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Microsoft word - che and aids in africa.doc

• Incurable, contagious, virtual y fatal • Consider disease and CHE’s role - theory • Emphasizes prevention (ie AIDS) at the family level – recurrent home visits • Married with strong evangelism and discipleship – changes the heart and motivation • Owned and operated by the community from the beginning – individual or family is the • Community is facilitated by outsiders to form their own program not managed by • Sustainable – CHE workers / local trainers are volunteers. Concept is applicable • Transfers relevant technical knowledge • Encourages the change of risky behaviors • 3 main groups of people in a CHE program • CHE trainers – Christians trained to facilitate communities to start their own programs • Community Committee – manages the CHE project for the community. • Trained by the trainer in relevant physical and spiritual topics (ie AIDS prevention). Usual y takes 6 months to ful y train. (ie use of Edward the Elephant AIDS materials) • Assigned 25 – 50 homes to regularly visit. • Each visit the CHE shares a physical and spiritual topic • CHE’s start Bible studies for the spiritual y hungry • Introduce the new converts to an evangelical church. • Does CHE work in changing addicting behaviours? Yes (example – community where • Focus of AIDS program – prevent high – risk behaviors • 77 - 89% al AIDS worldwide is found in Africa • 33 mil ion people in sub-Saharan Africa currently infected • From the onset of infection to disease manifestation – 11 years or more • Survival after disease onset – 5-14 months • Current rate of increase in cases – 20% per year • By 2021 Africa wil lose 245.12 mil ion • 1.7 mil ion children orphaned by AIDS in sub-Saharan Africa (90% of the world’s AIDS • Highest infection rate 15 – 24 year old age group • 35 X increased childhood AIDS in developing vs developed countries • 75% of new cases due to heterosexual contact • Major focus of AIDS prevention - six main areas 1. Vaccine development - needs more research 2. General blood and secretion precautions 3. Elimination of high risk behaviour -CHE 4. Improved prenatal and perinatal care (decrease lbw and premature infants) • Decrease invasive procedures during pregnancy and delivery - amniocentesis, episiotomy, forceps, scalp electrodes, vacuum extractors. • Use experienced centers for prenatal and perinatal care. 5. Control breast feeding in HIV positive mothers -CHE 6. Prophylaxis for pregnant mothers and newborns -CHE III. Prevent preadolescent high risk activities A. C. Everett Koop – Prior US Surgeon General – guidelines to prevent AIDS 1. Abstain from sex until marriage – best 2. After marriage only have sexual relations with your spouse 3. If a person refuses to do the above they should avoid sex with those known to be or at risk of being infected with AIDS and when having sexual relations use condoms 4. Target the preadolescent with education to prevent high – risk behavior B. Does Education alone significantly affect sexual behavior of preadolescents? • Despite AIDS education - correct AIDS knowledge - markedly deficient • 15% of 16-19 yo changed sexual behaviour due to AIDS risk • MMWR, 1988;37:133-38, MMWR, 1991;40:792 • Study of homosexuals practicing anal intercourse - use of condoms • Condom use increased from 1% (1981) to 79% (1987) • 5 sex education programs - evaluated • No change in sexual behaviour - teenage pregnancy (increase 13%) • Study condom use - sexual partners - col ege aged women • Modest increased use - 6% (1975) to 25% (1989) • 61-64% appropriate knowledge of otyher STD’s • Conclusion - “neither knowlege of HIV disease or STD, nor fear of acquiring AIDS or STD significantly influenced student sexual behaviour”. • Conclusion - HIV knowledge did not increase condom use. • Low rates of condom use despite high level of AIDS knowledge. • Had 5 basic sessions on sex and drug educations via health educators in 7th grade and 8 sessions taught by peers in the 9th grade focusing on abstinence • Intervention group were 3X less likely to have initiated vaginal intercourse and practiced • Those receiving HIV risk – reduction interventions – more favorable behavioral beliefs about condoms, greater self-efficacy, and stronger condom use intentions post • Given 14 face to face sessions emphasizing abstinence and safer sex • Intervention group believed they could be intimate