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AIDS action - Issue 10 - Epidemiology and Infections

AIDS action  Issue 10         Page 1   2 

Why some organizations will not be attending the largest international conference on AIDS

Discriminating against people infected with HIV, the virus that causes AIDS, does nothing to help stop the spread of this fatal disease; it can only increase the irrational fear and misunderstanding that drives HIV 'underground'. People become unwilling to confront the fact that they, or their sexual partner, may be infected. And they are unable to fully accept the need to change their behaviour.

 

• Restrictions against international travellers on the basis of their HIV status is one example of discrimination that is a senseless and ineffective attempt to slow down the spread of HIV. Despite a resolution passed by the World Health Assembly in 1988, urging governments to avoid discriminating against HIV infected travellers, a few governments have still imposed HIV-related restrictions. Such restrictions in the United States of America have caused a serious international dilemma surrounding the world's largest conference on AIDS - the Sixth International Conference, due to be held in San Francisco in June 1990. 

• If you are infected with HIV and you want to travel to the States, current law prohibits you from entering the country. HIV infection is included in a list of  'dangerous contagious diseases' - even though no - one else can catch HIV from you unless they have unsafe sex with you, or share needles to inject drugs. Travellers have two choices: to declare their HIV status to the American Embassy in their own country and apply for a waiver; or to hide their HIV status and hope they are not stopped at immigration. If a traveller is found to be carrying AIDS-related medication or other items that might raise suspicion of HIV infection, this could mean immediate deportation or imprisonment following detailed interrogation. 
   

• Applying for a waiver is a breach of the right to confidentiality for an HIV positive individual. Many organisations wishing to be represented at the AIDS conference in San Francisco are concerned about the problems facing HIV positive delegates. The then AIDS Coordinator for the League of Red Cross and Red Crescent Societies, Barbara Wallace, stated in November last year: 'I do not see how we can follow our humanitarian principles and still sponsor (fund) delegates to attend the Sixth International Conference. 
  
  In a number of countries, some of our most effective staff members working on AIDS are HIV positive. We can also expect that the National Society staff will have the same levels of infection found in the general adult population; in some areas this is now 20-35% or more. Offering them sponsorship would clearly mean they would have to declare their infection; not offering them sponsorship would mean we were participating in discrimination.'

• For many organisations, one option has been to withdraw from the conference in protest over the restrictions. Scandinavian AIDS organisations were the first to announce a boycott in October last year, followed by withdrawal of the League of Red Cross and Red Crescent Societies, which links 148 national societies worldwide. [See page 8 for a list of withdrawing organisations.]

•  Withdrawing participants hope to persuade the US Administration to change its travel restrictions permanently. Although some progress has been made, recent concessions only apply to two international conferences: a new, short-term (ten day) visa will be available for people attending the San Francisco Conference and the International Congress of the World Federation of Haemophilia to be held in Washington in August. Whilst these special ten-day visas do not require individuals to state whether they are HIV positive, it is most likely that only participants who know they are HIV positive will apply. 

• Following the introduction of the new ten-day waiver, the World Health Organization (WHO) announced its decision to continue to sponsor the San Francisco conference, but indicated that the situation regarding US travel restrictions was still 'not completely satisfactory.' So far, 8,000 participants have already registered for the conference, despite expectations of demonstrations surrounding conference events.

• Withdrawing from the conference has been a hard decision; many in the scientific community who have chosen to attend the conference have expressed regret at the absence of people with AIDS/HIV infection and the majority of non-government organisations (NGOs). Withdrawing participants were worried about losing the opportunity to meet with sister organisations and funders on an international level. However, the conference for NGOs - planned to occur prior to the San Francisco conference - is now being rescheduled later this year in a country without HIV-related travel restrictions, possibly France in October.

• It is now very unlikely that any significant changes to the law will be made before the Conference in June; the conference withdrawal is the beginning of a long-term campaign and not an end in itself. Neither is it about one conference or one country. Withdrawing organisations have demonstrated the strength of joint action in putting the issue of anti-discrimination on the agendas of national governments. Events around San Francisco have highlighted the need for a practical commitment to human rights in a country which usually sets international standards and legal precedents. 

In this issue   AIDS epidemiology Mexico and the Caribbean HIV-related skin conditions  Education Haiti and Mexico WHO Report What does adult AIDS look like? Reported cases worldwide

The international newsletter for information exchange on AIDS prevention and control.

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AIDS action  Issue 10    1   Page 2   3 

Skin conditions common to people with HIV infection or AIDS

Skin conditions are of great importance in the diagnosis of HIV/AIDS. Skin is often the first barrier the human body has against disease causing organisms. Skin is also an external indicator of disease. The health worker may use skin conditions to predict progression of immunodeficiency in a patient with HIV infection. 

The WHO clinical criteria for AIDS diagnosis in Africa include four skin conditions: Kaposi's sarcoma, Herpes zoster, Herpes simplex and pruritic (itching) maculopapular rash. These have been reported to have a predictive value for HIV seropositivity ranging from 71 per cent to 98 per cent. However, it is important to remember that many skin conditions suffered by people with HIV infection are also seen in non-infected patients.

