Introduction

AIDS is the plague of the 20th century, but how much do we really know about this deadly
disease? HIV is a virus that gets into the body and flows through the bloodstream. AIDS is the
disease that is caused by HIV. Once you are diagnosed as HIV positive, you do not automatically
have AIDS. There is a possibility of being HIV positive, and not having AIDS. Most people do
not know it is the infections that break down the body's immune system rather than the AIDS
that kills patients. In Bangladesh the no of AIDS patient are very low but it can increase at a very
alarming rate since the neighbouring countries are quite badly affected by this killer disease.

Definition of AIDS/HIV

Acquired Immune Deficiency Syndrome or Acquired Immunodeficiency Syndrome (AIDS)

is a disease of the human immune system caused by the Human Immunodeficiency Virus
(HIV).

This condition progressively reduces the effectiveness of the immune system and leaves
individuals susceptible to opportunistic infections and tumors. HIV is transmitted through direct
contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as
blood, semen, vaginal fluid, preseminal fluid, and breast milk.

This transmission can involve anal, vaginal or oral sex, blood transfusion, contaminated
hypodermic needles, exchange between mother and baby during pregnancy, childbirth,
breastfeeding or other exposure to one of the above bodily fluids.

AIDS is now a pandemic. In 2007, it was estimated that 33.2 million people lived with the
disease worldwide, and that AIDS killed an estimated 2.1 million people, including 330,000
children. Over three-quarters of these deaths occurred in sub-Saharan Africa, retarding economic
growth and destroying human capital.
Genetic research indicates that HIV originated in west-central Africa during the late nineteenth
or early twentieth century. AIDS was first recognized by the U.S. Centers for Disease Control
and Prevention in 1981 and its cause, HIV, identified in the early 1980s.

Although treatments for AIDS and HIV can slow the course of the disease, there is currently no
vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV
infection, but these drugs are expensive and routine access to antiretroviral medication is not
available in all countries. Due to the difficulty in treating HIV infection, preventing infection is a
key aim in controlling the AIDS pandemic, with health organizations promoting safe sex and
needle-exchange programs in attempts to slow the spread of the virus.

Picture: HIV-1 virus (green colored)

Symptoms of AIDS

The symptoms of AIDS are primarily the result of conditions that do not normally develop in
individuals with healthy immune systems. Most of these conditions are infections caused by
bacteria, viruses, fungi and parasites that are normally controlled by the elements of the immune
system that HIV damages.

Opportunistic infections are common in people with AIDS. These infections affect nearly every
organ system.
People with AIDS also have an increased risk of developing various cancers such as Kaposi's
sarcoma, cervical cancer and cancers of the immune system known as lymphomas. Additionally,
people with AIDS often have systemic symptoms of infection like fevers, sweats (particularly at
night), swollen glands, chills, weakness, and weight loss. The specific opportunistic infections
that AIDS patients develop depend in part on the prevalence of these infections in the geographic
area in which the patient lives.

• Pulmonary infections

Pneumocystis pneumonia (originally known as Pneumocystis carinii pneumonia, and still

abbreviated as PCP, which now stands for Pneumocystis pneumonia) is relatively rare in
healthy, immunocompetent people, but common among HIV-infected individuals. It is caused by
Pneumocystis jirovecii.

Before the advent of effective diagnosis, treatment and routine prophylaxis in Western countries,
it was a common immediate cause of death. In developing countries, it is still one of the first
indications of AIDS in untested individuals, although it does not generally occur unless the CD4
count is less than 200 cells per µL of blood.

Tuberculosis (TB) is unique among infections associated with HIV because it is transmissible to
immunocompetent people via the respiratory route, is not easily treatable once identified, may
occur in early-stage HIV disease, and is preventable with drug therapy. However, multidrug
resistance is a serious problem. Tuberculosis with HIV co-infection (TB/HIV) is a major world
health problem according to the World Health Organization: in 2007, 456,000 deaths among
incident TB cases were HIV-positive, a third of all TB deaths and nearly a quarter of the
estimated 2 million HIV deaths in that year.
 Picture: X-ray of Pneumocystis pneumonia (PCP).

