79-14352.)

sterile mating, including the humans.

understanding of the FSD; - Contrary to what was mentioned, sex is NOT "Like Dancing": Sex is a physiological impact; - There is evidence that the continuing promotion of condoms use as a "normal sexual behavior" and/or (PC) contraceptive practice is lethal (breast cancer); - "Sexual functioning is an integral part of our lives" and perhaps of (gender) physical survival; - The feminist nonsense as a recipe for producing FSD: "masturbation" in females; - The "Conspiracy of Silence" for FSD is even more so for the unabated breast cancer epidemic; - The FSD, "as potentially epidemic condition" could and should be better handled in the services and domain of the Gynecologists-Obstetricians rather than the Urologists. - The "environmental intervention" in FSD, like in the breast cancer epidemic: Eradication of the "INVERSE" environmental factor, the barrier of the condom use that is eliminating, reducing or making absence the protective biological mechanisms in the intimate and subtle, inter-human (sexual) environment and ecosystem.

No wonder that the FSD is so prevalent in British and American women (reportedly, about 43%), for both are "high-risk" populations of breast cancer and are among the leading breast-cancer epidemic countries, with the highest breast cancer incidence and death rates in the world. Since the CONDOMIZATION of human sexuality seems to be the singular most important factor in the women's sexual dysfunction, my humble and evidence-based suggestion is simple and brief:

ABOLISH THE USE OF CONDOMS FOR CONTRACEPTIVE, FERTILITY-CONTROL AND FAMILY-PLANNING PURPOSES in the British marriages and couples, and make an urgent shift to the "non-barrier" methods of contraception (Gjorgov & Narod, 2001a). It is long overdue to make the British and other women happy."

## **4.7.2 Condomization, abortions, 'missed abortions,' and pseudopregnancy**

The following letter to the **Editor of the New York Times**, referring to the editorial "Abortion, Condoms and Bush," by **Nicholas D. Kristof,** NYT November 5, 2006, tackles the issue of condoms, "missed abortion," and breast cancer:

### **Condoms, Condoms, Condoms…and Abortions. A critical reply**

"Mr. Kristof seems biased and medically ill-informed by discussing a biological issue like abortions and condoms. What kind of abortion "rise" and "fall" throughout the past (three) decades and during (six) presidential periods? Discussion of temporal changes of all (i) the artificial, (ii) spontaneous, and (iii) so-called "missed" abortions? And, on top of this professional mix-up and mystery of abortions, a cause-and-effect link is added to the (predominant) use of condoms?

The (i) artificial abortions are carried out by demands, and reflect a fertility capacity of at least the woman. The artificial abortions burden the soul of the women in tremendous psychological pain, are reluctantly performed, and socially have always been quite controversial.

The (ii) spontaneous abortions reflect an infertility / sub-fertility status of both partners, usually married, and may indicate a hidden plight in building the family. The infertility condition is an acknowledged risk factor of development of breast cancer and other women's ill health.

The (iii) "missed abortion" is an utterance of professional, clinical perplexity. As a

AIDS Changed America with the Twin

and the E.U.

negligible use of OC pills.

Dear Madam,

Queen of the country, as follows:

The Royal Palace, Stockholm, Sweden

solving this worrisome situation.

breast cancer in married American women.

**4.8 Anorexia-bulimia ('eating') disorders** 

Breast Cancer Epidemic: Exploring the Consequences of Condomization 551

The literature of Anorexia-Bulimia (conveniently called "eating") disorders match only that of breast cancer. The number of new cases of anorexia and bulimia disorders rose rapidly worldwide in the past three decades, 1980s, 1990s, and 2000s, the rampant condition is rising ever since, continuing its rise in the 2000s, especially in the developed West, such as, the U.S.

A descriptive study was conducted in young female patients in mid-200s, at the Psychiatric outpatient clinic at the Faculty of Medicine of the University Sts. Cyril and Methodius, in Skopje, Macedonia, in order to assess the sub-hypothesis that (illicit) barrier contraception (condom use and withdrawal practice) is a risk factor of anorexia-bulimia disorders in schoolgirls, college female students, and other young women and brides (Gjorgov, 2009a). The main results indicated of the study indicated that the anorexiabulimia patients [with mean age of 23.3 years (sd= 3.1)] used overwhelmingly condom device and equally practiced withdrawal technique for contraceptive purposes, during most of their young sexual experience and initial reproductive lives, as opposed to

On the basis of the prior observation (the sub-hypothesis), a confident communication along with a suggestion was forwarded almost 14 years ago to the **Swedish Royal Family**, concerning the announcement of the worrisome 'eating' disorder condition in the future

This is a humble attempt to try to address, as a physician and researcher, the reported news in the media of a heavy body-weight loss of Her Royal Highness Princess Victoria and to try to suggest a new possible approach in the efforts for

In my opinion, the heavy body-weight loss, so called *Anorexia nervosa*, is secondarily related to the problems of nutrition and diet. Rather, there is circumstantial evidence, that the life-threatening condition of *Anorexia nervosa* is perhaps causally related to the demands of reproductive and intimate life and to its applied technical barriers. The alternative hypothesis about the nature of *Anorexia nervosa* was deducted from a "byproduct" observation in my long research of the developmental processes in the field of breast cancer. Furthermore, the frequent condition of a prior excess body loss (and gain) in the affected, young, reproductive-aged women with breast cancer was controlled for and partially tested as a sub-hypothesis in my hypothesis-testing study of barrier contraception (the condom use and withdrawal practice) as an etiological risk factor associated to

During my field and ecological studies of breast cancer, it became obvious that the condom use in your country has been quite prevalent, with all the postulated subsequent consequences of the widespread misconception that "the use of condom has no side effects." On the other hand, breast cancer in Sweden has been reported and registered as one of the highest in the world, and still raising, mainly because of

M-me Elisabeth Tarras-Wahlberg, Spokeswoman, Skopje, December 10, 1997

pastime term it could only be found in older editions of gynecology textbooks. The contemporary professionals try hard to avoid diagnosis of "missed abortion," for its occurrence is not understood, and indicates a situation of false pregnancy. The condition is connected with the use of condoms. The 'failure-rate' of the use of condoms as contraceptive device is (uncritically) estimated to be around 9 percent. In fact, the use of condoms is induction of technical effects of absolute male sterility in the intimate (sexual) relations. (The prolonged or repetitious condition of false pregnancy is presumed as the initial, still reversible stage of breast cancer and other sex- (gender-) specific diseases in women of all ages.)

In my informed view, the reported, intermittent phrasing of "sharp rise," "tiny increase" and/or "tiny fall" of abortions throughout time are misleading, inaccurate and incomplete. Actually, who knows whether the reports of abortions could ever be better exact?

On the other hand, the sharp rise and spiraling advent of the breast cancer epidemic in the country, in the last two-and-a-half decades (since the beginning of 1980s), the unending epidemic of malignant disease associated with the persistent condom use, is strangely overlooked in the column assessment.

The professional misjudgment and incompetence seem to be manifested in the confusion and equation of the use of condoms as a general category of family planning. The euphemism of "comprehensive sex education" practically means condom promotion / distribution in the schools, with condomization of the nascent sexuality of the schoolgirls, the youngest generation(s) of the American population, with unknown grave consequences / sequels.

As a young congressman, George H.W. Bush may have sponsored the 1970 public health program of family planning services which, almost certainly, may have included condoms, but, as President, he is recorded at a series on ABC television stations, in 1990, as rejecting distribution of condoms: "Not for me and not for the federal government… I don't think that just passing out condoms, giving up on lifestyle, giving up on family and fundamental values is correct… In terms of just national passing out of condoms to people, I am not in favor of that." So, President George W. Bush seems to be actually continuing the family roots. His energetic condom-paradigm shift and the potential of curbing the current breast cancer epidemic with the new anti-condom reproductive policy are anticipated to achieve an impending 'eradication' of the dreaded epidemic disease to the levels of sporadic cases in the country and far beyond."

NOTE: In less than a month, on Dec. 5, 2006, the New York Times run an article entitled; "All the signs of pregnancy except one: A baby," by Elizabeth Svoboda (Svoboda, 2006). Apparently, the NYT editors have investigated the above critique, confirming the information of false pregnancy which was repeatedly termed by its ancient Greek name, *pseudocyesis*. By quoting certain medical authorities, a skepticism was underlined that "human pseudocyesis will never be completely scientifically understood," and another assertion that it is "one of the classic examples how the mind affects the rest of the body." In fact, the condomization of female sexuality (pseudocyesis) may prove to be one of the classic examples of how the injured body affects the mind, rather than the way around. The issue of false pregnancy is associated with the condom-related "reproductive freedom" fallacy (Gjorgov, 1980, 1996a).

## **4.8 Anorexia-bulimia ('eating') disorders**

550 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

pastime term it could only be found in older editions of gynecology textbooks. The contemporary professionals try hard to avoid diagnosis of "missed abortion," for its occurrence is not understood, and indicates a situation of false pregnancy. The condition is connected with the use of condoms. The 'failure-rate' of the use of condoms as contraceptive device is (uncritically) estimated to be around 9 percent. In fact, the use of condoms is induction of technical effects of absolute male sterility in the intimate (sexual) relations. (The prolonged or repetitious condition of false pregnancy is presumed as the initial, still reversible stage of breast cancer and other sex- (gender-) specific diseases in

In my informed view, the reported, intermittent phrasing of "sharp rise," "tiny increase" and/or "tiny fall" of abortions throughout time are misleading, inaccurate and incomplete. Actually, who knows whether the reports of abortions could ever be better

On the other hand, the sharp rise and spiraling advent of the breast cancer epidemic in the country, in the last two-and-a-half decades (since the beginning of 1980s), the unending epidemic of malignant disease associated with the persistent condom use, is

The professional misjudgment and incompetence seem to be manifested in the confusion and equation of the use of condoms as a general category of family planning. The euphemism of "comprehensive sex education" practically means condom promotion / distribution in the schools, with condomization of the nascent sexuality of the schoolgirls, the youngest generation(s) of the American population, with unknown grave

As a young congressman, George H.W. Bush may have sponsored the 1970 public health program of family planning services which, almost certainly, may have included condoms, but, as President, he is recorded at a series on ABC television stations, in 1990, as rejecting distribution of condoms: "Not for me and not for the federal government… I don't think that just passing out condoms, giving up on lifestyle, giving up on family and fundamental values is correct… In terms of just national passing out of condoms to people, I am not in favor of that." So, President George W. Bush seems to be actually continuing the family roots. His energetic condom-paradigm shift and the potential of curbing the current breast cancer epidemic with the new anti-condom reproductive policy are anticipated to achieve an impending 'eradication' of the dreaded epidemic

NOTE: In less than a month, on Dec. 5, 2006, the New York Times run an article entitled; "All the signs of pregnancy except one: A baby," by Elizabeth Svoboda (Svoboda, 2006). Apparently, the NYT editors have investigated the above critique, confirming the information of false pregnancy which was repeatedly termed by its ancient Greek name, *pseudocyesis*. By quoting certain medical authorities, a skepticism was underlined that "human pseudocyesis will never be completely scientifically understood," and another assertion that it is "one of the classic examples how the mind affects the rest of the body." In fact, the condomization of female sexuality (pseudocyesis) may prove to be one of the classic examples of how the injured body affects the mind, rather than the way around. The issue of false pregnancy is associated with the condom-related "reproductive freedom" fallacy (Gjorgov, 1980,

disease to the levels of sporadic cases in the country and far beyond."

women of all ages.)

consequences / sequels.

strangely overlooked in the column assessment.

exact?

1996a).

The literature of Anorexia-Bulimia (conveniently called "eating") disorders match only that of breast cancer. The number of new cases of anorexia and bulimia disorders rose rapidly worldwide in the past three decades, 1980s, 1990s, and 2000s, the rampant condition is rising ever since, continuing its rise in the 2000s, especially in the developed West, such as, the U.S. and the E.U.

A descriptive study was conducted in young female patients in mid-200s, at the Psychiatric outpatient clinic at the Faculty of Medicine of the University Sts. Cyril and Methodius, in Skopje, Macedonia, in order to assess the sub-hypothesis that (illicit) barrier contraception (condom use and withdrawal practice) is a risk factor of anorexia-bulimia disorders in schoolgirls, college female students, and other young women and brides (Gjorgov, 2009a). The main results indicated of the study indicated that the anorexiabulimia patients [with mean age of 23.3 years (sd= 3.1)] used overwhelmingly condom device and equally practiced withdrawal technique for contraceptive purposes, during most of their young sexual experience and initial reproductive lives, as opposed to negligible use of OC pills.

On the basis of the prior observation (the sub-hypothesis), a confident communication along with a suggestion was forwarded almost 14 years ago to the **Swedish Royal Family**, concerning the announcement of the worrisome 'eating' disorder condition in the future Queen of the country, as follows:

M-me Elisabeth Tarras-Wahlberg, Spokeswoman, Skopje, December 10, 1997 The Royal Palace, Stockholm, Sweden

Dear Madam,

This is a humble attempt to try to address, as a physician and researcher, the reported news in the media of a heavy body-weight loss of Her Royal Highness Princess Victoria and to try to suggest a new possible approach in the efforts for solving this worrisome situation.

In my opinion, the heavy body-weight loss, so called *Anorexia nervosa*, is secondarily related to the problems of nutrition and diet. Rather, there is circumstantial evidence, that the life-threatening condition of *Anorexia nervosa* is perhaps causally related to the demands of reproductive and intimate life and to its applied technical barriers. The alternative hypothesis about the nature of *Anorexia nervosa* was deducted from a "byproduct" observation in my long research of the developmental processes in the field of breast cancer. Furthermore, the frequent condition of a prior excess body loss (and gain) in the affected, young, reproductive-aged women with breast cancer was controlled for and partially tested as a sub-hypothesis in my hypothesis-testing study of barrier contraception (the condom use and withdrawal practice) as an etiological risk factor associated to breast cancer in married American women.

During my field and ecological studies of breast cancer, it became obvious that the condom use in your country has been quite prevalent, with all the postulated subsequent consequences of the widespread misconception that "the use of condom has no side effects." On the other hand, breast cancer in Sweden has been reported and registered as one of the highest in the world, and still raising, mainly because of

AIDS Changed America with the Twin

age span of women (Gjorgov, 2006).

and osteopenia in women.

