Peace Corps/Ukraine

PEPFAR Training: Biology Module

Biology Module

Session One: The Biology of HIV/AIDS or The Lab Coat Session

Purpose
The purpose of this module to provide Volunteers and counterparts with a thorough understanding of the biology of HIV/AIDS, including what happens at the cellular level and factors that affect its progression.

Rationale
Peace Corps Volunteers have various opportunities to be HIV/AIDS educators, and to do that, they need firm grounding in the biology of the virus and how it is, and is not, transmitted. Perhaps the most important role Volunteers can play is to explain or correct information about the virus. Incorrect information, or not thorough enough information, has been shown to be a major cause of stigma and discrimination, which in term facilitates further transmission of the virus.

Target Audience
Peace Corps Volunteers and Counterparts. Parallel sessions.

Duration
2 hours 20 minutes

Objectives
By the end of the session participants will be able to 1. Describe a virus and identify the unique characteristics of HIV. 2. Explain how HIV impacts the immune system. 3. Describe the life cycle of HIV. 4. Explain how a person living with HIV can prolong the onset of AIDS. 5. Explain the role of anti-retrovirals in the treatment of HIV.

Session Outline
I. II. III. IV. V. VI. Introduction (2 minutes) The Immune System and HIV (50 minutes) The HIV Life Cycle and AIDS (30 minutes) Health Maintenance for PLHA (30 minutes) Anti-Retroviral Therapy (20 minutes) Wrap Up (5 minutes)

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Materials
Flip charts, markers, tape Prepared flip charts A. Outline of session B. The HIV Life Cycle C. Train analogy pictures D. How Anti-Retroviral Therapy Works Handouts: A. HIV/AIDS Quiz B. The Life Cycle of HIV C. The Stages of HIV/AIDS Infection (slips) D. Blocking HIV Reproduction: How ARVs Work Fact Sheet: Anti Retroviral Drugs Ball (or other soft ball)

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Methodology
I. Introduction (2 minutes) Step 1: Introduce the session The purpose of this session is to provide an understanding of the biology of HIV/AIDS and how it affects the body. This information will be important in enabling you to effectively communicate to others the importance of prevention as well as compassion for those living with the virus. Some of you may already have a good understanding of much of this information; for others you may need reminding of some of the basics of cell development and human immunology. Step 2: Outline of session Reveal and review the flip chart with the outline of the session. II. The Immune System and HIV (50 minutes) Step 1. Define HIV (1 minute) Use flip chart B to define: Human immunodeficiency virus. Human it affects humans Immunodeficiency it affects the immune system and causes a deficiency Virus it is a virus Step 2: Define Immune System (4 minutes) a. Ask: What is the human immune system? Allow people to respond. b. Summarize with the following points: The immune system is our bodys way of fighting disease. It is very complex, but some basic facts about the immune system can provide a framework for understanding HIV. It can also help us understand what we can do to prevent infection and help slow progression of the virus if someone is already infected. Step 3: Cells Brief (30 minutes)

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

a. Explain that you are going to give an explanation of cells and how HIV affects them. This is important background information for understanding how HIV works to weaken and eventually overtake the immune system. b. Divide the group into 4. Explain that the teams will illustrate the workings of the immune system. Distribute one sheet of flipchart paper and markers to each team. Explain that you will share some important facts about the approximately 100 trillion cells in your body and the volunteer will attempt to illustrate this as you explain it (b-d). Encourage participants to use characters or other representations to show the functioning of the immune system as this will help them remember the information. Every cell in your body has receptors located on their surfaces these enable cells to communicate with their environment or other cells. Any protein that originates outside of your body is an antigen there are millions of these and most are harmless. An antigen that causes disease is called a pathogen. Your body is exposed to pathogens every second of every day, from bacteria to viruses in the air we breathe, the food we eat, the water we drink, even every surface that we touch. Our immune system prevents us from getting sick from all the pathogens we continuously encounter. The body has both red blood cells and white blood cells: Red blood cells carry oxygen from your lungs to the rest of your body, and white blood cells are involved in the human immune response. White blood cells are called lymphocytes and they fight infection by attacking harmful pathogens that get into your bloodstream. There are two major types of lymphocytes B cells and T cells. B cells make antibodies against a particular pathogen and are the "worker bees" of the immune system. T cells circulate continuously throughout the body looking for pathogens and determining whether to harm them or leave them alone. T cells are in charge of the immune system response-- when a pathogen is found, T cells direct the immune systems response by instructing B cells to make antibodies against the pathogen. A type of T cell called the T4 cell (also known as the "CD4" cell or the "helper T" cell) is a specific type of T cell that directs the bodys immune system against infection. c. Have all the teams display their illustrations. Then ask for a brave volunteer to use their illustration to explain back to the group the functioning of the immune system.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