Even though its incidence has declined because of the use of directly observed therapy and other
improved practices in Western countries, this is not the case in developing countries where HIV
is most prevalent. In early-stage HIV infection (CD4 count >300 cells per µL), TB typically
presents as a pulmonary disease. In advanced HIV infection, TB often presents atypically with
extrapulmonary (systemic) disease a common feature. Symptoms are usually constitutional and
are not localized to one particular site, often affecting bone marrow, bone, urinary and
gastrointestinal tracts, liver, regional lymph nodes, and the central nervous system.

Gastrointestinal infections

Esophagitis is an inflammation of the lining of the lower end of the esophagus (gullet or
swallowing tube leading to the stomach). In HIV infected individuals, this is normally due to
fungal (candidiasis) or viral (herpes simplex-1 or cytomegalovirus) infections. In rare cases, it
could be due to mycobacteria.

Unexplained chronic diarrhea in HIV infection is due to many possible causes, including
common bacterial (Salmonella, Shigella, Listeria or Campylobacter) and parasitic infections; and
uncommon opportunistic infections such as cryptosporidiosis, microsporidiosis, Mycobacterium
avium complex (MAC) and viruses, astrovirus, adenovirus, rotavirus and cytomegalovirus, (the
latter as a course of colitis).
In some cases, diarrhea may be a side effect of several drugs used to treat HIV, or it may simply
accompany HIV infection, particularly during primary HIV infection. It may also be a side effect
of antibiotics used to treat bacterial causes of diarrhea (common for Clostridium difficile). In the
later stages of HIV infection, diarrhea is thought to be a reflection of changes in the way the
intestinal tract absorbs nutrients, and may be an important component of HIV-related wasting.

Neurological and psychiatric involvement

HIV infection may lead to a variety of neuropsychiatric sequelae, either by infection of the now
susceptible nervous system by organisms, or as a direct consequence of the illness itself.

Toxoplasmosis is a disease caused by the single-celled parasite called Toxoplasma gondii; it

usually infects the brain, causing toxoplasma encephalitis, but it can also infect and cause disease
in the eyes and lungs. Cryptococcal meningitis is an infection of the meninx (the membrane
covering the brain and spinal cord) by the fungus Cryptococcus neoformans. It can cause fevers,
headache, fatigue, nausea, and vomiting. Patients may also develop seizures and confusion; left
untreated, it can be lethal.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease, in which the

gradual destruction of the myelin sheath covering the axons of nerve cells impairs the
transmission of nerve impulses. It is caused by a virus called JC virus which occurs in 70% of
the population in latent form, causing disease only when the immune system has been severely
weakened, as is the case for AIDS patients. It progresses rapidly, usually causing death within
months of diagnosis.

AIDS dementia complex (ADC) is a metabolic encephalopathy induced by HIV infection and
fueled by immune activation of HIV infected brain macrophages and microglia. These cells are
productively infected by HIV and secrete neurotoxins of both host and viral origin. Specific
neurological impairments are manifested by cognitive, behavioral, and motor abnormalities that
occur after years of HIV infection and are associated with low CD4+ T cell levels and high
plasma viral loads.
Prevalence is 10–20% in Western countries but only 1–2% of HIV infections in India. This
difference is possibly due to the HIV subtype in India. AIDS related mania is sometimes seen in
patients with advanced HIV illness; it presents with more irritability and cognitive impairment
and less euphoria than a manic episode associated with true bipolar disorder. Unlike the latter
condition, it may have a more chronic course. This syndrome is less often seen with the advent
of multi-drug therapy.

Tumors and malignancies

Picture: Kaposi's sarcoma

Patients with HIV infection have substantially increased incidence of several cancers. This is
primarily due to co-infection with an oncogenic DNA virus, especially Epstein-Barr virus
(EBV), Kaposi's sarcoma-associated herpesvirus (KSHV) (also known as human herpesvirus-8
[HHV-8]), and human papillomavirus (HPV).

Kaposi's sarcoma (KS) is the most common tumor in HIV-infected patients. The appearance of
this tumor in young homosexual men in 1981 was one of the first signals of the AIDS epidemic.
Caused by a gammaherpes virus called Kaposi's sarcoma-associated herpes virus (KSHV), it
often appears as purplish nodules on the skin, but can affect other organs, especially the mouth,
gastrointestinal tract, and lungs. High-grade B cell lymphomas such as Burkitt's lymphoma,
Burkitt's-like lymphoma, diffuse large B-cell lymphoma (DLBCL), and primary central nervous
system lymphoma present more often in HIV-infected patients. These particular cancers often
foreshadow a poor prognosis. Epstein-Barr virus (EBV) or KSHV cause many of these
lymphomas. In HIV-infected patients, lymphoma often arises in extranodal sites such as the
gastrointestinal tract. When they occur in an HIV-infected patient, KS and aggressive B cell
lymphomas confer a diagnosis of AIDS.