**4.9 Osteoporosis** 

Breast Cancer Epidemic: Exploring the Consequences of Condomization 553

Osteoporosis far exceeds in frequency (incidence and prevalence) all other conditions in the female populations. During the past decades, since the early 1980s, osteoporosis and its sequels rapidly rose and continued its unabated rise, reaching excess epidemic proportions. As a "silent epidemic," osteoporosis has become highly prevalent as a great clinical and societal burden, and a heavy public health problem of highest priority, especially in the affluent North American, European and other communities. A systemic disease, affecting 7.8 million women in the U.S. and worldwide, osteoporosis is diagnosed by low bone mass than average and steadily deteriorating bone tissues, leading to bone fragility and increased fracture risk. In the U.S. and Europe, 1 in 3 or even 2 women over 50 years of age will develop the disease, and more and more affecting premenopausal women. Presently, there is a gap in the efforts to control, treat and prevent the osteoporosis. The predominant theories of diet, calcium and vitamin D deficiency, and other macro-environmental factors have advanced no progress in the etiology, treatment and prevention of the osteoporosis in women. The traditional and doctrinaire approaches have neither identified the etiological causes of the osteoporosis epidemic nor defined the ways of preventing the disease in the community and at individual and family levels. Within the framework of the Bone and Joint Decade 2000-2010, an attempt was made by submitting a project proposal to test a new hypothesis of an etiological relationship between the barrier contraception and the risk of osteoporosis development in women. The proposed hypothesis of the etiology of osteoporosis (and osteopenia) and of the potential of primary prevention of the condition in women postulates that the osteoporosis is a late, delayed and/or a prolonged consequence of the marital exposure to (use of) barrier forms of contraception (specifically, condoms and/or withdrawal, and male/family infertility) during the reproductive, pre-menopausal

Once again, various manifestations of affected bone health, such as the low back pain, showed distinct increase in prevalence the U.S., after the 1980s, the same alleged time period

Osteoporosis, and its initial stage, osteopenia, are perplexed with misinformation and misconceptions. First, the proportion of women with osteoporosis over men with osteoporosis is almost nine times greater in women than in men, which fact is not always underlined for further considerations; Second, the condition fall into the setting of so called sex- (gender-) specific diseases in women (like breast cancer, in proportion 100:1 females to males; Third, the grave condition do not 'naturally' come with age (look at the Sybille figures of the Michelangelo frescoes); Fourth, not all women carry the same risk of osteoporosis; Fifth, the (mystified) "FRAX" osteoporosis / osteopenia risk assessment tool from the osteoporosis associations, consists of majority of the same spurious and secondary risk factors of breast cancer; Sixth, a primary (natural) prevention of the conditions has neither been mentioned nor considered. Since the idea of potential breast cancer prevention is that it should start long before the malignant tumors are diagnosed, it could be safe to suppose that the "natural" (non-chemical) prevention of the crippling conditions of osteoporosis/osteopenia should be attempted at the same time along with the prevention of the other gynecological lesions, or even earlier, during the peak of the reproductive lives of women. Information for prevention seems far superior to pharmaceutical marketing concerning the chemical control and 'treatment' of osteoporosis

during all other ill-health developments occurred in women (**Figure 17**).

the widespread and long-term condom use in the general population, as postulated. In my separate study of the epidemiology and rising trends of breast cancer in Sweden, in 1992, the potential for prevention and control of the current breast cancer epidemic in the country was elaborated and suggested. Because the study could not be publish, copies of it were sent from Kuwait University to a number of health and political authorities and institutions in Sweden, as a personal communication.

Based on my research experience, I do believe that the exposure to the condom use (i.e., to technically induced sterile stimulation) induces some devastating effects to a normal, young, vivacious, healthy woman, among which the life-threatening response of *Anorexia nervosa* seems to be one of the most frequent condition in the advanced countries, such as Sweden. The assessment of H.H. the Princess' condition is done on incomplete information and on certain assumptions, which might not be correct. Nevertheless, the possible way out of the anorectic danger for such a lady, in my opinion, would be the absolute elimination of the condom as a fertility-control device, by reverting to any of the non-barrier contraceptive methods (the pills, diaphragm, rhythm, IUDs, creams-jellies), in order to be able to preserve the healthy reproductive and inter-human life, and to prevent neoplastic phenomena.

Enclosure: Clipping from the daily newspaper. Respectfully submitted, …

(The letter was acknowledged with thanks for the 'wish to help.')

A similar communication was submitted recently to the Chairwoman of the **White House Council on Women and Girls** and Special Advisor the President, on December 10, 2010, concerning the rampant "eating' disorders cases in the U.S. and other developed countries of the West, as follows:

#### **Dear Madam Special Advisor: Re: Eating Disorders Prevention**

"Along with the Best wishes to Rep. Alcee L. Hastings and Patrick J. Kennedy and 34 Members of the Congress for their initiative to incorporate the global eating-disorders issue into the First Lady Michelle Obama "Let's Move Campaign" and the "Federal Response to Elimination of Eating Disorders (FREED) Act 2010."

Just to reiterate that there are no greater "strong environmental, cultural, and social factors" associated to or causing eating disorders, as mentioned in the letter to the First Lady (July 21, 2010), but the condomization of the nascent sexuality of schoolgirls, college and other women in the population. An all-inclusive approach to women's health and the new research of both the breast cancer epidemic and the rampant anorexia-bulimia disorders has identified as the main root cause of the specific sex- (gender-) diseases in women the misconceived and deadly, false belief of condom as a "safe" device for fertility-control and family-planning use.

My concern is, yet, that the blackout history of the past three decades may repeat itself, to continue stocking the unabated breast cancer epidemic in middle-age women (mothers), and extending the ill effects to the helpless anorexia-bulimia bewildered young women (daughters). The strongly reinforced, misleading, renewed condom-use offensive, oblivious of the greatest ill-health consequences to the half of the population, is poised to persist with the discrimination against women, girls and couples, by withholding the potentially lifesaving information of a primary (non-chemical, non-profit) prevention / protection against the grave female-specific diseases at personal, familial and community levels. "

#### **4.9 Osteoporosis**

552 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

political authorities and institutions in Sweden, as a personal communication.

reproductive and inter-human life, and to prevent neoplastic phenomena.

A similar communication was submitted recently to the Chairwoman of the **White House Council on Women and Girls** and Special Advisor the President, on December 10, 2010, concerning the rampant "eating' disorders cases in the U.S. and other developed countries

"Along with the Best wishes to Rep. Alcee L. Hastings and Patrick J. Kennedy and 34 Members of the Congress for their initiative to incorporate the global eating-disorders issue into the First Lady Michelle Obama "Let's Move Campaign" and the "Federal

Just to reiterate that there are no greater "strong environmental, cultural, and social factors" associated to or causing eating disorders, as mentioned in the letter to the First Lady (July 21, 2010), but the condomization of the nascent sexuality of schoolgirls, college and other women in the population. An all-inclusive approach to women's health and the new research of both the breast cancer epidemic and the rampant anorexia-bulimia disorders has identified as the main root cause of the specific sex- (gender-) diseases in women the misconceived and deadly, false belief of condom as a "safe" device for

My concern is, yet, that the blackout history of the past three decades may repeat itself, to continue stocking the unabated breast cancer epidemic in middle-age women (mothers), and extending the ill effects to the helpless anorexia-bulimia bewildered young women (daughters). The strongly reinforced, misleading, renewed condom-use offensive, oblivious of the greatest ill-health consequences to the half of the population, is poised to persist with the discrimination against women, girls and couples, by withholding the potentially lifesaving information of a primary (non-chemical, non-profit) prevention / protection against

the grave female-specific diseases at personal, familial and community levels. "

Enclosure: Clipping from the daily newspaper. Respectfully submitted, …

(The letter was acknowledged with thanks for the 'wish to help.')

**Dear Madam Special Advisor: Re: Eating Disorders Prevention** 

Response to Elimination of Eating Disorders (FREED) Act 2010."

fertility-control and family-planning use.

of the West, as follows:

the widespread and long-term condom use in the general population, as postulated. In my separate study of the epidemiology and rising trends of breast cancer in Sweden, in 1992, the potential for prevention and control of the current breast cancer epidemic in the country was elaborated and suggested. Because the study could not be publish, copies of it were sent from Kuwait University to a number of health and

Based on my research experience, I do believe that the exposure to the condom use (i.e., to technically induced sterile stimulation) induces some devastating effects to a normal, young, vivacious, healthy woman, among which the life-threatening response of *Anorexia nervosa* seems to be one of the most frequent condition in the advanced countries, such as Sweden. The assessment of H.H. the Princess' condition is done on incomplete information and on certain assumptions, which might not be correct. Nevertheless, the possible way out of the anorectic danger for such a lady, in my opinion, would be the absolute elimination of the condom as a fertility-control device, by reverting to any of the non-barrier contraceptive methods (the pills, diaphragm, rhythm, IUDs, creams-jellies), in order to be able to preserve the healthy Osteoporosis far exceeds in frequency (incidence and prevalence) all other conditions in the female populations. During the past decades, since the early 1980s, osteoporosis and its sequels rapidly rose and continued its unabated rise, reaching excess epidemic proportions. As a "silent epidemic," osteoporosis has become highly prevalent as a great clinical and societal burden, and a heavy public health problem of highest priority, especially in the affluent North American, European and other communities. A systemic disease, affecting 7.8 million women in the U.S. and worldwide, osteoporosis is diagnosed by low bone mass than average and steadily deteriorating bone tissues, leading to bone fragility and increased fracture risk. In the U.S. and Europe, 1 in 3 or even 2 women over 50 years of age will develop the disease, and more and more affecting premenopausal women. Presently, there is a gap in the efforts to control, treat and prevent the osteoporosis. The predominant theories of diet, calcium and vitamin D deficiency, and other macro-environmental factors have advanced no progress in the etiology, treatment and prevention of the osteoporosis in women. The traditional and doctrinaire approaches have neither identified the etiological causes of the osteoporosis epidemic nor defined the ways of preventing the disease in the community and at individual and family levels. Within the framework of the Bone and Joint Decade 2000-2010, an attempt was made by submitting a project proposal to test a new hypothesis of an etiological relationship between the barrier contraception and the risk of osteoporosis development in women. The proposed hypothesis of the etiology of osteoporosis (and osteopenia) and of the potential of primary prevention of the condition in women postulates that the osteoporosis is a late, delayed and/or a prolonged consequence of the marital exposure to (use of) barrier forms of contraception (specifically, condoms and/or withdrawal, and male/family infertility) during the reproductive, pre-menopausal age span of women (Gjorgov, 2006).

Once again, various manifestations of affected bone health, such as the low back pain, showed distinct increase in prevalence the U.S., after the 1980s, the same alleged time period during all other ill-health developments occurred in women (**Figure 17**).

Osteoporosis, and its initial stage, osteopenia, are perplexed with misinformation and misconceptions. First, the proportion of women with osteoporosis over men with osteoporosis is almost nine times greater in women than in men, which fact is not always underlined for further considerations; Second, the condition fall into the setting of so called sex- (gender-) specific diseases in women (like breast cancer, in proportion 100:1 females to males; Third, the grave condition do not 'naturally' come with age (look at the Sybille figures of the Michelangelo frescoes); Fourth, not all women carry the same risk of osteoporosis; Fifth, the (mystified) "FRAX" osteoporosis / osteopenia risk assessment tool from the osteoporosis associations, consists of majority of the same spurious and secondary risk factors of breast cancer; Sixth, a primary (natural) prevention of the conditions has neither been mentioned nor considered. Since the idea of potential breast cancer prevention is that it should start long before the malignant tumors are diagnosed, it could be safe to suppose that the "natural" (non-chemical) prevention of the crippling conditions of osteoporosis/osteopenia should be attempted at the same time along with the prevention of the other gynecological lesions, or even earlier, during the peak of the reproductive lives of women. Information for prevention seems far superior to pharmaceutical marketing concerning the chemical control and 'treatment' of osteoporosis and osteopenia in women.

AIDS Changed America with the Twin

marriage, underlying the following points:

the simple biological causes of the events.

widespread gynecological tumors and other afflictions.

earliest anticipated date, after the year 2010."

incidence and prevalence rates, the levels of condom-use acculturation.)

biological individuality.

Breast Cancer Epidemic: Exploring the Consequences of Condomization 555

In a response to the authors, Betsey Stevenson and Justin Wolfers, a critical commentary of the missing biological dimension in their scholarly analysis of national data of divorce and

"It seems we could not really know about the break-up of marriages, "long" or "new," if only the "broader economic and social consequences" are being considered, by forgetting

By looking into the primary source of the news ("*Marriage and Divorce: Changes and their Driving Forces*," by B. Stevenson & J. Wolfers, 2007 & 2009; Brining & Allen, 2000), besides the scholarly done review and presentation of official registry, raw data, the way of thinking, heavily influenced by the old-time feminism, seems very one-sided and insufficiently interpreted. The woman is analyzed manly as a technological, social, economy- and business- oriented personality, with no reference whatsoever to her (their)

It was rightly emphasized in the study that marriage and divorce laws and regulations along with technical changes in the family do not explain the rise of divorces over the past few decades. And yet, the women "who suffer" are those who in majority file for divorce. The figure 1 in the aforementioned study, presenting the rates of marriages and divorces (per 1000 American people), stretching for 145 years (1860-2005) is truly revealing. It seems to explain to a great extent the missing references to the most critical period of rapidly rising and still on-going period of exceptionally high-divorce rates in the country in the decades of 1980s, 1990s, and first part of the 2000s: the mass CONDOMIZATION of female sexuality. While the contraceptive pills and their impact upon the society have been studiously explained, the destructive impact of the promoted use of condoms over the past three decades has been strangely overlooked, with an utter oblivion to the current, excess breast cancer epidemic, the greatest scare, dread and real risk of women, along with the

Given the corroborated evidence that the condom use is significantly associated with the breast cancer development in American and other married women, it is not a wonder that many a woman is filing for divorce and, supposedly looking for a "new partner." Intimate condomized relations induce technical effects of absolute sterile husband in the marriage, perhaps worse stressor than other ones mentioned in the debate blog, such as "poor health, poverty, and unemployment." If in the biological struggle the wife is not supported (by a fertile husband), it is a general belief / observation, and she is turning against him. (The racial differences in rates of divorce are also consistent with the differences in breast cancer

The figure 1 in the study seems circumvented in the analysis of the causes of the sudden bulge of skyrocketed rates of divorces ever since the end of 1970s and still on-going (in 2005). (The condomization started with rumors at the end of the 1970s.) It may be safe to assume that it is the most likely a response of women "who suffer" and try to escape (mainly by divorce) from the unknown but felt devastating and carcinogenic effects of sterile mating, and the incremental bodily and breast-cancer changes. Since the figure 1 with unusual trends of divorce trends is rarely seen in the literature, it may be worth following up the trend data, to witness the probable rapid fall of the divorce rates along with the information of the root cause(s) for and elimination (fall) of the epidemic breast cancer incidence rates and the main risk factor, the condom-control of women, perhaps at the

Fig. 17. Low back pain increasing trend in the U.S., 1955-1995.

#### **5. Social and demographic consequences**

#### **5.1 Condomization adverse effects in marriage and divorce**

The issues of contraception, marriage and divorces have been speculated upon frequently, mainly in the denominational quarters, in the U.S and elsewhere, under the sign of "controversial" issues and in some instance under feministic tendencies of interpretation. In the numerous judicial and social literature of the causes of divorce, some findings seem novel, such as he information that more women seek divorce than men nowadays (Ambekar, 2009) that divorces take husbands by surprise (Peatlng, 2005), that sex is a reason for divorce and that "dissatisfied women are less likely to have sex" (Kimbal, 2010). Some older sources of religious discussion were practically out of reach (Peters, 1998). It was early warning that the divorce rates have much risen recently. Hardly any of the recent studies in marriage, divorce and sexuality ever considered condoms as an impediment to marital relations.

Other recent reports confirmed the rapidly increasing divorce rates in the U.S., with a distinct jump at the end of the 1970s and the beginning of the 1980s, greatly surpassing any divorce rates in the U.S. over the recorded past 150 years (Stevenson & Wolfers, 2007a, 2007b; Wolfers, 2010). The surprising rise of the divorce rate, greater than that recorded after WWII, and subsequently fluctuating and slowly declining trend was presented in the first figure in the text. The explanation of the truly distinct changes of the divorce rates, with the mass and still high jump in divorce rates was not fully explained in the report. (**Figure 18**). The presumed 'driving forces' of divorce talked about a variety of conventional causes, such as, importance of marriage has changed, rising age at first marriage, high remarriage rates, rise of cohabitation, rise of out-of-wedlock fertility, and other social and economic reasons.

Fig. 17. Low back pain increasing trend in the U.S., 1955-1995.