In HIV infected patients and non-infected patients, skin conditions may arise from single or multiple causes. For simplicity they may be classified as follows: 

1. Generalised dermatitis (inflammation) 

• pruritic maculopapular skin rash 

• drug reactions

2. Infections/infestations 

• bacterial

• fungal

• viral

• parasitic 

3. Skin tumours 

• e. g. Kaposi's sarcoma (a normally rare form of skin cancer, but commonly found in AIDS patients) phase sooth 

The skin conditions most indicative of HIV disease are described below. Treatment options may depend on local cost and availability of drugs. 

Pruritic maculopapular rash (prurigo)
 

Skin lesions (that is, any abnormal change in the skin tissue) are widespread and very itchy. The rash is often the first outward sign of HIV infection, and occurs as early as two years before the other signs of AIDS develop. In Uganda it occurs in 35 per cent of AIDS cases reported. No organism has yet been identified as the cause of this rash.  The small flat spots (macules) develop into papules or small blisters. Scratching may lead to secondary bacterial infection. Similar rashes may occur with syphilis (although syphilis is classically non-itchy), drug reaction and scabies.

Treatment: There is no specific treatment for prurigo. The patient can be reassured that the itching lasts only a short time but a permanent hyperpigmented 'rash' may remain. During the itchy phase soothing preparations such as calamine lotion or E45 emollient cream can be applied. Occasionally antihistamine may be necessary, e. g. chlorpheniramine 10mg 8 hourly.

Bacterial infections

Sometimes skin lesions become secondarily infected with bacteria; usually Staphylococcus aureus and Streptococcus species. This may lead to inflammation with redness, swelling and pain and  sometimes there may be frank pus visible. Patients with HIV are more prone to develop folliculitis with inflammation (and occasional infection) of the hair follicles.

Treatment: Superficial infection may clear with adequate cleaning with soap and water. Persistent folliculitis or carbuncles should be treated with flucoxacillin 250mg QDS for seven days (clindamycin 150mg QDS if penicillin allergic). Carbuncles may require incision and drainage. If there is spreading cellulitis (redness and swelling of the surrounding skin) the IV or IM antibiotics should be used if possible. Topical antibiotics should not be used. 

Fungal infections

In HIV/AIDS fungal infections are more severe and often develop secondary infection. A fungal infection should be suspected when a skin lesion is isolated, asymmetrical, itchy, dry and scaling. Fungal diseases are most often caused by the species Epidermophyton and Trichophyton. Candidiasis (thrush) is caused by yeasts, mainly Candida albicans and a small percentage by Tolurosis glabrata. 

Many HIV infected patients suffer from greasy lesions affecting the scalp in a dandruff-like manner (seborrhoeic dermatitis). Fungal diseases more typically present as ringworms of the scalp with grey rings of hair loss (Tinea capitis). Similar isolated rings may be seen as patches on the body (Tinea corporis), but if they present in widespread, rash-like manner they are known as Tinea vesicolor. Fungal disease in the pubic hair may form itchy, scaly lesions, similar to that caused by lice and scabies. 

The groin, armpits and skin folds (as well as the mouth) are more prone to Candida infections, which may be quite itchy, especially on sweating, and may even ulcerate. The nails and skin between the toes (athlete's foot) are also common sites of fungal infections. 

Treatment: Whitfield's ointment (compound benzoate ointment) is effective for ringworm but needs repeated application and may not be cosmetically acceptable to some patients. Specific antifungal, creams such as miconazole or clotrimazole are more effective. they should be applied twice daily to affected areas for at least two weeks (ideally four weeks). Powder forms also exist for treating fungal infections between toes. 

Systemic antifungal tablets such as ketoconazole, fluconazole and itraconazole are also effective but are no better than topical treatments. In addition to being costly, the drugs are more likely to have side effects such as nausea and vomiting. Ketoconazole has been known to cause liver damage but very rarely.

When there is significant inflammation in association with a fungal skin infection, it is sometimes useful to use an antifungal preparation combined with a mild steroid, e. g. Daktacort cream.

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AIDS action  Issue 10    2   Page 3   4 

Viral infections

In HIV/AIDS, viral infections are often more widespread, aggressive, recurrent or chronic than in non-infected patients. 

Herpes simplex
Infection by this virus commonly presents as a cold sore on the lips, or as a genital sore, but may present at other sites. In HIV disease, patients typically complain of repeated painful sores at the same site, preceded by irritation and vesicles (fluid filled patches). These ulcers become deep and get infected. In Africa four to six per cent of HIV patients have been reported to have chronic ulcerative Herpes simplex.

Treatment: Simple cold sores will usually heal by themselves. Genital herpes may be soothed by salt water baths (one tablespoon of salt in a bath of warm water). Gentian violet lotion may help to reduce secondary infection if applied twice daily.

If available, acyclovir tablets, 200mg five times daily for five days, help acute attacks settle quickly. For patients troubled by chronic infection, one acyclovir tablet daily helps to suppress symptoms.


Herpes zoster (shingles)
 

This is caused by Varicella zoster virus. It is said to follow reduced immunity in a dorsal nerve root. This is believed to activate a latent infection. HIV has been associated with an increased incidence of Herpes zoster. Reports from Africa suggest that it occurs in 6-23 per cent of AIDS cases seen. Its predictive value for HIV seropositivity in Uganda is 98 per cent.  In HIV, it may cover one or more sensory nerve dermatomes. Early symptoms consist of two to four days of intense pain and burning sensation in a particular area. The skin erupts to form vesicles which ulcerate to form deep ulcers. These heal with disfiguring scars. This looks like a belt round one part of the body, hence the name 'belt disease' as it is known in Uganda.