d. HIV enters the body via infected bodily fluids: blood, semen, breast milk, and vaginal secretions. We will go into more detail about this in a session dedicated specifically to HIV transmission. e. Continue the illustration on a flipchart showing what happens once HIV is in the body. Once inside the body, HIV enters the T4 cell. It latches on and enters through a special receptor on the cells surface. It then enters the cells nucleus where the DNA (genes) are located. It uses the enzyme reverse transcriptease to produce a DNA analog of its RNA that then becomes part of the host cell. In this way, it takes over the cell's inner machinery and uses it as a factory to produce more copies of itself. When this happens, the T4 cell is no longer able to function normally and direct the immune system. f. Distribute the handout The Life Cycle of the HIV Virus. Have participants read the handout and ask questions to ensure understanding. g. Explain that HIV can remain quiet within a cell or it can produce thousands of copies within a single cell every day. Mutations occur at this stage. These copies go on to infect even more T4 cells. h. As HIV destroys the body's T4 cells in the process of replicating itself, the body is no longer able to mount an immune response to pathogens. i. In HIV infected individuals, a decline in the T4 count signals the deterioration of the immune system, and thus the progressive inability of the body to combat infections. j. As the immune system weakens, the pathogens that are normally easily handled by the body's T4 cells can now cause serious infections, also known as "opportunistic infections". k. HIV is a retrovirus, which means it requires an extra step to make copies of itself after taking over a T4 cell. This extra step makes HIV highly prone to error during replication therefore HIV produces mutations as a natural part of its replication process. III. The HIV Life Cycle and AIDS (30 minutes) Step 1: Stages of Infection a.Explain briefly the stages of HIV infection and underline that: The course of HIV varies considerably from person to person. There are 4 stages of disease progression.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

b.Divide into 5 groups. Provide each group with characteristics of each stage written on individual slips of paper. Explain that they will have 10 minutes to determine at which stage a person infected with HIV will experience the written symptom. c.Review as a group by having participants read suggesting aloud characteristics for each stage. Correct and explain where necessary. d. A basic way to understand how HIV progresses to AIDS is by use of an analogy: the HIV/AIDS train. This may also be helpful when working with young people. Note to facilitator: While explaining, use the cut-outs with tape on the backside to illustrate: Imagine that our health is like a train running along a track. When a person becomes infected with HIV, their wagon switches to a different, and shorter, track. The last stop on this track is AIDS. Two things tell you how soon you will arrive at the AIDS stop. Your T-cell count or the number of cells that fight infection tell you how much track you have left before you reach destination-AIDS. The lower the count, the less track you have and the closer you are to AIDS. Your viral load or how much of the virus is in your body tells you how fast your train is traveling. The higher your viral load, the quicker your train is moving and the sooner you will reach AIDS. When you reach the AIDS stop, unwelcome passengers or infections that you cannot fight get into your wagon. If you are given the appropriate medicine, you can get rid of some or all of those passengers and continue traveling again. If you are not given medicine in time, the infections will continue to weaken your body until you can no longer fight them anymore. IV. Health Maintenance for PLHA (30 minutes) Step 1: The effect of behavior on the disease progression Referring back to the HIV/AIDS train illustration, label the time between switching tracks to arriving at destination AIDS as Incubation Period, noting that the time it takes for HIV to become AIDS can vary greatly. On average, AIDS develops 8 to 10 years after HIV infection, but our behaviors can considerably affect the length of this time period. Step 2: My Health in My Hands Explain that you will toss the ball and the person who catches it should respond with a suggestion for what someone with HIV can do to preserve her/his physical, emotional and spiritual health. Request a volunteer scribe to record the suggestions on a flipchart. Include the following: Eating healthy foods Getting enough rest