**5.1 Condomization adverse effects in marriage and divorce** 

The issues of contraception, marriage and divorces have been speculated upon frequently, mainly in the denominational quarters, in the U.S and elsewhere, under the sign of "controversial" issues and in some instance under feministic tendencies of interpretation. In the numerous judicial and social literature of the causes of divorce, some findings seem novel, such as he information that more women seek divorce than men nowadays (Ambekar, 2009) that divorces take husbands by surprise (Peatlng, 2005), that sex is a reason for divorce and that "dissatisfied women are less likely to have sex" (Kimbal, 2010). Some older sources of religious discussion were practically out of reach (Peters, 1998). It was early warning that the divorce rates have much risen recently. Hardly any of the recent studies in marriage, divorce and sexuality ever considered condoms as an impediment to marital

Other recent reports confirmed the rapidly increasing divorce rates in the U.S., with a distinct jump at the end of the 1970s and the beginning of the 1980s, greatly surpassing any divorce rates in the U.S. over the recorded past 150 years (Stevenson & Wolfers, 2007a, 2007b; Wolfers, 2010). The surprising rise of the divorce rate, greater than that recorded after WWII, and subsequently fluctuating and slowly declining trend was presented in the first figure in the text. The explanation of the truly distinct changes of the divorce rates, with the mass and still high jump in divorce rates was not fully explained in the report. (**Figure 18**). The presumed 'driving forces' of divorce talked about a variety of conventional causes, such as, importance of marriage has changed, rising age at first marriage, high remarriage rates, rise of cohabitation, rise of out-of-wedlock fertility, and other social and economic reasons.

**5. Social and demographic consequences** 

relations.

In a response to the authors, Betsey Stevenson and Justin Wolfers, a critical commentary of the missing biological dimension in their scholarly analysis of national data of divorce and marriage, underlying the following points:

"It seems we could not really know about the break-up of marriages, "long" or "new," if only the "broader economic and social consequences" are being considered, by forgetting the simple biological causes of the events.

By looking into the primary source of the news ("*Marriage and Divorce: Changes and their Driving Forces*," by B. Stevenson & J. Wolfers, 2007 & 2009; Brining & Allen, 2000), besides the scholarly done review and presentation of official registry, raw data, the way of thinking, heavily influenced by the old-time feminism, seems very one-sided and insufficiently interpreted. The woman is analyzed manly as a technological, social, economy- and business- oriented personality, with no reference whatsoever to her (their) biological individuality.

It was rightly emphasized in the study that marriage and divorce laws and regulations along with technical changes in the family do not explain the rise of divorces over the past few decades. And yet, the women "who suffer" are those who in majority file for divorce. The figure 1 in the aforementioned study, presenting the rates of marriages and divorces (per 1000 American people), stretching for 145 years (1860-2005) is truly revealing. It seems to explain to a great extent the missing references to the most critical period of rapidly rising and still on-going period of exceptionally high-divorce rates in the country in the decades of 1980s, 1990s, and first part of the 2000s: the mass CONDOMIZATION of female sexuality. While the contraceptive pills and their impact upon the society have been studiously explained, the destructive impact of the promoted use of condoms over the past three decades has been strangely overlooked, with an utter oblivion to the current, excess breast cancer epidemic, the greatest scare, dread and real risk of women, along with the widespread gynecological tumors and other afflictions.

Given the corroborated evidence that the condom use is significantly associated with the breast cancer development in American and other married women, it is not a wonder that many a woman is filing for divorce and, supposedly looking for a "new partner." Intimate condomized relations induce technical effects of absolute sterile husband in the marriage, perhaps worse stressor than other ones mentioned in the debate blog, such as "poor health, poverty, and unemployment." If in the biological struggle the wife is not supported (by a fertile husband), it is a general belief / observation, and she is turning against him. (The racial differences in rates of divorce are also consistent with the differences in breast cancer incidence and prevalence rates, the levels of condom-use acculturation.)

The figure 1 in the study seems circumvented in the analysis of the causes of the sudden bulge of skyrocketed rates of divorces ever since the end of 1970s and still on-going (in 2005). (The condomization started with rumors at the end of the 1970s.) It may be safe to assume that it is the most likely a response of women "who suffer" and try to escape (mainly by divorce) from the unknown but felt devastating and carcinogenic effects of sterile mating, and the incremental bodily and breast-cancer changes. Since the figure 1 with unusual trends of divorce trends is rarely seen in the literature, it may be worth following up the trend data, to witness the probable rapid fall of the divorce rates along with the information of the root cause(s) for and elimination (fall) of the epidemic breast cancer incidence rates and the main risk factor, the condom-control of women, perhaps at the earliest anticipated date, after the year 2010."

AIDS Changed America with the Twin

National Statistics UK, 2004)...

Fig. 19. Number of divorces in Australia, 1938-1991.

Breast Cancer Epidemic: Exploring the Consequences of Condomization 557

The unexplained changes in divorce rates reflected in other parts of the developed and affluent world. In **Australia**, a highly dramatic upsurge of divorce rates was recorded around 1978-1979, with a subsequent sharp decline and fluctuating changes afterwards (**Figure 19**) (Australian Historical Statistics, 2001). In the **UK**, the sudden almost threefold rise of the number of divorces was recoded somewhat earlier, in the mid-1978, and did not show appreciable decline for the next several years, until 2000 (**Figure 20**) (Office on

Fig. 18. Marriage and divorce rates in the United States, 1860-2000.

Fig. 18. Marriage and divorce rates in the United States, 1860-2000.

The unexplained changes in divorce rates reflected in other parts of the developed and affluent world. In **Australia**, a highly dramatic upsurge of divorce rates was recorded around 1978-1979, with a subsequent sharp decline and fluctuating changes afterwards (**Figure 19**) (Australian Historical Statistics, 2001). In the **UK**, the sudden almost threefold rise of the number of divorces was recoded somewhat earlier, in the mid-1978, and did not show appreciable decline for the next several years, until 2000 (**Figure 20**) (Office on National Statistics UK, 2004)...

Fig. 19. Number of divorces in Australia, 1938-1991.

AIDS Changed America with the Twin

social, economic, psychological, and legal unit.

Fig. 21. American and Japanese divorce rates, from 1940 to 2000.

In a nutshell, condom is not a contraceptive method. This old/new (high-tech) barrierdevice is literally a marriage-killer (divorce and a variety of psychosomatic phenomena and unhappiness) and woman-killer (breast cancer in mothers, and anorexia-bulimia disorders in young daughters). Condomization of female sexuality has been defined as the main and perhaps sole root cause of the unabated, excess breast cancer epidemic and other accompanying disorders of women and girls in the modern world. No other method of 'contraception' has been linked with the apparent natural experiment of the current breast cancer epidemic, or has shown the distinction to induce carcinogenic consequences on women on unprecedented scale in the country and societies globally. It seems that the study provided a basis of new understanding of contraception, and an attempt to use some of the (non-barrier) methods in preventive/therapeutical ways. In my view, the condomized control of women, rather the 'contraception' is the main causal factor for divorce, by which

women supposedly try to escape from the deeply felt cancer-initiation process.

epidemic disease(s) and other morbid phenomena."

A real concern may present, time and again, the newly reinitiated, so-called "Rubber Revolution," the renewed, forceful and reckless condom promotion, entirely oblivious to the unabated, excess breast cancer epidemic, worldwide, and insensitive to the plight of the half of population, exposed to the highest risk of developing and suffering of the malignant

Breast Cancer Epidemic: Exploring the Consequences of Condomization 559

inferences was that marriage along with sexuality, love and family is a profound biological union between woman and man, along with the conventional definition of marriage as a

Fig. 20. Divorce rates in the UK, from 1938 to 1999.

In **Japan** there was also a wave of increased divorces as well (**Figure 21**) (Japanese Ministry of Health, 2002). However, the increase of the divorce rate in Japan showed at least three different demographic features: the increase was incremental and relatively lower, less than two rates (per 1000 population), against the increase in the U.S. (reaching more than 5.5 rate); and the peak of the divorce rates occurred about five years later than in the U.S. It is assumed that the changes in the divorce incidence rates may have the same driving force, stretching within a time period of several years, at the beginning of the 1980s.

The attempt for explanation of the observed social phenomena of high divorce outbreak did not reach considerations of condomization as a possible root cause of the observable fact. An attempt was made to address the issue of condoms as newly introduced environmental pollution in the inter-human intimate relations, in a comment to the article "Contraception and Divorce: Insight from American Annulment Cases," of 1998, by Dr. Edwards N. Peters, Edmund Card. Szoka Chair in Faculty Development, Canon of the Law Blog, Christmas 2010

"What prompted me to (belatedly) comment your article of 12 years ago is the ongoing routine of addressing condom as "contraception." In the mid-1970s, I conducted a hypothesis-testing study (jointly at two American universities) of the barrier contraception (condom use and withdrawal practice) and the development of breast cancer in American (and other) married women. The results corroborated the hypothesis and showed evidence of a significant condom and breast cancer association, together with the defined potential of primary (non-chemical) prevention of breast cancer as an epidemic disease. One of the main

In **Japan** there was also a wave of increased divorces as well (**Figure 21**) (Japanese Ministry of Health, 2002). However, the increase of the divorce rate in Japan showed at least three different demographic features: the increase was incremental and relatively lower, less than two rates (per 1000 population), against the increase in the U.S. (reaching more than 5.5 rate); and the peak of the divorce rates occurred about five years later than in the U.S. It is assumed that the changes in the divorce incidence rates may have the same driving force,

The attempt for explanation of the observed social phenomena of high divorce outbreak did not reach considerations of condomization as a possible root cause of the observable fact. An attempt was made to address the issue of condoms as newly introduced environmental pollution in the inter-human intimate relations, in a comment to the article "Contraception and Divorce: Insight from American Annulment Cases," of 1998, by Dr. Edwards N. Peters, Edmund Card. Szoka Chair in Faculty Development, Canon of the Law Blog, Christmas

"What prompted me to (belatedly) comment your article of 12 years ago is the ongoing routine of addressing condom as "contraception." In the mid-1970s, I conducted a hypothesis-testing study (jointly at two American universities) of the barrier contraception (condom use and withdrawal practice) and the development of breast cancer in American (and other) married women. The results corroborated the hypothesis and showed evidence of a significant condom and breast cancer association, together with the defined potential of primary (non-chemical) prevention of breast cancer as an epidemic disease. One of the main

stretching within a time period of several years, at the beginning of the 1980s.

Fig. 20. Divorce rates in the UK, from 1938 to 1999.

2010

inferences was that marriage along with sexuality, love and family is a profound biological union between woman and man, along with the conventional definition of marriage as a social, economic, psychological, and legal unit.

Fig. 21. American and Japanese divorce rates, from 1940 to 2000.

In a nutshell, condom is not a contraceptive method. This old/new (high-tech) barrierdevice is literally a marriage-killer (divorce and a variety of psychosomatic phenomena and unhappiness) and woman-killer (breast cancer in mothers, and anorexia-bulimia disorders in young daughters). Condomization of female sexuality has been defined as the main and perhaps sole root cause of the unabated, excess breast cancer epidemic and other accompanying disorders of women and girls in the modern world. No other method of 'contraception' has been linked with the apparent natural experiment of the current breast cancer epidemic, or has shown the distinction to induce carcinogenic consequences on women on unprecedented scale in the country and societies globally. It seems that the study provided a basis of new understanding of contraception, and an attempt to use some of the (non-barrier) methods in preventive/therapeutical ways. In my view, the condomized control of women, rather the 'contraception' is the main causal factor for divorce, by which women supposedly try to escape from the deeply felt cancer-initiation process.

A real concern may present, time and again, the newly reinitiated, so-called "Rubber Revolution," the renewed, forceful and reckless condom promotion, entirely oblivious to the unabated, excess breast cancer epidemic, worldwide, and insensitive to the plight of the half of population, exposed to the highest risk of developing and suffering of the malignant epidemic disease(s) and other morbid phenomena."

AIDS Changed America with the Twin

condom use.

years.

community.

Breast Cancer Epidemic: Exploring the Consequences of Condomization 561

The recent report of the "Use of Contraception in the United States: 1982-2008" (Mosher and Jones, 2010) provided an abundance of data offering the opportunity to interpret the contraception figures, rates and trends in another way. There are a number of important findings which may shed a different light on the current discussion of the adverse impact of

 It was stated in the Report that "in 2006-2008, 93 percent had ever had 'a partner' who used the male condom; 82 percent had ever used the oral contraceptive pill; and 59

 The greatest increase of contraceptive methods recorded between 1982 and 1995 was for condoms, 79.5 percent of those who ever used the device, in comparison to OC pill, of only 7.9 percent increase. The increase of the condom 'ever used' prevalence in 1982 was 51.8 percent, and in 1995 82.0 percent, while the OC pill use remained virtually at a plateau, from ever-used prevalence of 94.5 percent in 1982 to 96.2 percent in 1995. For the next 13 years, until 2008, the increase of partners who have ever used condom was 93.0 percent (with 79.5 percent increase from 1982), while the OC pills ever used 82.3 percent (with 7.9 percent increase). The data may indicate that a combined (dual) use of condoms and OC pills might have been practiced, or an intermittent, non-consistent

 Changes in use of condom, pill and other contraceptive methods between 1982 and the subsequent years until 2008 clearly showed higher increases of all methods in certain ethnic groups in the U.S., corroborating the notion of condom acculturation as well. Thus, condom use by Hispanics at first sexual intercourse rose for 70.9 percent, for Afro-Americans 65.2 percent, and for whites 26.9 percent. OC pill dropped by -44.5 % for the Afro-American women, and withdrawal technique dropped by –17.3% for whites and -52.3% for Afro-Americans, but not for the Hispanics (which was low). The condom-use campaigns were not mentioned in taking place during the intervening

 Condom use by women aged 15-44 showed a declining trend after 1995, when the number of users (in thousands) declined from 13.1 to 11.1 in 2002, and to 10.0 in 2006- 2008. The qualification of "persistent" condom use, which is considered practically impossible, because of the early adverse effects, use was not mentioned in the report. Prevalence of contraception use, both condoms and OC pills, was higher in younger groups up to age 30-34 than in the older groups 35-44, what is to be expected. The data of use of condom has obviously shifted to women of younger age which helps explain the "debut" breast cancer age-specific incidence peaks. The pill was used almost twice as much than condoms by women aged 20-24 (26.2 versus 13.4 by age, respectively); the condom was used in average of 10.0% by young women, and between 8.4 and 6.8 percent in older age groups 35-39 and 40-44. It looks like the ancient Roman "decimation" penal code is still powerful enough to make a strong impact on the

 Female sterilization was assessed at 27.1% in the 2006-2008 periods. There was age gradient of increase, showing a prevalence rate of 50.3% in the 40-44 age group. However, the unexpected high rate of "female sterilization" was not specified, in terms of proportion of elective tubal ligation and non-elective sterilizing surgical procedures. Tubal ligation is an established contraceptive method, but the hysterectomies and/or oophorectomies (one- or double-sided), are salvage surgical procedures carried out for

condomization upon society, and could be underlined, as such.

percent had ever had 'a partner' who used withdrawal."

The so-called Marriage calculator- divorce360 (Stevenson, 2010) could hardly fulfill its intended predictive purpose, since the analysis was based mainly on the educational levels and other social profiles of the spouses, and the failure (bias?) to consider the biological (sexual) dimension of marriage. Besides the calculator seems incomplete, because it lacks the necessary putative external risk factor quantified exposure, in order to serve as a Bayes' probability theorem requirements (Gjorgov, 2009b, 2010).