Treatment: Most attacks of herpes zoster heal by themselves. It is often necessary to give analgesics like aspirin or paracetamol to control the pain. Gentian violet paint may help to prevent secondary infection. When shingles affects the eye, acyclovir tablets (800mg five times daily) should be given if available. Acyclovir drops or eye ointment should be given as well. The high cost of acyclovir means that its use to treat shingles on other parts of the body is rarely justified.

Skin tumours

Kaposi's sarcoma
 

This tumour of the endothelial cells of blood vessels has been endemic in tropical Africa and among European Ashkenazi Jews and some Mediterranean populations for decades. With the HIV pandemic it has presented in a different way. It affects wider age groups, both sexes, and it is disseminated and more aggressive than the endemic type. When seen in this form in HIV positive patients it is diagnostic of AIDS. It appears as a nodule or plaque which could be purple or red/brown and is often associated with swelling. A single lesion is not diagnostic and may need biopsy to differentiate it from other conditions, e. g. malignant melanoma.

Treatment: Disfigurement may necessitate treatment of the lesions. Treatment options include radiotherapy and systemic cytotoxics (drugs used to kill cancer cells), such as vincristine. Intralesional injections of the drug interferon have also given successful results with some patients. Patients should be referred to the nearest treatment centre wherever possible.

Dr Sam Kalibala, AIDS Physician, The AIDS Support Organisation (TASO), PO Box 676, Kampala, Uganda

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AIDS action  Issue 10    3   Page 4   5 

Haiti

This tiny country is populated by the poorest and most exploited people in Latin America and the Caribbean; it also has the region's highest recorded rate of AIDS. Out of a population of six million 2,331 cases of AIDS were registered between 1981 and September 1989. The Medium Term Plan for Haiti, covering the period 1989-1993, has a budget of nearly eight million dollars. But in a country where health and social services barely reach a fifth of the population, the government programme has had little impact on the poor majority. Executive editor Hilary Hughes describes two successful community-based campaigns coordinated by voluntary organisations. 

Beauty parlours and health promoters
In the poor neighbourhoods of the capital city of Port au Prince are hundreds of brightly painted beauty parlours, displaying signs like 'Femme Moderne, studio de beaute'. They are popular and cheap; between 70 and 80 per cent of the population use them. In the south of the city, a team of health promotion volunteers are turning some 64 beauty parlours into AIDS education and condom distribution centres - with the help and cooperation of the owners. 

The majority of these beauty parlours are owned and run by women who cannot find work elsewhere, including many immigrants from the Dominican Republic. Some proprietors work as prostitutes in the evenings because they cannot survive on the earnings of the parlours. These proprietors are now becoming AIDS educators - talking to customers, handing out leaflets and distributing free condoms. The team of young volunteers responsible for this education programme belong to the Centre for Haitian Social Services (CHASS); a non-profit, voluntary organisation set up in 1987 as a community response to the lack of government health and social services.

The Centre heads a multidisciplinary team of health workers and volunteers who collaborate closely with other agencies working in similar fields, such as AIDS, sexually transmitted diseases and drug addiction. 

One of the CHASS volunteers explains: 'The beauty parlours were chosen as a focal point for reaching the population. To start with, one box of condoms was distributed every week, now the owners are distributing three or four boxes. We encourage them to keep a record of numbers taken, client's age, sex, marital status and so on.' The majority of volunteer health promoters are ex-students who have given up their studies because of lack of funds. Many cannot find jobs, and they are encouraged to develop skills in their volunteer work which could help them find employment in the future. The team of volunteers meets every Saturday to discuss the programme and training needs that arise. 'At first the focus of our training was on AIDS, but now we need more information about other related issues, such as leprosy, or drug addiction, family planning and so on.'
 

The most urgent need is to find out what local people's thoughts and understandings are about the disease. CHASS has designed a questionnaire in Creole and French for use in a knowledge, attitude and practice (KAP) survey. Volunteers are interviewing over 1,000 local residents, and will randomly select 200 questionnaires to analyse. Information gathered will provide a basis for planning and orienting health education messages. 'The problem with planning any educational programme,' explains Daniel Bernier, 'is that Haitians work most of their waking hours and so we are trying to organise mass education at traditional public gatherings, such as at church and the gaga [a traditional religious ceremony].'

For further information: Daniel Bernier, CHASS, Fontamara 41, no 209, Carrefour, Port au Prince, Haiti.

Educating factory workers 
There are approximately 50,000 workers employed in the light assembly industry in Haiti. About 70% are women, the majority of whom are aged between 25 and 34 years, and are either single or in a non-permanent relationship with the father of their children. Many live and work in appalling conditions, surviving on very low wages to support several children and an extended family. AIDS is now a visible problem in many factories. 

In October 1988, the Centre for the Promotion of Women Workers (Centre de Promotion des Femmes Ouvriers/CPFO) launched a pilot AIDS education programme for factory women. The Centre, based in a large industrial zone near the airport, runs a health clinic and courses in literacy, communications skills, health promotion and family planning. 