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Not smoking cigarettes or marijuana (which weakens the immune system) Not drinking alcohol Not getting re-infected with HIV through risky behaviors (getting re-infected increases your viral load) Spending time with friends and family Taking vitamins daily (note that infections require greater nutrient intake) Taking care of colds/illnesses. When you get sick, T cells rush in to initiate the immune system response. Because T cells come together to fight any infection, the places where T cells congregate are places the risk of HIV replication increases also. V. Anti-Retroviral Therapy (20 minutes) Step 1: Explain (10 minutes) a. Ask, does anyone know someone who has taken or is taking antiretroviral therapy (ARVs)? What have you heard about ARVs? b. Anti Retroviral Therapy works in several ways. The goal is to slow down the replication of HIV. Taken properly ARV has significantly lengthened the period of time people living with HIV (PLHA) can lead normal and productive lives. c. Distribute Handout Blocking HIV reproduction: How ARV Works. Use the diagram to explain the critical points at which the progression of HIV can be stopped. Points to make: HIVs impact increases as it replicates and infects more cells in the body. The goal of antiretroviral drugs is to interfere with the replication process of the virus. o HIV uses an enzyme [reverse transcriptase] to change its RNA to DNA. This process can be blocked by interfering with the needed enzyme. o The virus uses another enzyme [protease a digestive enzyme used to generate new virus particles] to incorporate its genetic material into the host cell. This process can be blocked. o The release of the newly formed virus from the infected host can be stopped. Ongoing research makes this a quickly changing area.

d. One of the challenges of HIV is its tendency to mutate in the process of replicating itself. This makes it difficult to treat as it changes the new strain may be resistant to the treatment.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Step 2: Starting ARV Therapy (10 minutes) a. There are a lot of opinions in the medical community as to when to start ARV therapy. b. Some physicians and researchers are pushing for early therapy, while some adhere to a reactive regimen that initiates medication in response to a condition. c. Why not start treatment ASAP? Duration: The combination treatments often involve taking many pills a day that must be swallowed according to a rigid schedule. The timing centers around an empty stomach, and often causes severe stomach irritation. Adherence or compliance: It has been shown that the simplicity of a drug regimen has a great affect on adherence. Adherence to the HIV drug regimen means taking all of the prescribed anti-HIV drugs at the scheduled times and not missing ANY doses. Skipping only a few pills can trigger the emergence of drug resistant strains of HIV. This could create a worse problem than the initial infection because the resistant virus could overwhelm the individual taking the drugs and anyone else to whom the virus is transmitted. This could create strains resistant to all currently available drugs. Costs: AIDS is largely a disease of inequality. The cost in the U.S. can be between $12,000 - $20,000 a year. Currently, less than 3% of the 40 million people around the world are receiving treatment. About 2,000 people in Ukraine are currently receiving treatment. Side effects: Sometimes the medication feels worse than the disease, especially when treatment begins before symptoms arise. Some of the side effects- fat redistribution, hair loss, loss of bone mineral density, high cholesterol levels associated with coronary artery disease, liver disease, severe gastrointestinal irritation and diabetes to name a few. VI. Wrap Up Discussion (5 minutes) Link to stigma and discrimination Remind participants that stigma and discrimination keep people from finding out about their HIV status, learn about and change risky behaviors, and take steps to live the most productive (and non-transmitting) lives they can if they have it. Much stigma and discrimination is based on incorrect or inadequate understanding of the biology of HIV.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

As PCVs they may have the most impact by facilitating the dissemination of accurate information.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

Peace Corps/Ukraine

PEPFAR Training: Biology Module

Handout

The Life Cycle of the HIV Virus

2. The virus latches on 1. HIV virus finds a
T4 lymphocyte and enters the T4 cell through a special receptor on the cells surface

3. The virus
takes over the cells machinery and uses it to reproduce itself at a rapid pace. Mutations occur at this stage

4. New virus breaks

free of the T4 cell, damaging and eventually destroying the cell in the process. This newly formed HIV will find new T4 cells to infect and take over, repeating the process.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

HANDOUT Stages of HIV/AIDS Infection

I. Acute Infection (2-8 weeks): After initial infection, the bodys T4 cells rush in to fight the HIV, initiating the bodys immune response. Until the immune system has generated sufficient levels of antibodies for detection in the blood by available tests, HIV tests will be negative. This is the window period, the time that a person can be infected but test negative. Typically it lasts 1-3 months, but can be longer. Most people have mild flu-like symptoms for 1-2 weeks (sore throat, headache, fever), a skin rash and tender lymph notes; however there are not sufficient antibodies in the blood to be detected. Symptoms go away on their own as antibodies become detectable in the patients serum. HIV replicates rapidly during this stage, spreading to many organs, particularly the lymphoid tissues, where the virus can be stored. As T4 cells become infected and begin to replicate, the viral load in the blood is high. The person who is infected is particularly infectious.