The dilemma of the official, but mistaken emphasis on strict promotion of use of condoms (in all sexual relations) in the U.S. House of Representatives (Lincoln, 1979) is given in the following personal communication to the **Honorable James H. Scheuer**, Chairman of the House Select Committee on Population, on May 29, 1979, in Philadelphia, PA:

"In reference to the conclusions of your Committee on Population concerning family planning policy, as reported by Richard Lincoln in *Family Planning Perspectives*, March/April 1979, the promotion of the "barrier" methods of contraception become an objective of first priority in the contraceptive research "of methods that are not known to be associated with hazardous side effects." No definition of "barrier" methods was presented in the journal's report (Lincoln, 1979) of the conclusions of your Committee. This is to inform you and your Committee that there are indications that some forms of barrier contraceptive methods are perhaps the most inadequate and hazardous methods for fertility regulation. This is also to present to you the available evidence of a recently completed study, indicating an association between the use of barrier contraceptive techniques and long-term health hazards in women. A barrier contraceptive, as defined in the study, is one which obstructs the passage and resorption of seminal content during sexual contact, such as the condom and withdrawal. The results of the tested hypothesis of the study corroborated the evidence that there is a significant relationship between barrier contraceptive practice and the development of breast cancer in women. The final findings corroborated the research hypothesis and the preliminary results of the study that women who used barrier contraceptive methods for extended periods of time in their marriages have a risk of developing breast cancer that is 4.6 – 5.2 times the risk of women who used other forms of fertility control. The results of the research also indicate that there is a potential for preventive action against the disease for a sizeable proportion of women in the population. It is estimated that by eliminating barrier contraceptive techniques, specifically the condom, and the incidence of breast cancer among married women in the United States could be reduced by as much as 50 percent. The results of the study consistently showed that the effects of a number of other reproductive and biological factors, such as age at first birth, parity, menarche, and others, had non-causal associations with the disease; The carcinogenic effect of the barrier contraceptive use was operative within a five-year exposure to condom use in marriage, with a cumulative effect; The study helps explain the increasing incidence of breast cancer, the international variation of the disease, and most of the reproduction-related risk indicators.

The final report, which is my dissertation, along with some other documents and material of the study would be gladly submitted to you and your Select Committee, if necessary. It is my belief that until further work in this field is done and confirmatory studies are conducted that this information of the devastating effects of condom use on woman's health should be made available to the users in community without unnecessary delay."

The so-called Marriage calculator- divorce360 (Stevenson, 2010) could hardly fulfill its intended predictive purpose, since the analysis was based mainly on the educational levels and other social profiles of the spouses, and the failure (bias?) to consider the biological (sexual) dimension of marriage. Besides the calculator seems incomplete, because it lacks the necessary putative external risk factor quantified exposure, in order to serve as a Bayes'

The dilemma of the official, but mistaken emphasis on strict promotion of use of condoms (in all sexual relations) in the U.S. House of Representatives (Lincoln, 1979) is given in the following personal communication to the **Honorable James H. Scheuer**, Chairman of the

"In reference to the conclusions of your Committee on Population concerning family planning policy, as reported by Richard Lincoln in *Family Planning Perspectives*, March/April 1979, the promotion of the "barrier" methods of contraception become an objective of first priority in the contraceptive research "of methods that are not known to be associated with hazardous side effects." No definition of "barrier" methods was presented in the journal's report (Lincoln, 1979) of the conclusions of your Committee. This is to inform you and your Committee that there are indications that some forms of barrier contraceptive methods are perhaps the most inadequate and hazardous methods for fertility regulation. This is also to present to you the available evidence of a recently completed study, indicating an association between the use of barrier contraceptive techniques and long-term health hazards in women. A barrier contraceptive, as defined in the study, is one which obstructs the passage and resorption of seminal content during sexual contact, such as the condom and withdrawal. The results of the tested hypothesis of the study corroborated the evidence that there is a significant relationship between barrier contraceptive practice and the development of breast cancer in women. The final findings corroborated the research hypothesis and the preliminary results of the study that women who used barrier contraceptive methods for extended periods of time in their marriages have a risk of developing breast cancer that is 4.6 – 5.2 times the risk of women who used other forms of fertility control. The results of the research also indicate that there is a potential for preventive action against the disease for a sizeable proportion of women in the population. It is estimated that by eliminating barrier contraceptive techniques, specifically the condom, and the incidence of breast cancer among married women in the United States could be reduced by as much as 50 percent. The results of the study consistently showed that the effects of a number of other reproductive and biological factors, such as age at first birth, parity, menarche, and others, had non-causal associations with the disease; The carcinogenic effect of the barrier contraceptive use was operative within a five-year exposure to condom use in marriage, with a cumulative effect; The study helps explain the increasing incidence of breast cancer, the international

House Select Committee on Population, on May 29, 1979, in Philadelphia, PA:

variation of the disease, and most of the reproduction-related risk indicators.

unnecessary delay."

The final report, which is my dissertation, along with some other documents and material of the study would be gladly submitted to you and your Select Committee, if necessary. It is my belief that until further work in this field is done and confirmatory studies are conducted that this information of the devastating effects of condom use on woman's health should be made available to the users in community without

probability theorem requirements (Gjorgov, 2009b, 2010).

The recent report of the "Use of Contraception in the United States: 1982-2008" (Mosher and Jones, 2010) provided an abundance of data offering the opportunity to interpret the contraception figures, rates and trends in another way. There are a number of important findings which may shed a different light on the current discussion of the adverse impact of condomization upon society, and could be underlined, as such.


AIDS Changed America with the Twin

time period.

not relate to that of women.

(**Figure 22**).

women want?" which Freud failed to answer.

Breast Cancer Epidemic: Exploring the Consequences of Condomization 563

physiological marital inter-dependence on woman reflects possibly the remnants of the classical Hippocratic teaching on seed. The dramatic developments of the contemporary, ever-rising breast cancer epidemic and reproductive health and nature of women and girls may incite a renewed philosophical debate for better understanding as to what is in having sex for a woman, whether women need (drive for) sex for a different biological 'purpose' than men do, and to eventually reconsider the unanswered persistent question "What the

It should be mentioned here that in the meantime a fleeting attempt was made by the Israel Health Minister in the 1990s to ban AIDS campaign promoting condom as a prophylactic against the HIV infection, recommending divorce instead for the healthy wife, rather than use of condoms (Siegel-Itzkovich, 1999). More importantly, on December 19, 2002, the U.S. agency CDC (Centers for Diseases control and Prevention) in Atlanta, GA, proclaimed official news, entitled: **"CDC Fact Sheet Not Promoting Condom Use Anymore"** (Meckler, 2002), which was enforced by the American President, who acted on extra information about the ill-effects of condom use. The CDC declaration seems to have had an immediate but short-lived impact on decline of the breast cancer epidemic in the U.S. in the 2003-2004

A few years ago a series of reports appeared simultaneously indicating an unexpected decline in the life expectancy of American people (Ezzati et al., 2008; Brown, 2008; Danaei et al., 2010). The main point in these and other reports was that after a long while a shift in the in U.S. demography has happen, from the customary decrease to sudden increase of mortality The 'reversal of fortunes' as the shift was termed of the increasing mortality has happened in the last three decades, exactly after 1983. The fall of women's life expectancy was more pronounced than in men – of "one in five women" now experiencing lesser longevity and dying younger than before the beginning of 1980s. Although admitting that that the root causes for the downward trend is "impossible to know exactly," the search for causes was directed primarily on "modifiable behaviors and exposures," such as smoking, diet, and lack of exercise, along with the mortality of certain conditions of both sexes. "This is a story about smoking, blood pressure and obesity," was one of the over-confident statement of one of the Harvard researchers (Ezzati, 2008). Besides, the investigation included also diabetes, obesity and AIDS as possible causes of the fall in the life expectancy. The AIDS mortality, while insignificantly linked with the male life expectancy decline, did

A more recent background source, 'Explaining Divergent Levels of Longevity in High-Income Countries' review (Crimmins et al, 2011), offers more detailed information on the subject matter of declining life expectancy in the country, and in other comparative countries as well. The evidence in the review, indicated that: (1) the life expectancy is falling in the U.S., (2) the observable fact of falling life expectancy is particularly pronounced among women, (3) the new phenomenon of falling longevity occurred in the last 25 years (during the period 1980-2005), and (4) no risk factors, disease, or any other reason for the falling life expectancy in the U.S. and elsewhere has been determined for the evident, unexpected decline in life expectancy, especially in women

**5.2 The hidden impact of condomization on life expectancy of women** 

survival in many cases of breast, ovarian and other gynecological cancers. The blurred category of "female sterilization" showed a gradual increase of rates by parity, to highest proportion, of 58.7%, in women with three or more children. Once again, the purpose of the "sterilization" has not been specified, but helps explain the increasing survival rates of breast cancer in younger patients. (The male sterilization, vasectomy, assessed at 9.9% in the studied population sample, in 2006-2008, is still considered too controversial a method of contraception for pertinent comments.)

 Reasons for discontinuation of ever used contraceptive method, included prominent concern for the OC pill. To the question of "You had side effects," the pill users responded positively in 63.7 percent, while only 12.0 percent of condom users responded positively; to the question "Did not like changes to menstrual cycle," positive answer provided 10.6 percent of the pill-users, and none (zero percent) of the condom users. There was no side effect either recorded for condom use, even after more than 30 years of the condom - breast cancer link evidence first published.

The Scriptures and other classic literature throughout history seem to give ground for validity of the debates on the perennial issues of sexual relations, marriage, woman, love, conception, human seed, the "sin against nature" of sterile acts (coitus interruptus), prostitution, adultery and other human matters. A consensus in the polemic seems to be the belief that "husbands are the chief persons responsible for dissipation of their wives" (Flandrin, 1975; Gjorgov, 1977/1998). Many writers (Leo Tolstoy, Honoré de Balsac, Stefan Zweig, and many others), and other artists seem to have been ahead of the contemporary medical experts in assessing the natural forces of human intimate (sexual) relations. The Gustav Klimt's artistic vision of "Medicine" was unfairly discarded by the professors of the famous Faculty of Medicine of Vienna at the beginning of the 20th Century. The apotheosis of "Medicine" was angrily discarded by the professors, most likely because the artist portrayed superiority of nature (physical love) over medicine, and depicted his idea of the role of man as a biological complement and the key to functioning of (impact on) the captured woman's life, health, reproductive processes, fate, and exquisite beauty (Gjorgov, 2003b). (Remember the strange slay of Biblical Onan because of his 'mortal sin' of spilling the seed on the ground in sexual relations with his "dissatisfied" second wife?). No wonder that there were confounding 'clusters" of breast cancer in various public institutions around the world (Australia, the U.S.), given the multitude of fashionable, politically correct, condom-promoting zealots.

One of the major conclusions from the studies on marriage and divorce could be inferred that condomization has been implemented long before the AIDS epidemic emerged, during the second half of the decade of 1970s. That was the time of ascendance of feminism, with its primary anti-marriage mission. The promotion of condoms seemed as an "ideal" technical device for the "Our Bodies Ourselves" health-promotion movement. Although condompromotion started with whispers and rumors, it was quite fervent, distributing condoms at the entries / exits of some of the hospitals, in a somewhat confidential way. The semisecretive distribution extended for several year until he the solemnization of the mass condomization in the summer of 1986 (Koop, 1986).

The popular belief of the sexual relations exerting biological impact and health gain between woman and man, and for the woman in particular, is strongly imbedded in the minds of the people in the Mediterranean and Balkan regions, especially among the isolated Macedonian rural, mountainous, population (Gjorgov, 2001). It seems that the popular belief of

 Reasons for discontinuation of ever used contraceptive method, included prominent concern for the OC pill. To the question of "You had side effects," the pill users responded positively in 63.7 percent, while only 12.0 percent of condom users responded positively; to the question "Did not like changes to menstrual cycle," positive answer provided 10.6 percent of the pill-users, and none (zero percent) of the condom users. There was no side effect either recorded for condom use, even after more

The Scriptures and other classic literature throughout history seem to give ground for validity of the debates on the perennial issues of sexual relations, marriage, woman, love, conception, human seed, the "sin against nature" of sterile acts (coitus interruptus), prostitution, adultery and other human matters. A consensus in the polemic seems to be the belief that "husbands are the chief persons responsible for dissipation of their wives" (Flandrin, 1975; Gjorgov, 1977/1998). Many writers (Leo Tolstoy, Honoré de Balsac, Stefan Zweig, and many others), and other artists seem to have been ahead of the contemporary medical experts in assessing the natural forces of human intimate (sexual) relations. The Gustav Klimt's artistic vision of "Medicine" was unfairly discarded by the professors of the famous Faculty of Medicine of Vienna at the beginning of the 20th Century. The apotheosis of "Medicine" was angrily discarded by the professors, most likely because the artist portrayed superiority of nature (physical love) over medicine, and depicted his idea of the role of man as a biological complement and the key to functioning of (impact on) the captured woman's life, health, reproductive processes, fate, and exquisite beauty (Gjorgov, 2003b). (Remember the strange slay of Biblical Onan because of his 'mortal sin' of spilling the seed on the ground in sexual relations with his "dissatisfied" second wife?). No wonder that there were confounding 'clusters" of breast cancer in various public institutions around the world (Australia, the U.S.), given the multitude of fashionable, politically correct,

One of the major conclusions from the studies on marriage and divorce could be inferred that condomization has been implemented long before the AIDS epidemic emerged, during the second half of the decade of 1970s. That was the time of ascendance of feminism, with its primary anti-marriage mission. The promotion of condoms seemed as an "ideal" technical device for the "Our Bodies Ourselves" health-promotion movement. Although condompromotion started with whispers and rumors, it was quite fervent, distributing condoms at the entries / exits of some of the hospitals, in a somewhat confidential way. The semisecretive distribution extended for several year until he the solemnization of the mass

The popular belief of the sexual relations exerting biological impact and health gain between woman and man, and for the woman in particular, is strongly imbedded in the minds of the people in the Mediterranean and Balkan regions, especially among the isolated Macedonian rural, mountainous, population (Gjorgov, 2001). It seems that the popular belief of

controversial a method of contraception for pertinent comments.)

than 30 years of the condom - breast cancer link evidence first published.

condom-promoting zealots.

condomization in the summer of 1986 (Koop, 1986).

survival in many cases of breast, ovarian and other gynecological cancers. The blurred category of "female sterilization" showed a gradual increase of rates by parity, to highest proportion, of 58.7%, in women with three or more children. Once again, the purpose of the "sterilization" has not been specified, but helps explain the increasing survival rates of breast cancer in younger patients. (The male sterilization, vasectomy, assessed at 9.9% in the studied population sample, in 2006-2008, is still considered too physiological marital inter-dependence on woman reflects possibly the remnants of the classical Hippocratic teaching on seed. The dramatic developments of the contemporary, ever-rising breast cancer epidemic and reproductive health and nature of women and girls may incite a renewed philosophical debate for better understanding as to what is in having sex for a woman, whether women need (drive for) sex for a different biological 'purpose' than men do, and to eventually reconsider the unanswered persistent question "What the women want?" which Freud failed to answer.

It should be mentioned here that in the meantime a fleeting attempt was made by the Israel Health Minister in the 1990s to ban AIDS campaign promoting condom as a prophylactic against the HIV infection, recommending divorce instead for the healthy wife, rather than use of condoms (Siegel-Itzkovich, 1999). More importantly, on December 19, 2002, the U.S. agency CDC (Centers for Diseases control and Prevention) in Atlanta, GA, proclaimed official news, entitled: **"CDC Fact Sheet Not Promoting Condom Use Anymore"** (Meckler, 2002), which was enforced by the American President, who acted on extra information about the ill-effects of condom use. The CDC declaration seems to have had an immediate but short-lived impact on decline of the breast cancer epidemic in the U.S. in the 2003-2004 time period.