The new AIDS programme allowed CPFO staff to gain entry into factories for the first time. Other courses were held outside working hours and outside factory premises. Staff contacted managers by telephone to arrange a meeting to discuss AIDS and to ask permission to hold educational 'round tables' with workers. Of 18 managers in the factories approached over a 12 month period, only two refused entry to CPFO staff. Almost all managers reported they had registered between two and five deaths from AIDS among their employees over the past couple of years.

A total of 85 educational sessions, each lasting about two hours, were held within 28 different factories, community or labour organisations reaching 3,063 workers (male and female). In each session, the presentation was carried out by two CPFO trained monitors and included a slide show, flip charts and the video Met ko, originally produced for Haitian immigrants in New York. 

The most important aspect of the programme was the training of 38 volunteer factory-based health promoters. These promoters attended the round table sessions, where they facilitated discussion and distributed condoms and were subsequently available for counselling co-workers. Initially, the Centre intended to recruit only literate women as promoters, but several non-literate women were selected for training by labour organisations.

Eighteen hours of tuition and discussion on AIDS/HIV were held over two and a half weeks, including sessions on group dynamics and organisational skills. To improve communications skills, sessions included role play exercises which were videotaped and played back to trainees. Training in communication skills also helps promoters participate in activities aimed at supporting a broader range of workers' rights.

For a full report of the pilot phase contact: Centre de Promotion des Femmes Ouvriers, 14 Rue Barbancourt, (Rte de L' Aero-port), PO Box 1329, Port au Prince, Haiti. Fax: 20110.

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AIDS action  Issue 10    4   Page 5   6  

Mexico

What is the advantage of small, community- based organisations working together? Members of Mexicanos contra el SIDA, a confederation of non-government organisations, describe the powerful advantages of mutual co-operation and common planning.

'The confederation was formed in July 1989 and brings together around 15 groups working in the gay community, with women, HIV seropositive people, labourers, students and professionals. This form of cooperation allows each member group to have a stronger political presence, can strengthen its activities and have a better opportunity to gain access to international funds.

Pressure points 
 

During 1989 we started a series of radio programmes in collaboration with the Mexican Radio Institution, IMER. Over 90 radio spots, mostly aimed at youngsters, were transmitted daily from 27 July - 15 December 1989. The confederation member groups also made sixteen full-length programmes. The campaign was very successful, particularly among the youth of Mexico City: we noticed a huge demand for condoms and information from young people who attended rock concerts organised in collaboration with IMER. These radio programmes played an important part in pushing the National AIDS Programme, CONASIDA, into starting public educational campaigns again in September 1989. Before this the government campaign had been influenced by small rightwing pressure groups, such as the anti-abortionists Provida, who put a stop to public education on condoms and AIDS prevention in September 1988.

Legal pursuits
Although the confederation has criticisms of CONASIDA (for example, for not sufficiently confronting the problem of Mexicans infected through contaminated blood banks) we have also supported government efforts. When CONASIDA launched one of the more recent public information campaigns on the metro, Provida and the National Union of Parents in Families tried to take legal action against the Director, Dr Jaime Sepulveda Amor. In protest against these actions, we published a large paid advertisement in the national press threatening to take legal action against Provida for interfering with the public's right to life-saving information.

We have now signed a working agreement with CONASIDA, which is an official recognition of our role in AIDS care and prevention. However, this could be a double-edged sword: CONASIDA has political control over finances which largely come from abroad. Some funders do not support our projects directly, but work through CONASIDA. An official agreement with CONASIDA does not guarantee funds for our activities; in fact, the agreement could become very bureaucratic and slow down our work. For this reason, we are seeking more direct contact with international funding agencies.'

For further information: Arturo Diaz Betancourt, President, Mexicanos Contra el SIDA, Gante No. 7-401, 06000, Mexico DF.

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AIDS action  Issue 10    5   Page 6   7 

News

Director of Global Programme on AIDS resigns

Dr Jonathan Mann, head of the World Health Organization's (WHO) Global Programme on AIDS, resigned on 16 March, 1990. Dr M Merson, head of the Diarrhoeal Disease Control Programme, has been appointed Director of GPA.

Wonderwomen and Superman take on AIDS
 

Superbarrio is the name given to the folk hero and spokesperson of the Asamblea de Barrios - a democratic assembly of Mexico City's poorer neighbourhoods. Dressed like Batman, he is often the central figure in mass demonstrations for better living conditions. Now he is appearing with Superwoman in the Assembly's campaign against AIDS. In February 1990, Superbarrio spoke at the opening of a community AIDS information centre, set up and run by women members of the Assembly. A brigade of volunteer educators handed out leaflets and condoms in the surrounding streets and underground stations.

Epidemiology

HIV/AIDS in Mexico

Francisco Galvan Diaz and Rodolfo N. Morales, from the Mexican group GI-SIDA, look at the serious implications of the current rate of HIV infection.

The first case of AIDS in the country was detected in 1981; by the end of February 1990, 3,944 cases had been registered (Boletin Mensual CONASIDA). However, the exact number of cases is unknown. The government AIDS programme (CONASIDA) estimates that at least 26% of AIDS cases are not registered. In addition around 36.7% of cases, are registered in the final stages of illness: taking into consideration these figures, we estimate there, is actually a total of 6,429 AIDS cases; ha lf of the people affected have already died.