II. Asympotamatic HIV Stage (for adults 6-11 years, or more with medication): There are no symptoms of HIV. During this time HIV continues to replicate. A person with HIV in this stage, like all other stages, can infect others through contact with body fluids, although s/he is less infectious. The body continues to produce new T4 cells and antibodies to the virus, indicating that the immune system is fighting the virus. HIV RNA can be measured in the blood this is thought to be a more reliable indication of disease progression than the number of T4 cells, but both measures are important in monitoring the spread of HIV.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

III. Symptomatic HIV Stage (months or years): The number of T4 cells in the body drops significantly from a normal 1000/microlitre of blood to around 500/microlitre of blood. Levels of HIV RNA in the blood increase. The immune system is weakened, signaled by the inability to fight off infections that a healthy immune system can combat. As in all stages, a person can infect others. Good nutrition is very important at this stage. So is self-care: exercise, meditation, staying away from stress and people with obvious contagious diseases. IV. AIDS: Advanced HIV T4 cell count is below 200/microlitre of blood. HIV has progressed to AIDS when the immune system is weakened to the point that it cannot fight off diseases that a healthy person can resist. The person begins to develop opportunistic diseases that vary by geographic region. These include a large range of diseases such as tuberculosis, pneumonia, bowel infection, meningitis, and cancers such as non-Hodgkins lymphoma and Kaposis sarcoma. According to the World Health Organization, TB is the leading cause of death in people infected with HIV worldwide.1 T4 cells are no longer being replaced. AIDS does not mean immediate death. People get sick and recover from various diseases. As in all stages, a person can infect others. Characterized by loss of body weight, or wasting. Eventual death.

Stine, pg. 160.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Handout

Blocking HIV Reproduction: How ARVswork

HIV uses an enzym e to change its RNA to DNA. This process can be blocked by interfering with the needed enzym e The virus uses another enzym e to incorporate its genetic m aterial into the host cell. This process can be blocked.

The release of the new ly form ed virus from the infected host can be stopped

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Handout

FACT SHEET Antiretroviral (ARV) Drugs for HIV/AIDS

Antiretroviral Drugs
A dramatic reduction in viral load (the level of virus in the blood) with resulting arrest in immune damage is achieved by combining at least three drugs from the various classes of antiretroviral drugs into a "cocktail." This three-drug cocktail is called "Highly Active Antiretroviral Therapy" (HAART). Each class of anti-HIV drugs attacks the virus at a different stage of replication while is it growing in the human host lymphocyte cell. The common classes of drugs currently on the market are the nucleoside reverse transcriptase inhibiters such as zidovudine (AZT), lamivudine (3TC), abacavir; the nonnucleoside reverse transcriptase inhibitors such as nevirapine and efavirenz; and the protease inhibitors such as indinavir, ritonavir and lopinavir. Drug-related issues that influence their use include the following:

All ARVs are still costly, even with recent dramatic price reductions, when compared to STI or TB drugs, for example. Side effects of the drugs are common and need to be clinically monitored. Side effects may lead to stopping or changing the drug, or changing life style to reduce alcohol intake in case of liver toxicity. HIV can easily become resistant to ARVs, hence the need to combine different classes of ARVs to treat patients. Most of the ARVs interact with other drugs commonly used in the treatment of opportunistic diseases such as tuberculosis and fungal infections. This requires adjusting the dosage of the drugs or the discontinuing ARVs while taking other medication. Most of the ARVs currently available have strict medication schedules or storage requirements although medical advances are developing new drugs and drug combinations to make them easier to take with fewer side effects. The protease inhibitors, for example, require a very strict time regimen to be effective (e.g., indinavir every eight hours on an empty stomach). Some require refrigeration (e.g., ritonavir, lopinavir). Others need precautions to avoid severe side effects (indinavir, for example, requires at least 1 _ litres of water a day to avoid kidney stones; efavirenz can cause insomnia with chaotic dreams, requiring it to be taken only at night). Pregnant women should not use efavirenz. ARV must be taken lifelong if AIDS is to be a manageable chronic illness. It requires a lifelong relationship between client and the health team.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