## **5.2 The hidden impact of condomization on life expectancy of women**

A few years ago a series of reports appeared simultaneously indicating an unexpected decline in the life expectancy of American people (Ezzati et al., 2008; Brown, 2008; Danaei et al., 2010). The main point in these and other reports was that after a long while a shift in the in U.S. demography has happen, from the customary decrease to sudden increase of mortality The 'reversal of fortunes' as the shift was termed of the increasing mortality has happened in the last three decades, exactly after 1983. The fall of women's life expectancy was more pronounced than in men – of "one in five women" now experiencing lesser longevity and dying younger than before the beginning of 1980s. Although admitting that that the root causes for the downward trend is "impossible to know exactly," the search for causes was directed primarily on "modifiable behaviors and exposures," such as smoking, diet, and lack of exercise, along with the mortality of certain conditions of both sexes. "This is a story about smoking, blood pressure and obesity," was one of the over-confident statement of one of the Harvard researchers (Ezzati, 2008). Besides, the investigation included also diabetes, obesity and AIDS as possible causes of the fall in the life expectancy. The AIDS mortality, while insignificantly linked with the male life expectancy decline, did not relate to that of women.

A more recent background source, 'Explaining Divergent Levels of Longevity in High-Income Countries' review (Crimmins et al, 2011), offers more detailed information on the subject matter of declining life expectancy in the country, and in other comparative countries as well. The evidence in the review, indicated that: (1) the life expectancy is falling in the U.S., (2) the observable fact of falling life expectancy is particularly pronounced among women, (3) the new phenomenon of falling longevity occurred in the last 25 years (during the period 1980-2005), and (4) no risk factors, disease, or any other reason for the falling life expectancy in the U.S. and elsewhere has been determined for the evident, unexpected decline in life expectancy, especially in women (**Figure 22**).

AIDS Changed America with the Twin

comparable countries.

Breast Cancer Epidemic: Exploring the Consequences of Condomization 565

rather than the transmission of HIV/AIDS virus in any high-risk group, or hormone therapy (for breast cancer) for that matter, may better explain the decline of longevity of American women. It is almost certain that the extent of condom promotion / distribution in the U.S. has been more persistent and more indiscriminate than in the other high-income,

Fig. 23. Percentage of all deaths in women attributable to breast cancer (in 1990s).

women aged 40-45, and around 20% in the adjacent age groups 35-39 and 45-49.

race, after the point of departure of all events at the beginning of the 1980s.

The breast cancer epidemiology in the **U.K.**, in the mid-1990s (McPherson et al, 2000), included mortality figures of percentage of all deaths in women attributable to breast cancer (**Figure 23**). The proportion of breast cancer deaths was more than 20 percent in young

In fact, the remarkable, long-term decline of life expectancy in American women may become a unique proof and testimony for both the medical, and perhaps political, misconception of social benefit of the indiscriminate, mass condomization, associated with the breast cancer epidemic, and the wrong-for-long misleading, deadly false belief of condom use as a "safe" hi-tech device for fertility-control and family-planning purposes. [The data of parallel decline on a lesser scale of male longevity might indicate that the devastating and carcinogenic effects of condomization on women's health and lives, resulting in epidemics of breast-ovarian-gynecological cancers, might exert some reciprocal, unknown social or any other biological effect on men as well.] The hope remains, however, that the elimination (practical 'eradication' to levels of rare, sporadic cases) of epidemic breast cancer, by elimination of the sole breast-cancer risk of condomized control of women's sexuality, to reflect rapidly on both decline of the breast cancer epidemic, and restoration of rising women's life expectancy, in a fast manner as the disease entered human

Fig. 22. Gender differences in declining life expectancy at age 50 for U.S. men and women, 1980-2006.

There must be some better way than unconvincing explanation of the confounding smoking and obesity factors, imparting them as the main culprit factors for the slashed longevity of American (and other) women. Missing factors in the review seem to be the unspoken breast cancer epidemic and the mass condomization of female sexuality. Breast cancer is generally treated in the analysis as a passing reference throughout the review. Conspicuously, the unabated and excess epidemic disease of breast cancer is hardly mentioned in the analysis. In the Chapter 8 of the review, entitled Hormone Therapy (in women), the main point of considerations was given on Coronary heart disease and Stroke, and Lung cancer, rather than on Breast cancer. Instead, Lung cancer was sited uncritically as a mortality factor for the decline of longevity even of men and women, because of neglected information that metastases of breast cancer to lungs account for more than 21 to 25 percent. The transmission of HIV/AIDS virus has not been found in the review as a risk factor for the enduring, 25-year decline of women's life expectancy.

The condomization of women's sexuality has been defined as a root cause of the current breast cancer epidemic along with the widespread, accompanying gynecological diseases, tumors and lesions of the organs of reproductive system and other phenomena in American women. The consequences, however, of the general condomization of women's and girls' sexuality in the mainstream population, in a misconceived attempt to stem the emergent AIDS epidemic by barrier birth-control device, has changed the demography of the American society, perhaps the most in the world. The never before experienced change of decline in longevity in of the people has been achieved by a profound corruption of the nature of the intimate (sexual) ecosystem of people, due to elimination of the biologically protective, primordial physiological impact of mutual woman-man relations. That is the change has been achieved by inducing technical effects of absolute male sterility in the marital and inter-gender micro-environment. Namely, the evidence of a significant association between condom use and breast cancer development in the population at large,

Fig. 22. Gender differences in declining life expectancy at age 50 for U.S. men and women,

There must be some better way than unconvincing explanation of the confounding smoking and obesity factors, imparting them as the main culprit factors for the slashed longevity of American (and other) women. Missing factors in the review seem to be the unspoken breast cancer epidemic and the mass condomization of female sexuality. Breast cancer is generally treated in the analysis as a passing reference throughout the review. Conspicuously, the unabated and excess epidemic disease of breast cancer is hardly mentioned in the analysis. In the Chapter 8 of the review, entitled Hormone Therapy (in women), the main point of considerations was given on Coronary heart disease and Stroke, and Lung cancer, rather than on Breast cancer. Instead, Lung cancer was sited uncritically as a mortality factor for the decline of longevity even of men and women, because of neglected information that metastases of breast cancer to lungs account for more than 21 to 25 percent. The transmission of HIV/AIDS virus has not been found in the review as a risk factor for the

The condomization of women's sexuality has been defined as a root cause of the current breast cancer epidemic along with the widespread, accompanying gynecological diseases, tumors and lesions of the organs of reproductive system and other phenomena in American women. The consequences, however, of the general condomization of women's and girls' sexuality in the mainstream population, in a misconceived attempt to stem the emergent AIDS epidemic by barrier birth-control device, has changed the demography of the American society, perhaps the most in the world. The never before experienced change of decline in longevity in of the people has been achieved by a profound corruption of the nature of the intimate (sexual) ecosystem of people, due to elimination of the biologically protective, primordial physiological impact of mutual woman-man relations. That is the change has been achieved by inducing technical effects of absolute male sterility in the marital and inter-gender micro-environment. Namely, the evidence of a significant association between condom use and breast cancer development in the population at large,

enduring, 25-year decline of women's life expectancy.

1980-2006.

rather than the transmission of HIV/AIDS virus in any high-risk group, or hormone therapy (for breast cancer) for that matter, may better explain the decline of longevity of American women. It is almost certain that the extent of condom promotion / distribution in the U.S. has been more persistent and more indiscriminate than in the other high-income, comparable countries.

Fig. 23. Percentage of all deaths in women attributable to breast cancer (in 1990s).

The breast cancer epidemiology in the **U.K.**, in the mid-1990s (McPherson et al, 2000), included mortality figures of percentage of all deaths in women attributable to breast cancer (**Figure 23**). The proportion of breast cancer deaths was more than 20 percent in young women aged 40-45, and around 20% in the adjacent age groups 35-39 and 45-49.

In fact, the remarkable, long-term decline of life expectancy in American women may become a unique proof and testimony for both the medical, and perhaps political, misconception of social benefit of the indiscriminate, mass condomization, associated with the breast cancer epidemic, and the wrong-for-long misleading, deadly false belief of condom use as a "safe" hi-tech device for fertility-control and family-planning purposes. [The data of parallel decline on a lesser scale of male longevity might indicate that the devastating and carcinogenic effects of condomization on women's health and lives, resulting in epidemics of breast-ovarian-gynecological cancers, might exert some reciprocal, unknown social or any other biological effect on men as well.] The hope remains, however, that the elimination (practical 'eradication' to levels of rare, sporadic cases) of epidemic breast cancer, by elimination of the sole breast-cancer risk of condomized control of women's sexuality, to reflect rapidly on both decline of the breast cancer epidemic, and restoration of rising women's life expectancy, in a fast manner as the disease entered human race, after the point of departure of all events at the beginning of the 1980s.

AIDS Changed America with the Twin

women perished).

health action in the field.

2003

Breast Cancer Epidemic: Exploring the Consequences of Condomization 567

discovering other approaches with unemployment, academic and professional uprooting and deportation; very soon afterwards, the breast cancer epidemic suddenly and sharply rose and unabated continued its ever-rising increase. The estimate of the U.S. Senate has been that about 2,000,000 women became breast cancer victims during the decade of the 1990s, with 500,000 deaths of the disease. Nowadays, it has been reported that one million of new American breast cancer cases (most of them affluent victims) are registered in four years (rather than in five years, like in the 1990s). The incidence of breast cancer in the United States (as well as in Europe) has been at least seven times higher than the spread of AIDS, the deadly twin epidemic disease. Based on the available WHO data, during the two-decade period, 1981 till 2000, in the U.S have been registered 500,000 (accumulated) cases of AIDS, with about 150,000 deaths (and not less than four million women afflicted with breast cancer, including in-situ cases, with mote than a quarter of the affected

Apparently, by this backdrop of massacre of women, shattered families, widespread fear, real threat and tragedy in the Country and worldwide, the promotion of the indiscriminate, absolutistic and persistent exposure to (use of) condom in the mainstream population had to be reassessed and amended. The previous administration (at the highest possible levels), regretfully, missed the opportunity to properly address and entirely eliminate the breast cancer epidemic in the country and beyond, and to make the American women happy. With the resolute campaign of President George W. Bush against condom education among the teenagers in the schools, the ultimate objective of condomization of the society has been terminated and the cornerstone of a condom culture has been removed, I hope. In addition, I wonder as to whether a solution of the present gloomy breast cancer emergency or a sustainable prevention of breast cancer could be reached in the Country or elsewhere as long as an American study in primary breast cancer prevention and etiology, such as my monograph "*Barrier Contraception and Breast Cancer*" (1980), is effectively banned from public view, professional scrutiny and clinical assessment for a possible basis of a new breast cancer policy and efficient public

cc: Dr. Andrew C. von Achenbach, Director of the National Cancer Institute, January 12,

The breast cancer epidemic has remained a perplexing epidemic, and is the case in point of a gender-specific, malignant disease, replacing the routine models of traditional epidemics of contagious, infectious diseases in the general population of both genders and all age groups. The traditionally known in the human history epidemics of infectious diseases have had defined source(s) of the contagious agent, are known to take a course of three main phases (slow or explosive beginning, reaching acme (the peak), and a protracted self-decline ('tail') of the natural end of the epidemics. It seems that the incidence, new HIV/AIDS cases, globally, have reached the peak at the beginning of the 1990s, and are presently showing sings of gradual, protracted, steady decline ever since (McNeil, 2010; USAIDS, 2010). Contrary to the medical experience, the breast cancer epidemic emerged fast, continued its unabated rise, never reached its culmination (acme), and never subsided in expected, tailed decline in the last three decades, since the beginning of 1980s. To the contrary, the new epidemic of breast cancer and other malignant disease(s) in women is not expected to vanish 'naturally,' by its own. Almost certainly, the current breast cancer epidemic is to be

cc: The Editors of the New York Times, February 12, 2003

## **6. The future: Prevention of the breast cancer epidemic**

In the perspective of breast cancer, the future is present. The answer is the primary, nonchemical prevention of the breast cancer epidemic, although the idea about prevention seems lost and no-existent in the West (Ferlay et al, 2010; EuropaDonna, 2010). Based on 2002 to 2006 trend of increase, the projected future trend of breast cancer increase was estimated at 53% by 2030. Similar disturbing forecast of breast cancer increase of 66.3% in the England and Wales by 2025 has been computed by using a mathematical model based on abortion prevalence rates and several other secondary reproductive factors; the predicted increase being from 39,229 in 2004 to 65,252 in 2025 (Carroll, 2007). Other projected/predicted increase of breast cancer of 32.9% in the U.K., from 2005 till 2024, the present number of 41,900 new cases annually to 55,700 new breast cancer cases in 2024 was assessed by Cancer Research UK (2007). The basic assumption being that the present, sad situation of the breast cancer epidemic in the country will stretch helplessly in the next 20 years, and beyond, into infinity.

To the contrary, the breast cancer epidemic could change by a dramatic decline in the UK, by not less than -80%, from both the forecasted by Carrol excess number of 65,252 cases to eventually 13,050 in 2024, and the forecasted by the Cancer Research UK organization (2007) also excess number of 55,700 cases to 11,140 or less, by 2024, provided primary prevention is implemented in the meantime. The mentioned number of in-situ (DCIS) cases, defined as non-breast cancer (0-zero stage), is expected to decline to a level of one-third (1276 in-situ cases) or less, of the 3,827 cases in England & Wales in 2004 (Carroll, 2007), provided, again, primary prevention is initiated. This is just for laying the groundwork for testing *in vivo* the two opposite theories of breast cancer preventability in the near future.

The following comment was conveyed to **Nicholas D. Kristof**, the New York Columnist as a reply to his article "The secret war on condoms," NYT, Jan. 12, 2003:

#### "**The War On Condoms Is The War Against Breast Cancer**

With reference to your article, "The Secret War on Condoms" (NYT, January 10, 2003), your bitter denigration of the efforts and the politics of the U.S. President, George W. Bush, for dismissal of the condom use as a device for contraceptive, fertility-control and family-planning purposes is misplaced, one-sided and seemingly rational. Apparently, Mr. Bush is in command of extra information of the devastating, adverse and carcinogenic effects of the consistent condom use in married American and other women. It is not your fault, of course, that you might have been ignorant of a hypothesis-testing study, which defined and corroborated the true etiology of breast cancer in the country, determined a potential of a primary (non-chemical) prevention of the breast cancer epidemic in the community, predicted the imminent epidemic rise of the malignant disease and, I believe, provided ANSWER for solution and creation of a public health policy in the field of breast cancer and other accompanying diseases. The study was initiated, supported and completed during the mid-1970s, at the University of North Carolina School of Public Health, at Chapel Hill, NC, and at the University of Pennsylvania School of Medicine and Hospital, in Philadelphia, PA. The final report of the aforementioned study was published in the distant 1980, as well as in 1979 by the Michigan University Dissertation International, Ann Arbor, MI.