The World Health Organization (WHO) estimates that for each person with AIDS, there are between  50-100 HIV infected people. This would indicate that there are between 321,450 and 642,900 people infected with HIV. The official estimate of 20,000 AIDS cases by the year 2000 is not accurate. Since both CONASIDA and the health secretariat agree that at least half of the infected population will develop AIDS over the next ten years, we believe that the real figure for people with AIDS will be nearer 65,000 by the second half of 1992. The numbers of HIV infected people would be several hundreds of thousands.

Sexual transmission
The nature of the epidemic has changed over time. Only eighteen months ago, for every 24 cases of AIDS in men, there was one woman with AIDS. Now the male/female ratio is 7:1. The increase in AIDS cases in women has largely been attributed to contaminated blood transfusions (see below) rather than sexual trans mission. The current trend of heterosexual and bisexual spread is also growing. Boletin Mensual CONASIDA states that homosexuals account for around 35 per cent of cases, bisexuals for nearly 20 per cent and heterosexuals for just over 14 per cent. Transmission of HIV through blood and blood products accounts for around 17.5 per cent of total cases.

Blood transmission
Of the 468 registered cases in women, 69.7% are associated with contaminated blood transfusions. The authorities have not been able to confront the problem of blood transmission effectively because of the black market trade in blood; the use of blood and sold in this way is responsible for the of cases attributed to of HIV transmission. The most dramatic example is the case of Netzahualcoyotl town, where entire families have been infected with the virus. Of 426 documented cases in the State of Mexico, the majority of them come from this one township where official estimates put the level of infection through blood transfusion at 24 per cent - much higher than the national average.

Campaigning and resources
There is an urgent need to intensify preventive campaign.  The recent government poster campaign on the underground in Mexico City has not been successful - perhaps because the campaign images were better suited to rural areas rather than urban. Nevertheless, this was an important learning experience, and could be extended to the mass media. There is a need for more public sector involvement and intersectoral co-ordination to make the government campaigns more effective - for example, better use of schools and university networks. Up to now, there has been a lack of political will and the government has not addressed the problem of funding for AIDS prevention activities. Campaigns have often been used to promote political events rather than addressing the real issues. We believe that combined efforts of the private and public sector are essential in the fight against this disease. Neither the Red Mexicana (Mexican Network of organisations working on AIDS) nor the Mexicanos contra el SIDA (non-government confederation - see page 5) have yet solved this problem of funding, despite the importance of their organisations. Nevertheless, the popular struggle against AIDS is intensifying. The government sector has not had the last word, and non-government organisations are showing signs of maturity in their combined efforts. This may still change the direction of the epidemic, before 1992. Only time will tell...

Grupo de Investigacion Social sobre el SIDA y Defensa de Derechos Humanos (GI-SIDA), Queretaro No 219-H, 06700 Mexico DF, Mexico.

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AIDS action  Issue 10    6   Page 7   8  

Caribbean

Dr, Jai Narain, from the Caribbean Epidemiology Centre (CAREC) based in Trinidad, summarises regional epidemiological data on HIV/AIDS

The first patient with AIDS reported in the Caribbean was thought to have been diagnoses in Haiti in 1979. In the English speaking Caribbean, the first cases were reported in 1983 from Trinidad y Tobago. All were homosexual or bisexual males with histories of homosexual relationship, with men from North America. However, transmission of HIV now occurs mainly among the heterosexual active population.

As of February 1990, a total of 5707 cases had been reported from the Caribbean basin; 1597 from the English speaking Caribbean countries and Suriname; 3594 from Haiti, Dominican Republic and Cuba; 405 from the French territories Guiana, Guadeloupe and Martinique; 41 from the Netherlands Antilles; and 70 from the US Virgin Islands. Of the 1597 cases in CAREC member countries reported so far, nearly 87 per cent are from five countries: Trinidad and Tobago (551 cases), Bahamas (437), Jamaica (141), Bermuda (135), and Barbados (111). These countries make up approximately 70 per cent of the combined population of CAREC member states. All countries in the region have reported one or more cases. Some countries have exceptionally high case rates. During 1989, the incidence rates of AIDS cases in the Bahamas and Bermuda were in the range of 590-700 per million population, although for CAREC member countries as a whole, the overall rate is considerably lower (97 per million population).

Mode of transmission
The distribution of reported cases by transmission categories are as follows: homosexual or bisexual males 38.6 per cent, heterosexual males and females 42.6 per cent, intravenous (IV) drugs users 7.2 per cent blood transfusion recipients 1.1 per cent, and haemophiliacs 0.5 per cent. In addition, 8.1 per cent perinatal transmission (from infected mother to baby). Overall, sexual transmission was responsible for 82 per cent of the total cases. The proportion of AIDS cases among women has been increasing steadily over the years, from 18.3 speaking of total cases in 1985 to cases were in 1988. 

About ten per cent of all AIDS cases were diagnosed in children under 15 years of age, a portion much higher than in the USA, Canada or the UK where children make up only 1.5 per cent cases. Almost all (97.5 were born to HIV positive mothers.

