disease prevention. World AIDS Day - and the many successful community-based AIDS projects it represents - points the way towards a more effective response to many other worldwide illnesses. When asked: 'Why so much emphasis on AIDS? Why AIDS when there are so many other diseases?' Dr Jonathan Mann, Director of the WHO Global Programme on AIDS, replied: 'Why not approach other diseases with this kind of solidarity?'

Adapted from AIDS Health Promotion Exchange

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