However, there are strong indications that the research study has been concealed and secretly suppressed by the previous ("liberal") administrations, dealing with researchers

In the perspective of breast cancer, the future is present. The answer is the primary, nonchemical prevention of the breast cancer epidemic, although the idea about prevention seems lost and no-existent in the West (Ferlay et al, 2010; EuropaDonna, 2010). Based on 2002 to 2006 trend of increase, the projected future trend of breast cancer increase was estimated at 53% by 2030. Similar disturbing forecast of breast cancer increase of 66.3% in the England and Wales by 2025 has been computed by using a mathematical model based on abortion prevalence rates and several other secondary reproductive factors; the predicted increase being from 39,229 in 2004 to 65,252 in 2025 (Carroll, 2007). Other projected/predicted increase of breast cancer of 32.9% in the U.K., from 2005 till 2024, the present number of 41,900 new cases annually to 55,700 new breast cancer cases in 2024 was assessed by Cancer Research UK (2007). The basic assumption being that the present, sad situation of the breast cancer epidemic in the country will stretch helplessly in the next 20

To the contrary, the breast cancer epidemic could change by a dramatic decline in the UK, by not less than -80%, from both the forecasted by Carrol excess number of 65,252 cases to eventually 13,050 in 2024, and the forecasted by the Cancer Research UK organization (2007) also excess number of 55,700 cases to 11,140 or less, by 2024, provided primary prevention is implemented in the meantime. The mentioned number of in-situ (DCIS) cases, defined as non-breast cancer (0-zero stage), is expected to decline to a level of one-third (1276 in-situ cases) or less, of the 3,827 cases in England & Wales in 2004 (Carroll, 2007), provided, again, primary prevention is initiated. This is just for laying the groundwork for testing *in vivo* the

The following comment was conveyed to **Nicholas D. Kristof**, the New York Columnist as

With reference to your article, "The Secret War on Condoms" (NYT, January 10, 2003), your bitter denigration of the efforts and the politics of the U.S. President, George W. Bush, for dismissal of the condom use as a device for contraceptive, fertility-control and family-planning purposes is misplaced, one-sided and seemingly rational. Apparently, Mr. Bush is in command of extra information of the devastating, adverse and carcinogenic effects of the consistent condom use in married American and other women. It is not your fault, of course, that you might have been ignorant of a hypothesis-testing study, which defined and corroborated the true etiology of breast cancer in the country, determined a potential of a primary (non-chemical) prevention of the breast cancer epidemic in the community, predicted the imminent epidemic rise of the malignant disease and, I believe, provided ANSWER for solution and creation of a public health policy in the field of breast cancer and other accompanying diseases. The study was initiated, supported and completed during the mid-1970s, at the University of North Carolina School of Public Health, at Chapel Hill, NC, and at the University of Pennsylvania School of Medicine and Hospital, in Philadelphia, PA. The final report of the aforementioned study was published in the distant 1980, as well as in 1979 by the

However, there are strong indications that the research study has been concealed and secretly suppressed by the previous ("liberal") administrations, dealing with researchers

two opposite theories of breast cancer preventability in the near future.

a reply to his article "The secret war on condoms," NYT, Jan. 12, 2003:

"**The War On Condoms Is The War Against Breast Cancer** 

Michigan University Dissertation International, Ann Arbor, MI.

**6. The future: Prevention of the breast cancer epidemic** 

years, and beyond, into infinity.

discovering other approaches with unemployment, academic and professional uprooting and deportation; very soon afterwards, the breast cancer epidemic suddenly and sharply rose and unabated continued its ever-rising increase. The estimate of the U.S. Senate has been that about 2,000,000 women became breast cancer victims during the decade of the 1990s, with 500,000 deaths of the disease. Nowadays, it has been reported that one million of new American breast cancer cases (most of them affluent victims) are registered in four years (rather than in five years, like in the 1990s). The incidence of breast cancer in the United States (as well as in Europe) has been at least seven times higher than the spread of AIDS, the deadly twin epidemic disease. Based on the available WHO data, during the two-decade period, 1981 till 2000, in the U.S have been registered 500,000 (accumulated) cases of AIDS, with about 150,000 deaths (and not less than four million women afflicted with breast cancer, including in-situ cases, with mote than a quarter of the affected women perished).

Apparently, by this backdrop of massacre of women, shattered families, widespread fear, real threat and tragedy in the Country and worldwide, the promotion of the indiscriminate, absolutistic and persistent exposure to (use of) condom in the mainstream population had to be reassessed and amended. The previous administration (at the highest possible levels), regretfully, missed the opportunity to properly address and entirely eliminate the breast cancer epidemic in the country and beyond, and to make the American women happy. With the resolute campaign of President George W. Bush against condom education among the teenagers in the schools, the ultimate objective of condomization of the society has been terminated and the cornerstone of a condom culture has been removed, I hope. In addition, I wonder as to whether a solution of the present gloomy breast cancer emergency or a sustainable prevention of breast cancer could be reached in the Country or elsewhere as long as an American study in primary breast cancer prevention and etiology, such as my monograph "*Barrier Contraception and Breast Cancer*" (1980), is effectively banned from public view, professional scrutiny and clinical assessment for a possible basis of a new breast cancer policy and efficient public health action in the field.

cc: Dr. Andrew C. von Achenbach, Director of the National Cancer Institute, January 12, 2003

cc: The Editors of the New York Times, February 12, 2003

The breast cancer epidemic has remained a perplexing epidemic, and is the case in point of a gender-specific, malignant disease, replacing the routine models of traditional epidemics of contagious, infectious diseases in the general population of both genders and all age groups. The traditionally known in the human history epidemics of infectious diseases have had defined source(s) of the contagious agent, are known to take a course of three main phases (slow or explosive beginning, reaching acme (the peak), and a protracted self-decline ('tail') of the natural end of the epidemics. It seems that the incidence, new HIV/AIDS cases, globally, have reached the peak at the beginning of the 1990s, and are presently showing sings of gradual, protracted, steady decline ever since (McNeil, 2010; USAIDS, 2010). Contrary to the medical experience, the breast cancer epidemic emerged fast, continued its unabated rise, never reached its culmination (acme), and never subsided in expected, tailed decline in the last three decades, since the beginning of 1980s. To the contrary, the new epidemic of breast cancer and other malignant disease(s) in women is not expected to vanish 'naturally,' by its own. Almost certainly, the current breast cancer epidemic is to be

AIDS Changed America with the Twin

Breast Cancer Epidemic: Exploring the Consequences of Condomization 569

heavily on the efforts and experience of the inefficient and fruitless breast cancer control measures in stopping breast cancer before it starts in the developed countries of the West and the WHO. The added rhetoric and new terminology in the Guidelines about the new approaches, innovative research, stratification of the levels of needs, community-based programs, social support, and other envisioned activities against the epidemic of the cancer of the breast, may only replicate the conceptual vacuum and futility in understanding of the etiology and prevention of breast cancer (along with other tumors of the reproductive

The recent, dramatic "condom paradigm shift" entailed by the U.S. Government (2002) in favor of an "anti-condom" reproductive policy was, most probably, imposed by no accident… Informed observations seem to indicate that race might play a more lethal outcome to married 'non-white' women (Afro-American, Hispanics, Asian-American), exposed to absolute-sterile mating (condom use), than to 'white' women, in terms of breast cancer development, earlier death, shorter survival and physical devastation. If anything, empowerment of women and their husbands / partners with information of the real breast cancer risk would prove to be more useful in preventing the disease at individual, familial

The following **Table 5** is an attempt to define and elaborate the proposal of the hypothesis 1978 (Gjorgov, 1978a,b, 1979, 1980) of the etiology of breast cancer, and a likely shift of the

**Old Paradigm New Paradigm**  1. No Prevention of Breast Cancer (BC) 1. Yes, Primary (non-chemical) Prevention

3. The risk factors of BC are not amenable 3. The main risk factor readily amenable;

of Breast Cancer

BC is preventable

as epidemic disease

due to Sterile mating

environment

2. Public-health emphasis on primary prevention; Instead of exposure to the BC risks; the *in-situ* cases counted as BC cases;

4. Primary (non-chemical) prevention of BC

hypothesis: The main etiological cause: the widespread use of Barrier methods: of contraception: Condom devices, Withdrawal practice and male

sterility/infertility in marriages. Condomuse technical effects of absolute male sterility: condomization of female sexuality

6. Inverse environmental factor of BC: absence or elimination of putative protective factors in the intimate (sexual) ecosystem and inter-human micro-

5. Semen-factor deficiency tested

organs and ill-health phenomena in women) in new settings around the world…

and community levels, than the planned regulations and guidelines..."

conceptual framework of the epidemic disease:

2. Public-health emphasis on

*in-situ* cases

the BC epidemic

Genes and mutations

mammography screening and early BC detection; Epidemiologically: (unreported)

4. Treatment and chemical prevention of

5. Nutritional presumed causes (fat, alcohol, smoking, diet, environmental chemicals, toxins, etc), and Reproductive causes: Early menarche, Late births (>30 yrs), Family history, Low parity, No breast-feeding, OC pill use, Late menopause, Lack of exercise, 'Marital' Infertility issue, and other risk factors;

6. Environmental toxic substances & Industrial waste as BC causes, Polluted living settings (home, food, water, working place, streets); Radiation; Gene mutations

terminated by deliberate and conscious human intervention only. The data indicate that the increase of the 'cancer' epidemic in the West, and in other parts of the world, is fueled up mainly by the cancer of the breast and its steady epidemic increase. Apparently, to try to eliminate the current, unabated and excess breast cancer epidemic, a new way of thinking may be needed. The misconception about the breast cancer etiology and community burden hinders the efforts to understand, prevent and control the epidemic malignant breast disease. "What is of concern…is the way the medical-industrial complex uses the research. They would have us believe that because of various findings, such as cancer genes, the cure lies just around the corner. The truth is, however, it doesn't make much difference if a cure ever emerges. The search is a splendid money generator," by quoting other authors, declared the unheeded UK Working Group on the Primary Prevention of Breast Cancer (2007) and, in addition stated, that "there is no sign of leadership from government regarding... (prioritizing).. primary prevention" of breast cancer.

In the last three decades, breast cancer epidemic has spread to other, developing countries of Africa, South Asia, Latin America and elsewhere, as expected. The emerging breast cancer epidemic in the "poor" countries is attracting increasing attention in western countries, with projects and programs relied on old science, and the failing strategy of "palliative care" and "no cure" attitude to continue to be applied against the epidemic disease(s) everywhere. Practically, the inner nature and hormonal balance of woman is still considered to be at fault, which should and could be 'corrected' by chemical agents and human interventions.

The basic strategy of a breast cancer prevention is chemoprevention, particularly with the obsolete *tamoxifen* and other 'selective estrogen modulators,' conducting "downstream" clinical activities of early detection with mammographic screening, so-called 'preventive' mastectomies and oophorectomies, and ineffective counsels for "lessening" spurious risk factors of breast cancer, among which the condom use as a contraceptive method is never considered and maybe still suppressed (Mills, 1987; Bray et al., 2004; National Cancer Policy Board, 2005; Anderson, 2008; WHO-PAHO, 2008; Frenk, 2009; Lancet Editorial, 2009; Meriman, 2010; .Miller, 2010; European Breast Cancer Network, 2010).

Several years earlier, a communication was directed to **Dr. Mitra Roses Periago,** Director of the Pan-American Health Organization-PAHO, Washington, DC, February 14, 2006, regarding the "*Guidelines for International Breast Health and Cancer Control*," *Breast Journal* Suppl., January-February 2006, conveying the following critical comments (fragments):

"First and foremost, NO PREVENTION of breast cancer was ever mentioned in the PAHO Guidelines. The long-standing, tested evidence (Barrier Contraception and Breast Cancer," 1980), strongly indicating a potential of primary (non-chemical) prevention of breast cancer in American married women, was not taken under consideration in the Guidelines. The evidence, neither disputed nor rejected, showed that breast cancer is a preventable epidemic disease.

The PAHO Guidelines documented the fact that the expected epidemic wave of breast cancer, expanding from the affluent and prosperous Western World (North America and Europe, and others), has already reached the shores and lands of the developing world of Latin America, Africa, and Asia. The Guidelines displayed the growing rates of breast cancer in 'low-resource countries' as an equally serious, rapidly emerging political crisis and a grave public health issue and burden in both developed and developing world. The PAHO Guidelines for breast cancer control in developing countries, however, have relied

terminated by deliberate and conscious human intervention only. The data indicate that the increase of the 'cancer' epidemic in the West, and in other parts of the world, is fueled up mainly by the cancer of the breast and its steady epidemic increase. Apparently, to try to eliminate the current, unabated and excess breast cancer epidemic, a new way of thinking may be needed. The misconception about the breast cancer etiology and community burden hinders the efforts to understand, prevent and control the epidemic malignant breast disease. "What is of concern…is the way the medical-industrial complex uses the research. They would have us believe that because of various findings, such as cancer genes, the cure lies just around the corner. The truth is, however, it doesn't make much difference if a cure ever emerges. The search is a splendid money generator," by quoting other authors, declared the unheeded UK Working Group on the Primary Prevention of Breast Cancer (2007) and, in addition stated, that "there is no sign of leadership from government

In the last three decades, breast cancer epidemic has spread to other, developing countries of Africa, South Asia, Latin America and elsewhere, as expected. The emerging breast cancer epidemic in the "poor" countries is attracting increasing attention in western countries, with projects and programs relied on old science, and the failing strategy of "palliative care" and "no cure" attitude to continue to be applied against the epidemic disease(s) everywhere. Practically, the inner nature and hormonal balance of woman is still considered to be at fault, which should and could be 'corrected' by chemical agents and human interventions. The basic strategy of a breast cancer prevention is chemoprevention, particularly with the obsolete *tamoxifen* and other 'selective estrogen modulators,' conducting "downstream" clinical activities of early detection with mammographic screening, so-called 'preventive' mastectomies and oophorectomies, and ineffective counsels for "lessening" spurious risk factors of breast cancer, among which the condom use as a contraceptive method is never considered and maybe still suppressed (Mills, 1987; Bray et al., 2004; National Cancer Policy Board, 2005; Anderson, 2008; WHO-PAHO, 2008; Frenk, 2009; Lancet Editorial, 2009;

Several years earlier, a communication was directed to **Dr. Mitra Roses Periago,** Director of the Pan-American Health Organization-PAHO, Washington, DC, February 14, 2006, regarding the "*Guidelines for International Breast Health and Cancer Control*," *Breast Journal* Suppl., January-February 2006, conveying the following critical comments (fragments):

"First and foremost, NO PREVENTION of breast cancer was ever mentioned in the PAHO Guidelines. The long-standing, tested evidence (Barrier Contraception and Breast Cancer," 1980), strongly indicating a potential of primary (non-chemical) prevention of breast cancer in American married women, was not taken under consideration in the Guidelines. The evidence, neither disputed nor rejected, showed that breast cancer is a

The PAHO Guidelines documented the fact that the expected epidemic wave of breast cancer, expanding from the affluent and prosperous Western World (North America and Europe, and others), has already reached the shores and lands of the developing world of Latin America, Africa, and Asia. The Guidelines displayed the growing rates of breast cancer in 'low-resource countries' as an equally serious, rapidly emerging political crisis and a grave public health issue and burden in both developed and developing world. The PAHO Guidelines for breast cancer control in developing countries, however, have relied

regarding... (prioritizing).. primary prevention" of breast cancer.

Meriman, 2010; .Miller, 2010; European Breast Cancer Network, 2010).

preventable epidemic disease.

heavily on the efforts and experience of the inefficient and fruitless breast cancer control measures in stopping breast cancer before it starts in the developed countries of the West and the WHO. The added rhetoric and new terminology in the Guidelines about the new approaches, innovative research, stratification of the levels of needs, community-based programs, social support, and other envisioned activities against the epidemic of the cancer of the breast, may only replicate the conceptual vacuum and futility in understanding of the etiology and prevention of breast cancer (along with other tumors of the reproductive organs and ill-health phenomena in women) in new settings around the world…

The recent, dramatic "condom paradigm shift" entailed by the U.S. Government (2002) in favor of an "anti-condom" reproductive policy was, most probably, imposed by no accident… Informed observations seem to indicate that race might play a more lethal outcome to married 'non-white' women (Afro-American, Hispanics, Asian-American), exposed to absolute-sterile mating (condom use), than to 'white' women, in terms of breast cancer development, earlier death, shorter survival and physical devastation. If anything, empowerment of women and their husbands / partners with information of the real breast cancer risk would prove to be more useful in preventing the disease at individual, familial and community levels, than the planned regulations and guidelines..."