What is CAREC? The Caribbean Epidemiology Centre was set up in 1975, in response to the need for epidemiologic surveillance and a reference laboratory in the English-speaking Caribbean. The Centre receivers joint funding by member governments, the Pan American Health Organisation (PAHO), and international research and donor agencies. CAREC currently serves 18 English-speaking countries and Suriname. It has two main division (epidemiology and laboratories) and three special programmes: the Expanded Programme on Immunisation (EPI), Zoonoses and Mammalogy, and the Special Programme on Sexually Transmitted diseases (STDs), developed mainly in response to the AIDS epidemic.

Trends
Analysis of transmission categories during the epidemic demonstrates a shift from homo-sexually or bisexually acquired HIV infection to mainly heterosexual transmission, with increasing numbers of women and children affected. Of the adults cases reported in 1986; 34 per cent were in heterosexuals; this proportion rose to 59 per cent in 1989. This pattern has been recorded in all the member countries except Guyana and Bermuda. The male to female ratio in member states has also been declining from 5.4:1 during the period 1983-5, to 2.1:1 in 1989.

Bermuda is the only country in the region (apart from Puerto Rico) which  reports AIDS cases among intravenous (IV) drug users: 60 per cent of all AIDS cases on the island are among IV drug users.

Long-term predictions AIDS are unreliable, but an estimate based on current data indicates that the cumulative total of reported cases by the end of 1990 could reach 2,500 in CAREC member countries.

CAREC, P. O. Box 164, 16-18 Jamaica Blvd., Federation Park, Port of Spain, Trinidad, WI.

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AIDS action  Issue 10    7   Page 8   9 

The following is a partial list of organisations boycotting the San Francisco conference:
 

Africa delegates of ICASO AIDES (France) AIDS Co-ordination Group of Dutch NGOs (Netherlands)  APARTS (France) Australian Federation of AIDS Organisations (AFAO) Austrian AIDS Help Body Positive (UK)  Brazilian Interdisciplinary AIDS Association (ABIA)  British Haemophilia Society British Medical Association (BMA) AIDS Foundation Caritas International (Vatican City) Catholic Fund for Overseas Development (CAFOD, UK) Canadian AIDS Society Canadian Haemophilia Society  Canadian Red Cross Canadian Public Health Association  Christian Medical Commission (Switzerland)  Colectivo Sol (Mexico) Comite Cuidadano Anti-SIDA (Spain) Deutsche AIDS Hilfe (Germany) Dutch Association of People with AIDS  Dutch Gay and Lesbian Organisation  ECHO (UK) Foundation of Dutch Volunteers French Red Cross Frontliners (UK organisation of people with HIV infection)  GAPA -( Brazil)  Gay Men's Health Crisis (USA) Grupo Autoapoyo/EK Ciempies (Spain) Grupa Pela VIDDA (Brazil)  International Council of AIDS Service Organisations (ICASO) International Association of People with AIDS Landmark Trust (UK)

Latin American Network of AIDS Service Organisations League of Red Cross and Red Crescent Societies  London Lighthouse (UK)  Medical Co-ordination Secretariat (Netherlands)  Medical Mission Institute (Germany)  Memisa Medicus Mundi (Netherlands)  Mexicanos Contra el SIDA A. C. Misereor (Germany) Names Project International AIDS Memorial Quilt (USA) National Association of People with AIDS (USA) National Gay and Lesbian Task Force (USA) Native American AIDS Prevention Centre Netherlands STD Foundation  New Zealand AIDS Foundation  Noah's Ark (Sweden) Norwegian AIDS Foundation  Norwegian Red Cross  Pacific Gay Alliance People with HIV in Sweden Group PLUSS (Norway)  Positivigruppen (Denmark) Postiv Leben (Austria) RFSL HIV Kansliet (Sweden)  SCIAF (UK) Shanti project (US)  Swiss AIDS Help  Swiss Federal Centre for Health TASO (The AIDS Support Organisation, Uganda)  Terrence Higgins Trust (UK) Township AIDS Project (South Africa) UK NGO AIDS Consortium for the Third World (includes international organisations such as Action Aid, AHRTAG, British Red Cross, Oxfam, Christian Aid, the International Planned Parenthood Federation, Save the Children Fund) World Council of Churches, AIDS Working Group (Switzerland)

 

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AIDS action  Issue 10    8   Page 9  10 