without sex, could explain how to use • Current AIDS education works with high risk groups (homosexuals) • Doesn’t work wel enough with adolescents • Feel invulnerable? That’s why they are good soldiers? C. What can be done to decrease preadolescent high – risk behavior? • Study of the 5 most successful substance abuse programs in the US – 1989 • Relates to other behavior change programs 3. Adequate duration, intensity and program structure 4. An emphasis on values and appropriate life styles • Impacts al of the 4 common principles • Great mechanism to disseminate information – AIDS booklets like Edward the Elephant • Reaches the whole family with AIDS prevention message recurrently – face to face • Emphasize evangelism and discipleship – God can help a person to be holy • 6th leading cause of death (15-24 yo). • Group
Percentage
• Mothers with AIDS or at risk of AIDS • Most cases - vertical transmission - mother to child • 2/3 before or during birth - AZT prophylaxis, Neviripine, Combination • 77% vertical transmission - preventable • Transmission rate of an HIV + mother to child - 12 - 43% 3). Preterm labor and delivery (< 34 wga - 3.80 odd’s ratio) 5). STD’s with ulcers (chanchroid, syphil is, herpes) 11). Vaginal delivery (c-section .56 odds ratio) 12). Procedures when not routine - episiotomy, scalp electrodes, forceps, vacuum extractors. • Duration of breast feeding (Increase in transmission rate 1m - 45%, 2 m - 64%, 3m - • New infection - lactating - 26%, prior infection 8-18% • Encourage al HIV neg or unknown status to breast feed • Known HIV + mother (must do testing in mother) - inform of breast feeding risks • Find breast feeding options - Breast milk substitute (must have clean water) • Alternate sources not available - dc breast feeding at 6 months. • Decrease childhood infectious diseases - immunizations, sanitation, hygiene, clean water, early curative care – (microcosm of health around existing clinics and • PCR, Viral cultures and p24 antigen - expensive, unavailable consider - repeat C. Community Health Evangelism considerations • Must have an accessible clinical facility - (early curative care, HIV testing • Effective recurrent home visits could impact the fol owing • Arrange for HIV testing and fol ow-up • Encourage prophylactic antiviral treatment • Encourage formula usage and distribution • Encourage appropriate general preventive measures (immunizations, sanitation, ORS • Encourage early curative treatment of sick infants • Arrange for HIV testing at 6 - 18 months for children • Encourage appropriate birth control for HIV positive mothers • Rapid tests most desirable (ie Dipstick HIV 1 and 2) • Sensitivity / Specificity – same as with ELISA • Assay time – 3 minutes – 3 hours 5 minutes • Test infant at 6 –18 months. 6 months probably adequate • Repeat the rapid test to confirm a + particularly where the prevalence is low (<10%) • PPV based on Prevalence (Test with Sensitivity 99.9% and Specificity 99.6%) 1. Testing of infants 16w to 6 months. Uganda study used PCR at 16 weeks. 2. Nevirapine – 200 mg at onset of labor and 2 mg / kg to the newborn within 72 hours • Cost of powdered formula - $5.58-6.85 / 2.7 quarts or approximately $2.30 / quart • Community of 5000, with 2500 children, 2500 adults and 1250 women at • 12% prevalence (i.e Kenya) of HIV = 150 adult women of reproductive age with HIV or 300 risk pregnancies over 4 years or 75 per year. • 27.5 % vertical transmission rate or 21 vertical transmissions per year • With 61% prevention (Neviripine + breast feeding) - 13 HIV cases could be prevented • Pregnancy of al susceptible women every 2 years = 2500 pregnancies in 4 years or • $.50 per HIV test = $312.50 / year / pregnant mothers. $312.50 / year / child at 6 months. Total = $625. Retesting of positives $37.50 / year. • Neviripine costs = $4.83 / course or $362.25 per year • Assume 1 qt per child per day or 324 quarts per year • Cost $2.30 per quart or $745.20 for 1 year / at risk child • For 75 at risk babies per year = $55,890 / year / community of 5000 or $27945 / 6 • $350.00 – Preliminary testing and retesting of positives • $312.50 – Post testing of the baby • $1024.75 – to prevent 13 vertical transmission cases of AIDS per year in a • $78.83 to prevent one HIV case in a child – Is it worth it? • With formula - $1931.32 – $3794.32 to prevent one case in a child (assuming 15

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