The following **Table 5** is an attempt to define and elaborate the proposal of the hypothesis 1978 (Gjorgov, 1978a,b, 1979, 1980) of the etiology of breast cancer, and a likely shift of the conceptual framework of the epidemic disease:


AIDS Changed America with the Twin

disease in women

in women

BC figure)

method

sterile mating

women

23. 'Second' most common malignant

24. Competing high rates of Lung Cancer

26. Ostensibly, BC mortality decline due to

programs; (Consensus: *in-situ* cases not to be included in the total annual number of

27. Promotion of condoms as "safe" device for fertility-control and family-planning

28. Priority: 'downstream' activities: screening for more cases & clinical salvage

29. No definition of female response to

30. Primary (non-chemical) prevention of the BC epidemic not considered, despite the failed chemoprevention trials

31. Chemo-prevention of BC: assuming "wrong" female nature to be corrected by

32. Ovarian, endometrial and thyroid cancers and other gynecological diseases

34. Plan for action: Search for cure, better therapy, and new drugs and 'better armamentarium' for BC screening

35. Overlooked impact of condomization

divorce, and women's mortality and life

Tamoxifen / Raloxifene & drugs

33. Silence and suppression of the information of the potential for prevention of the current BC epidemic

as unrelated to BC entities

upon issues of marriage,

expectancy

March 2011)

of BC affected women;

25. Higher BC incidence rates in white

early detection and BC screening

Breast Cancer Epidemic: Exploring the Consequences of Condomization 571

**Old Paradigm New Paradigm** 

in women

living standards

oophorectomy)

Missed abortion

BC

Table 5. Breast cancer hypothesis 1978 and shift of the conceptual framework. (Updated:

In the strategy for the global Millennium Development Goals 2015 (MDGs) decisions, a similar situation presented itself regarding condomization of women in less-developed regions. In a letter to the United Nations Secretary-General, the **Hon. Ban Ki-moon**, on September 25, 2010, the following message about the harmful effects of condom-use programs was conveyed:

lungs

23. BC - the commonest malignant disease

24. Fueled by >20% BC metastases to the

25. Higher BC rates in women of higher

26. If there is a BC mortality decline, then probably due to therapy and surgical modalities, particularly hysterectomy, (with or without one-sided or two-sided

contraceptive purposes in population as the main etiological risk of the BC epidemic

28. Priority: Prevention of the risks & cause(s) of current BC epidemic: shift to non-barrier birth-control methods

29. Inner imbalance (Pseudopregnancy),

30. Primary prevention ('eradication'), w/ estimated >80% reduction at individual,

31. Nothing wrong with women's nature

33. Decision (pending?) for non-mutually exclusive primary prevention against the

prevention: Elimination of condom use for

35. Considerable protective impact upon social issues of marriage, divorce, and women's mortality and life expectancy

Misconceived toxic-substance prevention of

27. Elimination of condoms for

family and community levels

subject to chemical correction:

32. Ovarian, endometrial, thyroid & gynecological cancers, lesions of same etiology, condomization of women all ages

twin epidemics of BC and AIDS

contraceptive purposes.

34. Needed plan for action for BC


**Old Paradigm New Paradigm** 

local treatment 10. BC a systemic disease, No known cure

male infertility

hormones"( HRT)

gone wrong

evidence & data

results / data

cure

7. Toxic waste: Indirect cause of BC *via*

8. 'Deficiency' of Prostaglandins, seminal fluid; Inner endocrine imbalance in women-related to causes of BC; Foretold BC carcinogenicity of "exogenous

9. Marriage (along sex & love): a biological union w/ profound physiological impact;

11. High-tech devices (condoms, HRTs)

12. BC: Systemic disease with no known

14. Empowerment of women and couples with information of the root cause & BC prevention; Cause-effectiveness assessment

15. Solution/answer to the current, excess BC epidemic, subject to the will and commitment of highest political level

16. Evidence-based definition of the main BC risk: Marital and persistent (long-term)

17. Evidence-based and hypothesis-tested

18. Short BC latent period: between 2½ to five years; Evidence confirmed / verified by forecasted BC natural experiment

19. Comprehensive approach to women's health: BC, Ovarian cancer / cysts, uterine cancer/lesions, thyroid cancer / nodules. Anorexia disorders; female osteoporosis;

20. Shift to young women (<50); debut peak

21. Rise of the BC epidemic predicted;

22. Evidence of rapid, unabated & ever-

13. Research-based, hypothesis-tested

for protection made 'at the bottom,'

personal and family levels

exposure to (use of) condoms

Body-mind phenomena

condom users

Verified by events

rising BC epidemic

Sex (gender) inter-dependence

7. Toxic environmental waste as direct

8. Estrogen-Progestin model; 'Toxicloaded' bodies, HRT, Ignored carcinogenic effects of external steroids, 'Endocrine disrupters' as causes of the current BC

9. Marriage as a social, psychological, economic & legal unit only. Biological independence of spouses-genders

10. BC: poorly known, 'random' disease;

11. Hopes & trials in BC chemoprevention

12. BC: poorly understood disease, treated

endurance of women, learned helplessness and ignorance for self-protection against BC; Decisions of BC 'reduction' at the top,

13. Focus on selected BC figures &

14. 'Heroic' treatment procedures,

15. BC as a political crisis, because of progressively rising epidemic spread of the

malignant disease in the society

16. The risk of BC unknown; Early detection & treatments as secondary prevention of early death, longer survival

17. Focus on selected BC figures and

18. Long latent period of BC: between 10- 20 years or, starting even "in the womb"

19. No comprehensive theory (conceptual vacuum) of BC & women's ill health and associated BC equivalents of tumors of the reproductive system; BC linked to ovarian

20. BC prevalent in older, postmenopausal

21. Current BC epidemic-rapid rise: Denial

22. Officially, not recognized & nonexistent

cause of BC

epidemic

(*Tamoxifen*)

as a local one

emphasis to find cure

governmental levels

prejudiced data

cancer mainly

women (>50)

BC epidemic

/ artifact claims

(both unsubstantiated)


Table 5. Breast cancer hypothesis 1978 and shift of the conceptual framework. (Updated: March 2011)

In the strategy for the global Millennium Development Goals 2015 (MDGs) decisions, a similar situation presented itself regarding condomization of women in less-developed regions. In a letter to the United Nations Secretary-General, the **Hon. Ban Ki-moon**, on September 25, 2010, the following message about the harmful effects of condom-use programs was conveyed:

AIDS Changed America with the Twin

marital malfunctions, and reduced longevity.

way of thinking may be needed.

the top decision-making level.

**8. Acknowledgments** 

support.

**9. References** 

**7. Conclusion** 

Breast Cancer Epidemic: Exploring the Consequences of Condomization 573

The perplexing worldwide breast cancer epidemic, defined as unintended consequence of widespread condomization of women's sexuality, carried out in fervent campaigns for both contraceptive and prophylactic (anti-HIV/AIDS) purposes continue to reign supreme, globally. It is the quintessence of a deadly female sex- (gender-) specific, malignant disease. The data indicate that the increase of the 'cancer' epidemic in the West, and in other parts of the world, is fueled up almost entirely by the breast cancer epidemic and its steady increase. The breast cancer epidemic is thriving mainly because of lack of commitment to eliminate the disease(s) to rare, sporadic cases, at personal, familial and community levels. The condomization of women's and girls' sexuality is directly related to multitude aspects of female ill health, disturbed functions, specific and accompanying diseases, life, death,

Most of the researchers in the field of cancer research and birth control seem to refer to a "recreational" value of sex, by searching only for technical aspects ("frequency") of intimate encounters and utterly ignoring the biological aspects and barriers to the primordial 'gender' communication, sexual relations. It is amazing that the authors have consistently missed the opportunity to consider barriers to sex as a part of life, particularly of women. The new epidemic of breast cancer and other malignant disease(s) in women is not expected to vanish 'naturally,' by its own. The data indicate that the increase of the breast cancer epidemic in the West, and in other parts of the world, is fueled up mainly by the deceptive condomization of female sexuality in mainstream populations. Almost certainly, the current breast cancer epidemic is to be terminated by deliberate and conscious human intervention only. To try to eliminate the current, unabated and excess breast cancer epidemic, a new

The answer to the current breast cancer contingency is to undertake a primary, nonchemical, no-profit, prevention of the epidemic. Since information in public health actions is superior to legislation, it seems better to take the first steps with subtle, nonjudgmental attitude. Perhaps the true information of the devastating and carcinogenic effects of condom use should be communicated to the consumers and displayed on the commercial product. The information (warning) of the breast cancers risk being included in condom labeling. No doubt that women and couples, empowered with preventative, potentially life-saving information, will be able to make correct assessment of the risks and benefits values on matters of life and death, at a bottom, personal and familial, rather than at the detached at

Thanks to Ing, Emil Gjorgov, from the University American College Skopje, and Ing. Dr. Kosta Mangaroski, from the University St. Cyril and Methodius, Skopje, for the technical

Ambekar A. (2009). Causes and Effects of Divorce. Article. January 12. Internet web: www.articleswave.com/divorce-articles/causes-and-effects-ofdivorce.html

"As a former United Nations Fellow, Fulbright Scholar, physician and researcher, I like to take the liberty of trying to draw your attention to the grave consequences on women's and girls' reproductive health and lives of continuation of the fallacious condom policy in pursuing the future global Millennium Development Goals 2015 (MDGs).

The condomization of female sexuality, defined long ago as the root cause of the current breast cancer epidemic worldwide, is going o be perpetuated by the UN global MDG Plan for Action. The Plan is apparently oblivious to the global twin epidemic of breast cancer along with AIDS, and is projecting the mass condomization as the main critical plan for action for the Goal 5 and Goal 6 in particular. The breast cancer epidemic has been superseding manifold the HIV/AIDS epidemic in the developed, affluent world of the West, including the U.S., UK, and other EU countries, from the outset, in the early 1980s.

From the affluent, rich western world, the breast cancer epidemic is rapidly spreading to the so-called developing, 'poor' world of Africa and Asia, as anticipated. The typically affected by the disease young / younger women (the main condom users), testify in favor of the defined etiology of the raising breast cancer crisis in the developing regions of the world... Besides breast cancer, there is a myriad of accompanying gynecological tumors and diseases increasingly afflicting women of all races and age-cohorts during their reproductive lifespan. It is anticipated that another, more fatal category of female suffering may soon appear, of women affected by both HIV/AIDS and breast cancer diseases combined.

The main culprit of the on-going global breast cancer crisis is the deadly false belief of the use of condom is a "safe" device for fertility-control and family-planning purposes. (By this token, let me mention some official data of the Korean women in the U.S. who have been and still are with the lowest recorded breast cancer incidence rates, which, in my experience, could be attributed to a traditionally low prevalence of condom use and, accordingly, to the assumed lowest condom acculturation in the new/old country.) Almost certainly, it was not by accident that the former President, George W. Bush, acting most likely on extra information, imposed a bold 'condom-paradigm shift,' in favor of an anticondom reproductive policy, followed by a global ban on condom promotion and distribution, and termination of the unlimited condom funds to global agencies at home and abroad (including WHO, UNFPA, UNAIDS, World Bank and others)… At the present, I believe, the signs may seem encouraging that President Barack Obama would proceed with the same policy of non-condomization of the mainstream population, which policy is expected to prove to be extremely beneficial for elimination, i.e., for primary prevention (non-chemical, non-profit) of the current breast cancer epidemic, and for a better control of the other gender- (sex-) specific diseases in women of all ages. What seem to be happening now, instead, is that the United Nations and its agencies continue to sponsor / promote the relentless push of condoms, disguised as family planning methods, with lingering ill-effects and inevitably up-dating and transferring the current, breast cancer epidemic and other harmful experience of the West into poor world regions…

Ii is my belief that your post of UN Secretary-General embodies a unique opportunity to be able to try to help reassess the new scientific evidence about the epidemiological and social consequences of the never openly debated, arbitrary silenced issue of condomized control of women's and girls' sexuality, a deceptive protection of their reproductive health in the UN sponsored MDGs 5 & 6."

E-mailed and AIRMAILED

## **7. Conclusion**

572 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

"As a former United Nations Fellow, Fulbright Scholar, physician and researcher, I like to take the liberty of trying to draw your attention to the grave consequences on women's and girls' reproductive health and lives of continuation of the fallacious condom policy in

The condomization of female sexuality, defined long ago as the root cause of the current breast cancer epidemic worldwide, is going o be perpetuated by the UN global MDG Plan for Action. The Plan is apparently oblivious to the global twin epidemic of breast cancer along with AIDS, and is projecting the mass condomization as the main critical plan for action for the Goal 5 and Goal 6 in particular. The breast cancer epidemic has been superseding manifold the HIV/AIDS epidemic in the developed, affluent world of the West, including the U.S., UK, and other EU countries, from the outset, in the early

From the affluent, rich western world, the breast cancer epidemic is rapidly spreading to the so-called developing, 'poor' world of Africa and Asia, as anticipated. The typically affected by the disease young / younger women (the main condom users), testify in favor of the defined etiology of the raising breast cancer crisis in the developing regions of the world... Besides breast cancer, there is a myriad of accompanying gynecological tumors and diseases increasingly afflicting women of all races and age-cohorts during their reproductive lifespan. It is anticipated that another, more fatal category of female suffering may soon

appear, of women affected by both HIV/AIDS and breast cancer diseases combined.

harmful experience of the West into poor world regions…

health in the UN sponsored MDGs 5 & 6."

E-mailed and AIRMAILED

The main culprit of the on-going global breast cancer crisis is the deadly false belief of the use of condom is a "safe" device for fertility-control and family-planning purposes. (By this token, let me mention some official data of the Korean women in the U.S. who have been and still are with the lowest recorded breast cancer incidence rates, which, in my experience, could be attributed to a traditionally low prevalence of condom use and, accordingly, to the assumed lowest condom acculturation in the new/old country.) Almost certainly, it was not by accident that the former President, George W. Bush, acting most likely on extra information, imposed a bold 'condom-paradigm shift,' in favor of an anticondom reproductive policy, followed by a global ban on condom promotion and distribution, and termination of the unlimited condom funds to global agencies at home and abroad (including WHO, UNFPA, UNAIDS, World Bank and others)… At the present, I believe, the signs may seem encouraging that President Barack Obama would proceed with the same policy of non-condomization of the mainstream population, which policy is expected to prove to be extremely beneficial for elimination, i.e., for primary prevention (non-chemical, non-profit) of the current breast cancer epidemic, and for a better control of the other gender- (sex-) specific diseases in women of all ages. What seem to be happening now, instead, is that the United Nations and its agencies continue to sponsor / promote the relentless push of condoms, disguised as family planning methods, with lingering ill-effects and inevitably up-dating and transferring the current, breast cancer epidemic and other

Ii is my belief that your post of UN Secretary-General embodies a unique opportunity to be able to try to help reassess the new scientific evidence about the epidemiological and social consequences of the never openly debated, arbitrary silenced issue of condomized control of women's and girls' sexuality, a deceptive protection of their reproductive

pursuing the future global Millennium Development Goals 2015 (MDGs).

1980s.

The perplexing worldwide breast cancer epidemic, defined as unintended consequence of widespread condomization of women's sexuality, carried out in fervent campaigns for both contraceptive and prophylactic (anti-HIV/AIDS) purposes continue to reign supreme, globally. It is the quintessence of a deadly female sex- (gender-) specific, malignant disease. The data indicate that the increase of the 'cancer' epidemic in the West, and in other parts of the world, is fueled up almost entirely by the breast cancer epidemic and its steady increase. The breast cancer epidemic is thriving mainly because of lack of commitment to eliminate the disease(s) to rare, sporadic cases, at personal, familial and community levels. The condomization of women's and girls' sexuality is directly related to multitude aspects of female ill health, disturbed functions, specific and accompanying diseases, life, death, marital malfunctions, and reduced longevity.

Most of the researchers in the field of cancer research and birth control seem to refer to a "recreational" value of sex, by searching only for technical aspects ("frequency") of intimate encounters and utterly ignoring the biological aspects and barriers to the primordial 'gender' communication, sexual relations. It is amazing that the authors have consistently missed the opportunity to consider barriers to sex as a part of life, particularly of women. The new epidemic of breast cancer and other malignant disease(s) in women is not expected to vanish 'naturally,' by its own. The data indicate that the increase of the breast cancer epidemic in the West, and in other parts of the world, is fueled up mainly by the deceptive condomization of female sexuality in mainstream populations. Almost certainly, the current breast cancer epidemic is to be terminated by deliberate and conscious human intervention only. To try to eliminate the current, unabated and excess breast cancer epidemic, a new way of thinking may be needed.