Invasive cervical cancer in HIV-infected women is also considered AIDS-defining. It is caused

by human papillomavirus (HPV).

In addition to the AIDS-defining tumors listed above, HIV-infected patients are at increased risk
of certain other tumors, notably Hodgkin's disease, anal and rectal carcinomas, hepatocellular
carcinomas, head and neck cancers, and lung cancer. Some of these are causes by viruses, such
as Hodgkin's disease (EBV), anal/rectal cancers (HPV), head and neck cancers (HPV), and
hepatocellular carcinoma (hepatitis B or C). Other contributing factors include exposure to
carcinogens (cigarette smoke for lung cancer), or living for years with subtle immune defects.

Interestingly, the incidence of many common tumors, such as breast cancer or colon cancer, does
not increase in HIV-infected patients. In areas where HAART is extensively used to treat AIDS,
the incidence of many AIDS-related malignancies has decreased, but at the same time malignant
cancers overall have become the most common cause of death of HIV-infected patients. In recent
years, an increasing proportion of these deaths have been from non-AIDS-defining cancers.

Other infections

AIDS patients often develop opportunistic infections that present with non-specific symptoms,
especially low-grade fevers and weight loss. These include opportunistic infection with
Mycobacterium avium-intracellulare and cytomegalovirus (CMV). CMV can cause colitis, as
described above, and CMV retinitis can cause blindness.

Penicilliosis due to Penicillium marneffei is now the third most common opportunistic infection
(after extrapulmonary tuberculosis and cryptococcosis) in HIV-positive individuals within the
endemic area of Southeast Asia.
An infection that often goes unrecognized in AIDS patients is Parvovirus B19. Its main
consequence is anemia, which is difficult to distinguish from the effects of antiretroviral drugs
used to treat AIDS itself.

Mode of transmission of AIDS

• Sexual transmission

You may become infected if you have vaginal, anal or oral sex with an infected partner whose
blood, semen or vaginal secretions enter your body. You can also become infected from shared
sexual devices if they're not washed or covered with a condom. The virus is present in the semen
or vaginal secretions of someone who's infected and enters your body through small tears that
can develop in the vagina or rectum during sexual activity. If you already have another sexually
transmitted disease, you're at much greater risk of contracting HIV. Contrary to what researchers
once believed, women who use the spermicide nonoxynol 9 also may be at increased risk. This
spermicide irritates the lining of the vagina and may cause tears that allow the virus into the
body.

• Transmission through infected blood

In some cases, the virus may be transmitted through blood and blood products that you receive in
blood transfusions. Since 1985, American hospitals and blood banks have screened the blood
supply for HIV antibodies. This blood testing, along with improvements in donor screening and
recruitment practices, has substantially reduced the risk of acquiring HIV through a transfusion.

• Transmission through needle sharing

HIV is easily transmitted through needles and syringes contaminated with infected blood.
Sharing intravenous drug paraphernalia puts you at high risk of HIV and other infectious
diseases such as hepatitis. Your risk is greater if you inject drugs frequently and also engage in
high-risk sexual behaviour. Avoiding the use of injected drugs is the most reliable way to prevent
infection. If that isn't an option, you can reduce your risk by participating in a needle exchange
program that allows you to trade used needles and syringes for sterile ones.

• Transmission through accidental needle sticks

Transmission of the virus between HIV-positive people and health care workers through needle
sticks is low. Experts put the risk at far less than 1 percent.

• Transmission from mother to child

Each year, nearly 600,000 infants are infected with HIV, either during pregnancy or delivery or
through breast-feeding. But if women receive treatment for HIV infection during pregnancy, the
risk to their babies is significantly reduced. In the United States, most pregnant women are pre-
screened for HIV, and anti-retroviral drugs are readily available. Not so in developing nations,
where women seldom know their HIV status, and treatment is often limited or nonexistent. When
medications aren't available, Caesarean section is sometimes recommended instead of vaginal
delivery. Other options, such as vaginal disinfection, haven't proved effective.