WHO Report - Special Programme on AIDS

Reported AIDS Cases, as at 31 March, 1990

Taken from Weekly Epidemiological Record, 6 April, 1990

Africa

Country  Last report Cases to date Algeria  26/03/88 13 Angola  31/12/88 104 Benin 05/09/89 60 Botswana  17/01/90 87 Burkina Faso  31/03/89 555 Burundi  30/06/89 2355 Cameroon  31/03/89 78 Cape Verde 31/12/89 28 Central African Republic 31/12/88 662 Chad  17/11/89 21 Comoros 23/01/90 1 Congo  09/12/87 1250 Côte  d'Ivoire 01/02/90 3647 Djibouti  15/02/90 7 Egypt  15/02/90 16 Equatorial Guinea 27/06/89 3 Ethiopia  06/02/90 320 Gabon  10/01/90 51 Gambia  24/08/89 66 Ghana  31/10/89 1077 Guinea 10/10/89 82 Guinea-Bissau 18/05/89 76 Kenya  30/06/89 6004 Lesotho 15/09/89 8 Liberia  11/03/88 2 Libya  15/02/90 0 Madagascar  01/02/89 0 Malawi 30/06/88 2586 Mali  31/10/89 178 Mauritania  31/07/88 0 Mauritius  31/12/89 4 Morocco 31/01/90 45 Mozambique  22/01/90 64 Niger  31/12/89 80 Nigeria  02/08/89 35 Reunion 13/02/90 47 Rwanda  31/12/89 2285 Sao Tome and Principe     14/04/89 2 Senegal  08/03/90 307 Seychelles  08/01/90 0 Sierra Leone 30/06/89 21 Somalia  15/02/90 15 South Africa 15/02/90 353 Sudan  15/02/90 188 Swaziland  16/06/88 14 Tanzania 31/12/89 5627 Togo  13/12/89 56 Tunisia 15/02/90 50 Uganda  15/04/89 7375 Zaire  31/01/90 11732 Zambia  29/01/90 2709 Zimbabwe 19/02/90 1632 Total 51978

Americas

Country Last report Cases to date Anguilla  31/12/89 4 Antigua and Barbuda 31/03/89 3 Argentina 31/12/89 566 Bahamas  31/12/89 437 Barbados  31/12/89 112 Belize  30 09/88 11 Bermuda  31/12/89 135 Bolivia  30/ 06/89 11 Brazil 03/02/90 10058 British Virgin Islands  30/09/89 1 Canada  05/03/90 3557 Cayman Islands  30/09/89 5 Chile  31/12/89 178 Colombia  31/12/89 643 Costa Rica 31/12/89 151 Cuba  31/12/89 63 Dominica  31/12/89 10 Dominican Republic  31/12/89 1200 Ecuador  30/09/89 72 EI Salvador 31/12/89 165 French Guiana  30/06/89 150 Grenada  30/06/89 14 Guadeloupe 13 11/89 175 Guatemala  31/12/89 65 Guyana  31/12/89 84 Haiti  30/09/89 2331 Honduras 31/12/89 512 Jamaica  31/12/89 140 Martinique  31/12/89 115 Mexico  31/12/89 3512 Montserrat  30/06/89 1 Nicaragua  31/12 89 4 Panama  31/12/89 180 Paraguay  30/09/89 13 Peru  31/12/89 254 St Kitts and Nevis  31/12/88 18 St Lucia  31/03/89 16 St Vincent  31/12/89 22 Suriname  31/12/89 48 Trinidad and Tobago  31/12/89 557 Turks and Caicos Islands 31/12/88 8 United States of America  31/03/90 124282 Uruguay  31/03/90 90 Venezuela 30/09/89 646 Total 150619

 

Asia

Country Last Report Cases to date Afghanistan  15/02/90 0 Bahrain 15/02/90 0 Bangladesh  30/11/89 0 Bhutan 04/12/89 0 Brunei Darussalam  04/06/89 1 Burma (see Myanmar)       China 30/09/88 3 Cyprus  15/02/90 15 Dem P Rep of Korea 30/09/89 0 Democratic Yemen 15/02/90 0 Hong Kong 28/02/90 22 India 15/11/89 40 Indonesia  31/12/89 6 Iran 15/02/90 9 Iraq  15/02/90 0 Israel 31/12/89 101 Japan  31/12/89 182 Jordan  15/02/90 9 Kuwait  15/02/90 1 Lebanon 15/02/90 31 Malaysia  18/01/90 12 Maldives 30/09/89 0 Mongolia  02/03/90 0 Myanmar  30/11/89 0 Nepal  16/01/90 2 Oman 15/02/90 14 Pakistan  15/02/90 13 Philippines  31/07/89 26 Qatar 15/02/90 23 Republic of Korea 10/09/88 4 Saudi Arabia - - Singapore  12/01/90 15 Sri Lanka 22/01/90 4 Syrian Arab Republic  15/02/90 8 Thailand 30/11/89 32 Turkey  31/01/90 31 United Arab Emirates - - Viet Nam 08/09/87 0 Yemen 31/12/88 0 Total 618

 

Europe

Country  Last report Cases to date  Albania  31/12/89 0 Austria 28/02/90 391 Belgium 31/12/89 596 Bulgaria   13/12/89 7 Czechoslovakia                31/12/89 19 Denmark  28/02/90 549 Finland  31/12/89 56 France  31/12/89 8883 German Dem Republic 31/12/89 19 German Fed Republic 28/02/90 4544 Greece 31/12/89 277 Hungary  28/02/90 33 Iceland 31/12/89 13 Ireland  31/12/89 124 Italy  31/12/89 5307 Luxembourg  31/12/89 24 Malta 31/12/89 14 Monaco  31/12/89 2 Netherlands 28/02/90 1174 Norway  28/02/90 149 Poland 28/02/90 33 Portugal  28/02/90 369 Romania  08/02/90 74 San Marino 31/12/89 1 Spain  31/12/89 4633 Sweden 31/12/89 380 Switzerland  28/02/90 1220 UK 31/01/90 2920 USSR 15/01/90 26 Yugoslavia 31/01/90 111 Total   31948