The Client on ARV

Adherence (also called compliance or concurrence) to the complex and lifelong ARV medication is the key to sustained effectiveness and less of a chance that HIV will become resistant to ARVs. In general, regimens without protease inhibitors are easier to take. Other regimens require taking medication once or twice a day, and do not require strict timing, an empty stomach or large fluid intake. The following are issues from the client's perspective that should be considered and incorporated in planning:

Starting ARVs is committing to lifelong medication and entails enduring the almost universal initial period of unpleasant side effects. It also requires identifying financial resources necessary for regular medical visits, costs of laboratory tests and treatment costs. The self-discipline and financial burden associated with ARV should be discussed at the start of treatment. Continuous drug information or even drug counseling by the care provider and pharmacist is essential to improved adherence. Emotional support for clients on ARV remains a cornerstone of care. Treatment failure is common and when there are no alternatives to the initial ARV regimen, there must be support to ensure continuation of care and referral to palliation and home care. ARV may create false hope of safety among users and result in increased high-risk behavior. Services have to ensure ongoing counseling about the need to continue protective action and information on the effects of ARV for clients and their sexual partners. Information and education for communities and society on the realities of ARV use should also be in place. ARVs are neither a cure nor a preventive tool per se.

The Health Systems

To optimize the benefits of ARV for greatly reduced morbidity, mortality and improved quality of life, the following need to be addressed simultaneously:

Training health teams in both the public and private sectors, with regular updates on treatment and care options. Reorganizing services to integrate HIV care in outpatient departments and at health centers to allow for space, privacy and time and linkages with TB-DOTS and STI programs Expanding and integrating quality VCT into health systems as an entry point to prevention and care. Strengthening and upgrading laboratory facilities. Although viral load measurements may not be essential for safe and effective use, CD4 counts or cheaper alternatives are needed to help providers and clients decide together when to start and when to switch or stop treatment. There needs to be laboratory monitoring for potential side effects. Communicating to the public at large on the benefits and risks of ARV treatment. Strengthening and scaling up comprehensive care programs (management of opportunistic infections, preventive therapies, TB-DOTS, home care, palliative care, social support) to accommodate ARV use and continue to care for a majority of patients not on ARV.

Strengthening prevention programs to link closely with care and ARV treatment programs and reinforce the need for prevention as a primary goal within and beyond the health sector.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov

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PEPFAR Training: Biology Module

Global Patterns of HIV Transmission

Worldwide, there are now three types or patterns of HIV epidemics unfolding. The first pattern is occurring in wealthy countries, such as the United States, where the epidemics are heterogeneous but dominantly involve male to male sexual transmission. After a long period of decline, those epidemics are now showing troubling signs of resurgence, largely due to unsafe sexual practices among gay men. The second pattern is seen in sub Saharan Africa and Latin America, driven by heterosexual transmission. Africa continues to have the largest numbers of people living with HIV and dying of AIDS. The third pattern and labeled as explosive by UNAIDS has almost nothing to do with sex. It is driven by needles shared among people who inject narcotics. All over the world the narcoticsdriven HIV pandemic seems to begin, unnoticed by government officials, in isolated communities of injection drug users, spreads like wildfire, and then suddenly takes on national significance. The most disturbing examples of this phenomenon are the epidemics of eastern Europe and Asia, which regionally are in the midst of an HIV explosion that was predicted some years ago. Injection drug use associated HIV infections are out of control in Russia, China, and Indonesia.

In the US- Who is dying of AIDS?

In proportion, since 1985, the rate of death was higher for women than for men. Through the year 1990, over 120,000 people died from AIDS. In 2004, about 527, 000 people died from AIDS. To place the death rate due to AIDS in perspective, each day in America in 2003, about 6000 people died from assorted causes while about 40 died each day from AIDS. Worldwide, an estimated 3 million people died from AIDS in 2001, 2002, and 2003. For 2002 and 2003, of these deaths, half were women and 8% were children. The rate of increase in new AIDS cases has slowed, but the number of new cases exceeds the number who die of AIDS by over 60% annually.

Questions? Contact Helen Petrozzola at hpetrozzola@ua.peacecorps.gov