• Other methods of transmission

In rare cases, the virus may be transmitted through organ or tissue transplants or unsterilized
dental or surgical equipment.

Misconceptions

A number of misconceptions have arisen surrounding HIV/AIDS. Three of the most common are
that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure
AIDS, and that HIV can infect only homosexual men and drug users. Other misconceptions are
that any act of anal intercourse between gay men can lead to AIDS infection, and that open
discussion of homosexuality and HIV in schools will lead to increased rates of homosexuality
and AIDS.
Current situation of AIDS in Bangladesh

HIV in Bangladesh remains at relatively low levels in most at-risk population groups, with the
exception of injecting drug users (IDUs) where prevalence continues to grow. UNAIDS
estimates that about 12,000 Bangladeshis were living with HIV at the end of 2007. Although
overall HIV prevalence remains under 0.1 percent among the general population in Bangladesh,
there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and
vigorous action is needed to strengthen the quality and coverage of HIV prevention programs,
particularly amongst IDUs.

Bangladesh’s seventh round of serological surveillance (2006) showed that HIV prevalence
among all high-risk groups remained below 1 percent with the exception of injecting drug users.
Among injecting drug users, prevalence was less than 2 percent in all sites except Dhaka. In
Dhaka, prevalence rose from 1.7 percent in 1999 to 7 percent in 2006 marking the first
concentrated epidemic among any high-risk group in Bangladesh. Bangladesh is vulnerable to an
expanded HIV epidemic due to the prevalence of behavior patterns and risk factors that facilitate
the rapid spread of HIV.
Risk factors

• Large Commercial Sex Industry

There are over 105,000 male and female sex workers in Bangladesh. Brothel-based female sex
workers reportedly see around 18 clients per week, while street based and hotel-based workers
see an average of 17 and 44 clients per week, respectively.

• Condom Use
Sixth round BSS (2006-2007) data indicate significant improvement in condom use during last
sex with new client particularly among brothel- and street-based workers. Condom use was
70percent for brothel workers and ranged between 51 to 81 percent among street workers.
However, condom use was low among hotel based sex workers in Dhaka and Chittagong at 40
and 36 percent, respectively. Hotel-based workers are especially vulnerable to HIV as they have
the largest number of clients. Consistent condom use andwith regular clients are lower for all
sub-groups.

• Sexually Transmitted Infections

Syphilis rates fell among brothel and street-based sex workers in Dhaka and among IDUs in
Dhaka and Rajshahi between 2004 and 2006. Syphilis rates, however, have remained unchanged
for hotel-based sex workers, male sex workers, and street based workers in Chittagong,
indicating the presence of other risky sexual behaviors that facilitate the spread of the HIV.

• Needle-sharing among Injecting Drug Users

The seventh round of serological surveillance data shows that there is a concentrated epidemic
among IDUs in one neighborhood of Dhaka with an HIV prevalence of 10.4 percent. This level
of infection among IDUs poses a significant risk as the infection can spread rapidly – and is
spreading within the group, then through their sexual partners and their clients into the general
population. The BSS data for 2006-2007 indicate the persistence of unsafe injecting practices
among IDUs and the majority still shares needles and syringes. Another concern is the
significant number of IDUs who sell their blood professionally. Bangladesh continues to rely on
professional blood-sellers to meet part of the transfusion needs of its people.

• Lack of Knowledge
Data on knowledge and behavior indicates that only 17 percent of the most-at-risk populations
have correct knowledge about prevention and misconceptions on HIV/AIDS. Furthermore, a
2005 population based survey among adolescents and young people (15-24 years) indicated that
only one out of three males in urban and one out of four in rural areas had correct knowledge of
HIV and AIDS. Among the general population, data indicate that 59 percent of ever-married
women and 42 percent of men of age 15-54 could not mention a single way to avoid contracting
HIV.
High level of stigma associated with people living with HIV.People engaged in high-risk
behaviors often has limited access to health care.