Oceania  

Country   Last report Cases to date Australia  23/02/90 1760 Cook Islands 08/09/87 0 Fiji  21/06/89 2 French Polynesia 20/01/90 13 Kiribati  18/01/88 0 Mariana Islands 05/08/87 0 New Caledonia  01/08/88 2 New Zealand 11/01/90 156 Papua New Guinea          28/06/89 13 Samoa  18/10/88 0 Solomon Islands 08/09/87 0 Tonga  01/08/88 1 Tuvalu 08/09/87 0 Vanuatu  20/02/90 0 Total 1947

 

World Grand Total

237110

Clinical sign of AIDS
An illustrated guide to the most common sign and symptoms of HIV disease/AIDS is printed overleaf. It is intended only as a general overview. The insert may be pulled out and pinned up on a hospital or clinic notice board, and/or used in training  sessions.

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AIDS action  Issue 10    9   Page 10  11 

What does adult AIDS look like?

Earlier signs of HIV infection
People with HIV infection (the virus that causes AIDS) are initially symptomless and may have enlarged lymph nodes in the neck, axilla and groins which may persist. Some infected people will develop early HIV disease after a few months or years. This can consist of all or any of the following:
 

• Unexplained weight loss of more than ten per cent of body weight 

• Unexplained fever lasting more than one month 

• Unexplained chronic diarrhoea 

• Shingles (caused by Herpes zoster virus)

• Oral thrush (infection by a fungus, candida albicans)

• Oral hairy leukoplakia 

• Persistent increase (more than three month) in the size of the lymph nodes in several sites of the body; known persistent generalised lymphadenopathy
   

Most of these symptoms are not specific to the early signs of HIV disease: many other diseases, mostly benign, can cause the same manifestations. What raises the suspicion of early HIV disease is the persistent and unexplained nature of these symptoms. Some people with early HIV disease go on to develop AIDS (the severe and fatal form of HIV disease) others do not. 

It is currently impossible to accurately predict which patients with HIV infection will develop AIDS.
 
  

 

Later signs of HIV infection (AIDS)
Between 30 and 40 per cent of seropositive patients will develop AIDS (the severe form of HIV disease) within seven years after infection. These manifestations appear when the immune system is severely damaged. AIDS is responsible for two main categories of disease:
 

• Opportunistic infections 

• Certain tumours (lymphomas and Kaposi's sarcoma)

Opportunistic infections
 

We are surrounded by bacteria, viruses and parasites, which normally do not cause diseases as they are controlled by the immune system. When the immunity of the body is deficient, these germs take advantage of the opportunity to invade the body and induce severe so-called 'opportunistic' infections. These infections are serious, as the body is not able to prevent their spontaneous development and, without treatment and sometimes even despite treatment, they can be fatal.

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Clinical signs
The clinical signs vary according to the germ responsible and the organ affected. The principal organs affected are the lungs, the gastrointestinal tract, the brain and the skin. The following is a list of the main signs of the opportunistic infections more specifically diagnostic of AIDS: 
 

General state 
Fever, weight loss, and other systemic symptoms. Weakness may accompany all infections.

Certain tumours 

(a) Kaposi's sarcoma 
Generalised Kaposi's sarcoma is the cancer most frequently associated with AIDS. It affects around 15 per cent of patients with AIDS in Africa. It presents in the form of purple or red/brown cutaneous plaques or nodules. These lesions are found not only in the skin, but also most notably in the mucosal lining, such as the mouth, and in the lungs and gut.

(b) Lymphomas
The risk of lymphoma (tumours of the lymph nodes, skin, gut and brain) is about one hundred times greater in patients with AIDS than in normal subjects.

What is the course of the disease in AIDS patients?
The disease develops in the form of episodes between which the patient may return to a more or less normal state. The average survival of a person with AIDS varies greatly (several month to years) and depends mainly on available medical support.

Opportunistic infections
Episodes of opportunistic infections can be successfully treated, by means of anti-infectious drugs, leading to remission of the disease. The patient may again appear to be in good health. However, the immune deficiency is still present, and other increasingly serious episodes of opportunistic infections may occur that eventually become unresponsive to treatment.

Tumors
An improvement may be obtained in certain cases, as a result of treatment.

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WHO clinical case definition for AIDS in adults when diagnostic resources are limited 

The following clinical definition was developed five years ago. It is currently being revised by GPA and will include details of neurological signs and a revision of skin infections.

AIDS in adults is defined by the existence of at least two of the major signs associated with at least one minor sign, in the absence of known causes of immunosuppression such as cancer or severe malnutrition or other recognised aetiologies.

1. Major signs

• weight loss of more than ten per cent of body weight

• chronic diarrhoea for more than one month

• prolonged fever for more than one month  (intermittent or constant)

2. Minor signs 

• persistent cough for more than  one month

• generalised pruritic dermatitis

• recurrent Herpes zoster

• Oropharyngeal candidiasis

• chronic progressive and disseminated Herpes simplex infection

• generalised lymphadenopathy

The presence of generalised Kaposi's  sarcoma or cryptococcal meningitis are sufficient by themselves for the diagnosis of AIDS.

Any questions about the content of the WHO Report should be sent to: WHO/GPA/HPR, 20 Avenue Appia, 1211  Geneva 27; Switzerland. AIDS

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