National response to AIDS/HIV

• Government
In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare
outlined a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was
formed, with a Technical Advisory Committee, and a National AIDS/STD Program (NASP) unit
in the ministry. The NAC includes representatives from key ministries, NGOs, and a few
parliamentarians. Action has been taken to develop a multi-sector response to HIV/AIDS.
Strategic action plans for the National AIDS/STD Program set forth fundamental principles, with
specific guidelines on a range of HIV issues including testing, care, blood safety, prevention
among youth, women, migrant workers, sex workers, and STIs. While earlier commitment was
limited and implementation of HIV control activities was slow, Bangladesh has strengthened its
programs to improve its response. The 2005 Poverty Reduction Strategy Paper of the
government highlighted HIV/AIDS in the health section. The Government of Bangladesh also
prepared the National Strategic Plan for HIV/AIDS for the period 2004-2010 under the guidance
of NAC and with the involvement and support of different stakeholders. Efforts to mainstream
HIV/AIDS in public sectors outside the Ministry of Health and Family Welfare were initiated
through designation and training of focal points on HIV/AIDS in 16 government ministries.

• Nongovernmental Organizations (NGOs)

More than 380 NGOs and AIDS Service Organizations have been implementing
programs/projects in different parts of the country. These initiatives focused on prevention of
sexual transmission among high-risk groups involving mostly female sex workers, MSM, IDUs,
rickshaw pullers, and truckers. NGOs are often in a better position than the public sector to reach
high-risk groups, such as sex workers and their clients and injecting drug users. Building the
capacity of NGOs, especially the small ones, and combining their reach with the resources and
strategic programs of the government is an effective way to change behavior in high-risk groups
and prevent the spread of the virus to the general public.

• Donors
A Global Fund grant for US$40 million (Round 6) to promote prevention of HIV among
adolescents and young people brings together government and Save the Children, USA, and is
being implemented through NGOs. The FHI/USAID-supported project (US$13 million, 2005-
2008) is also focusing on selected interventions for some high-risk groups including expansion
of VCT services.

Prevention of AIDS/HIV

The only way to protect from contracting AIDS sexually is to abstain from sex outside of a
mutually faithful relationship with a partner whom the person knows is not infected with the
AIDS virus. Otherwise, risks can be minimized if they:

• Don't have sexual contact with anyone who has symptoms of AIDS or who is a member
of a high risk group for AIDS.
• Avoid sexual contact with anyone who has had sex with people at risk of getting AIDS.
• Don't have sex with prostitutes.
• Avoid having sex with anyone who has multiple and/or anonymous sexual partners.
• Avoid oral, genital and anal contact with partner's blood, semen, vaginal secretions, feces
or urine. Unless they know with absolute certainty that their partner is not infected, a
latex condom should be used during each sexual act, from start to finish. The use of a
spermicidal agent may provide additional protection.
• Avoid anal intercourse altogether.
• Don't share toothbrushes, razors or other implements that could become contaminated
with the blood of anyone who is or might be infected with the AIDS virus.
• Exercise caution regarding procedures, such as acupuncture, tattooing, and ear piercing,
etc., in which needles or other nonsterile instruments may be used repeatedly to pierce the
skin and/or mucous membranes.

Such procedures are safe if proper sterilization methods are employed or disposable
needles are used. Ask what precautions are taken before undergoing such procedures.

• If an individual is scheduling surgery in the near future, and is able, they could consider
donating blood for their own use. This will eliminate completely the already very small
risk of contracting AIDS through a blood transfusion. It will also eliminate the risk of
contracting other bloodborne diseases (such as hepatitis) from a transfusion.
• Scale up behavioral change activities and health promotion interventions for high-risk
behaviors and vulnerable groups, particularly IDUs and sex workers.
• Expand advocacy and awareness among the general population through multi-sectoral
agencies.
• Promote the social acceptability of condom use and ensure adequate supply and access.
• Reduce discrimination against those infected with HIV, or groups engaging in high-risk
behaviors, through appropriate advocacy, policies, and related measures.
• Strengthen the government’s capacity for program implementation, management, and
monitoring of program activities.
• Promote NGO capacity for program planning, implementation, and supervision of
interventions.
 • Strengthen mechanisms for collaboration and coordination within and between
government, the nongovernmental sector, development partners, and other stakeholders.

If a person is an IV drug user, adhere to the prevention tips mentioned earlier, as well as:

• Get professional help for terminating the drug habit.

• Do not share needles or syringes. Be aware that some street sellers are resealing
previously used needles and selling them as new.
• Clean the needle before using.

Conclusion

Remember AIDS does not discriminate caste, creed, race, religion, educational or social status.
Prevention of AIDS is our joint responsibility. Education and awareness is the only weapon in
our hand. Let us accept the challenge to fight against AIDS. We must support and care for the
people with HIV / AIDS with compassion and understanding.