The answer to the current breast cancer contingency is to undertake a primary, nonchemical, no-profit, prevention of the epidemic. Since information in public health actions is superior to legislation, it seems better to take the first steps with subtle, nonjudgmental attitude. Perhaps the true information of the devastating and carcinogenic effects of condom use should be communicated to the consumers and displayed on the commercial product.

The information (warning) of the breast cancers risk being included in condom labeling. No doubt that women and couples, empowered with preventative, potentially life-saving information, will be able to make correct assessment of the risks and benefits values on matters of life and death, at a bottom, personal and familial, rather than at the detached at the top decision-making level.

## **8. Acknowledgments**

Thanks to Ing, Emil Gjorgov, from the University American College Skopje, and Ing. Dr. Kosta Mangaroski, from the University St. Cyril and Methodius, Skopje, for the technical support.

## **9. References**

Ambekar A. (2009). Causes and Effects of Divorce. Article. January 12. Internet web: www.articleswave.com/divorce-articles/causes-and-effects-ofdivorce.html

AIDS Changed America with the Twin

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**Part 4** 

**From the Clinic to the Patients:** 

**Transmission, Diagnosis and Therapies** 


## **Part 4**

**From the Clinic to the Patients: Transmission, Diagnosis and Therapies** 

580 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

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Pan American Health Organization). Web:

and

**23** 

**Transmission of HIV Through Blood –** 

*ID Consulting for International Development of Transfusion Medicine/* 

Of all blood donations 65% are made in developed (very high human development index or VH-HDI) countries, home to just 25% of the world's population. In 73 countries, donation rates are still less than 1% of the population (the minimum needed to meet basic needs in a country). Of these, 71 are either developing (low HDI) or transitional (medium to high HDI) countries; 42 countries collect less than 25% of their blood supplies from the safest source: voluntary non-remunerated blood donors. However, less than 50% of these donors donates regularly, the other half just one time only. In 2007, 31 countries (19%) still reported collecting paid donations, which is more than 1 million donations in total, where 41 countries (25%) were not able to screen all blood donations for one or more of the following transfusion-transmissible infections (TTIs) – HIV, hepatitis B, hepatitis C and syphilis (WHO

Blood transfusion as a supportive haemotherapy contributes to saving lives and improving health, but millions of patients needing transfusion do not have timely access to or can afford safe blood. In 2007, 162 countries provided data to WHO on 85.4 million blood donations (World Health Organization [WHO] 2010a). These data come from countries that account for a total of 5.9 billion people, representing 92% of the global population. The report covers around 8,000 blood centres. In developed countries, the average annual collection per blood centre was 13,600 (range 49–289,075), in transitional countries 6,000

While the need for blood is universal, there is still a major imbalance between developing and advanced countries in the level of access to safe blood. It is estimated that blood donation by 1% of the total population (10 per 1,000 population) is generally the minimum needed to meet a nation's most basic requirements for blood; the requirements are higher in

Of the 85.4 milion donations in 2007, about 65 % were collected in developed countries. Blood donations per 1,000 population, which also reflect the general availability of blood in a country, vary widely and the lowest levels of availability are found in developing and transitional countries (WHO 2010a). The average donation rate in developed (VH-HDI)

(range 20–499,212) and in developing countries 2,800 (range 114–23,251).

countries with more advanced health care systems and medical interventions.

**1. Introduction** 

2010a).

**1.1.1 Blood supply** 

**1.1 HIV and blood transfusion – The current state of the art** 

**How To Bridge the Knowledge Gap** 

Smit Sibinga, Cees Th and John P. Pitman

*University of Groningen* 

*The Netherlands* 

## **Transmission of HIV Through Blood – How To Bridge the Knowledge Gap**

Smit Sibinga, Cees Th and John P. Pitman

*ID Consulting for International Development of Transfusion Medicine/ University of Groningen The Netherlands* 

## **1. Introduction**

#### **1.1 HIV and blood transfusion – The current state of the art**

Of all blood donations 65% are made in developed (very high human development index or VH-HDI) countries, home to just 25% of the world's population. In 73 countries, donation rates are still less than 1% of the population (the minimum needed to meet basic needs in a country). Of these, 71 are either developing (low HDI) or transitional (medium to high HDI) countries; 42 countries collect less than 25% of their blood supplies from the safest source: voluntary non-remunerated blood donors. However, less than 50% of these donors donates regularly, the other half just one time only. In 2007, 31 countries (19%) still reported collecting paid donations, which is more than 1 million donations in total, where 41 countries (25%) were not able to screen all blood donations for one or more of the following transfusion-transmissible infections (TTIs) – HIV, hepatitis B, hepatitis C and syphilis (WHO 2010a).

Blood transfusion as a supportive haemotherapy contributes to saving lives and improving health, but millions of patients needing transfusion do not have timely access to or can afford safe blood. In 2007, 162 countries provided data to WHO on 85.4 million blood donations (World Health Organization [WHO] 2010a). These data come from countries that account for a total of 5.9 billion people, representing 92% of the global population. The report covers around 8,000 blood centres. In developed countries, the average annual collection per blood centre was 13,600 (range 49–289,075), in transitional countries 6,000 (range 20–499,212) and in developing countries 2,800 (range 114–23,251).

#### **1.1.1 Blood supply**

While the need for blood is universal, there is still a major imbalance between developing and advanced countries in the level of access to safe blood. It is estimated that blood donation by 1% of the total population (10 per 1,000 population) is generally the minimum needed to meet a nation's most basic requirements for blood; the requirements are higher in countries with more advanced health care systems and medical interventions.

Of the 85.4 milion donations in 2007, about 65 % were collected in developed countries. Blood donations per 1,000 population, which also reflect the general availability of blood in a country, vary widely and the lowest levels of availability are found in developing and transitional countries (WHO 2010a). The average donation rate in developed (VH-HDI)

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 585

Of the 162 responding countries 57 (35%) report collecting 100% of their blood supplies from voluntary unpaid donors (fig. 2). Since World Blood Donor Day (14th June, birthday of Karl Landsteiner) celebration began in 2004, 111 countries (68.5%) reported an increase of the number of voluntary donations; 32 of these 111 (29%) have more than doubled the number of voluntary donations as compared to 2004 figures. All these 32 countries are developing or transitional countries. Additionally, 11 countries (Bosnia and Herzegovina, Burkina Faso, Cook Islands, Cape Verde, Kuwait, Guinea Bissau, Mauritania, Myanmar, Niue, Vanuatu and Vietnam) reported more than a 10% increase in voluntary unpaid donations in 2007, as compared to 2006 figures. However, a major problem remains the retention of voluntary

Forty-two countries (26%) collect less than 25% of their blood supplies from voluntary unpaid blood donors. A significant amount of the blood supply in these countries is still dependent on family/replacement and paid blood donors. Thirty-one countries (18%) still report collecting paid donations in 2007, which represents more than 1 million donations in

The average donation rate in high-income countries is 45,400 donations per million people. This compares with 10,100 donations per million people in middle-income countries and 3,600 donations in low-income countries. If 1% to 3% of a country's population would donate blood, it would be sufficient to meet the country's needs. But in 77 countries,

Fig. 2. Percentage voluntary non-remunerated blood donors, 2007. Source: Global Database

**1.1.2.1 Voluntary, unpaid donations** 

non-remunerated blood donors.

donation rates are still less than 1%.

total.

**1.1.2.2 Family/replacement donors and paid donors** 

on Blood Safety (GDBS), 2007 survey (WHO2010a)

countries is 38.1 donations/1,000 population (range 4.92–68.01); in transitional (H and M-HDI) countries this rate is 7.5 (range 1.07–35.18) and in developing (L-HDI) countries an average of 2.3 (range 0.40–7.46) donations per 1,000 population were collected. In 2007, 73 countries (45%) reported collecting fewer than 10 donations per 1,000 population. Among them, 71 (97%) are either developing or transitional countries. Due to relatively high TTI marker prevalence the drop out of collected blood varies between 11 and over 20%, reducing the clinical availability substantially.

#### **1.1.2 Blood donation**

There are three major types of blood donation: voluntary unpaid donations (nonremunerated/altruistic), family/replacement donations (coerced), and paid donations. Donors who give blood voluntarily, regularly and for altruistic reasons have the lowest prevalence of HIV, hepatitis viruses and other blood-borne infections, as compared to people who donate for friends and family members or because of payment. Family and replacement donations are often hidden paid and seriously coerced. Sufficient supplies of safe blood can only be assured by regular donations from voluntary unpaid and anonymous donors. The 2007 WHO data reveal some improvements in such donations worldwide, but many developing and transitional countries still rely heavily on relatively unsafe one time only family/replacement donors and paid donors (fig 1).

This means a considerable gap in public awareness and knowledge about the essentials of blood donation as an act of social solidarity and blood transfusion as an integral element of the health care system.

Fig. 1. Annual blood donations per 1,000 population, 2007. Source: Global Database on Blood Safety (GDBS), 2007 survey (WHO2010a)

## **1.1.2.1 Voluntary, unpaid donations**

584 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

countries is 38.1 donations/1,000 population (range 4.92–68.01); in transitional (H and M-HDI) countries this rate is 7.5 (range 1.07–35.18) and in developing (L-HDI) countries an average of 2.3 (range 0.40–7.46) donations per 1,000 population were collected. In 2007, 73 countries (45%) reported collecting fewer than 10 donations per 1,000 population. Among them, 71 (97%) are either developing or transitional countries. Due to relatively high TTI marker prevalence the drop out of collected blood varies between 11 and over 20%,

There are three major types of blood donation: voluntary unpaid donations (nonremunerated/altruistic), family/replacement donations (coerced), and paid donations. Donors who give blood voluntarily, regularly and for altruistic reasons have the lowest prevalence of HIV, hepatitis viruses and other blood-borne infections, as compared to people who donate for friends and family members or because of payment. Family and replacement donations are often hidden paid and seriously coerced. Sufficient supplies of safe blood can only be assured by regular donations from voluntary unpaid and anonymous donors. The 2007 WHO data reveal some improvements in such donations worldwide, but many developing and transitional countries still rely heavily on relatively unsafe one time

This means a considerable gap in public awareness and knowledge about the essentials of blood donation as an act of social solidarity and blood transfusion as an integral element of

Fig. 1. Annual blood donations per 1,000 population, 2007. Source: Global Database on

Blood Safety (GDBS), 2007 survey (WHO2010a)

reducing the clinical availability substantially.

only family/replacement donors and paid donors (fig 1).

**1.1.2 Blood donation** 

the health care system.

Of the 162 responding countries 57 (35%) report collecting 100% of their blood supplies from voluntary unpaid donors (fig. 2). Since World Blood Donor Day (14th June, birthday of Karl Landsteiner) celebration began in 2004, 111 countries (68.5%) reported an increase of the number of voluntary donations; 32 of these 111 (29%) have more than doubled the number of voluntary donations as compared to 2004 figures. All these 32 countries are developing or transitional countries. Additionally, 11 countries (Bosnia and Herzegovina, Burkina Faso, Cook Islands, Cape Verde, Kuwait, Guinea Bissau, Mauritania, Myanmar, Niue, Vanuatu and Vietnam) reported more than a 10% increase in voluntary unpaid donations in 2007, as compared to 2006 figures. However, a major problem remains the retention of voluntary non-remunerated blood donors.

#### **1.1.2.2 Family/replacement donors and paid donors**

Forty-two countries (26%) collect less than 25% of their blood supplies from voluntary unpaid blood donors. A significant amount of the blood supply in these countries is still dependent on family/replacement and paid blood donors. Thirty-one countries (18%) still report collecting paid donations in 2007, which represents more than 1 million donations in total.

The average donation rate in high-income countries is 45,400 donations per million people. This compares with 10,100 donations per million people in middle-income countries and 3,600 donations in low-income countries. If 1% to 3% of a country's population would donate blood, it would be sufficient to meet the country's needs. But in 77 countries, donation rates are still less than 1%.

Fig. 2. Percentage voluntary non-remunerated blood donors, 2007. Source: Global Database on Blood Safety (GDBS), 2007 survey (WHO2010a)

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 587

prescribing parts of the vein-to-vein blood transfusion chain in transitional (M-HDI) and

Fig. 3. Numbers of countries screening for HIV, HBV, HCV and syphilis Source: Global

Since UN together with its health organization WHO became operational in 1948, universal principles have been laid down in the UN Declaration of Universal Human Rights (UN 1948). For the health care and blood transfusion chain art. 25.1 – Right of Health through securing food, clothing, shelter and health care, and art. 26 – Right of Education, elementary

In1975 the WHA passed a Resolution 28.72 (Utilization and Supply of Human Blood and Blood Products), indicating that blood is a national resource, to be 'shared' voluntarily and altruistically and to be given as a social act of solidarity, and that human blood and tissue

These principles have been worked out by e.g. the International Society of Blood Transfusion (ISBT) in the Code of Ethics (ISBT 2000), but also by the EU in the Directives

Blood transfusion in its vein-to-vein structure should be seen as a part of a larger project to develop a safe, sustainable, high quality and efficacious blood supply and transfusion system that is fully integrated into the health care system. Ensuring the safety and availability of blood and blood products is an essential public health responsibility. Measures to ensure blood safety also play a major role in preventing the transmission of HIV, hepatitis viruses and other blood born pathogens in health care settings. The Ministry

Database on Blood Safety (GDBS), 2007 survey (WHO 2010a)

and access to vocational education, are paramount.

should never be subject to commerce (WHO 1978)

related to blood transfusion (EU 2003, Directive 2002/98/EC).

**1.2 Basics of the blood supply** 

even more prominent in developing (L-HDI) countries.

#### **1.1.3 Blood screening for transmissible infections**

WHO recommends that all donated blood to be used for transfusion should be screened at minimum for HIV, hepatitis B, hepatitis C and syphilis (WHO 2010). Complete and accurate data on the screening of donated blood are not available from many developing countries, particularly those where blood services are not coordinated. Many countries do not have reliable testing systems because of staff shortages, lack of basic laboratory services, poor quality test kits or their irregular supply. Of the 162 countries that provided data on screening for transfusion-transmissible infections including HIV, hepatitis B, hepatitis C and syphilis, 41 (25%) are not able to screen all donated blood for one or more of these infections (fig. 3). The other 121 countries provided data on whether blood donations were screened in a quality-assured manner (use of standard operating procedures and participation in an external quality assessment scheme or EQAS). Overall, 88% of the blood collected are screened following these basic quality procedures: 89% in developed countries, 87% in transitional countries and 48% in developing countries. For the blood donations collected in the remaining 41 countries, which account for 22% of the global donations reported to WHO, the use of these basic quality assurance procedures for laboratory screening is still unknown. Additionally there is still a widespread mix of test kits used within countries, both ELISA and rapid test depending on availability and supply. Quality of performance and reliability of test results remain a problem of considerable concern.

#### **1.1.4 Clinical use of blood**

Data on the clinical use of donated blood is limited, but studies suggest that transfusions are often given unnecessarily when simpler, less expensive treatments can provide equal or greater benefit. Not only is this a waste of a scarce resource but it also exposes patients to the risk of serious adverse transfusion reactions or infections transmitted through the blood. Hospital transfusion committees and a system for reporting adverse transfusion reactions should be established in each hospital to implement the national policy and guidelines and to monitor the safe and rational use of blood and blood products at the local level. However, in a substantial proportion of the transition and developing countries there is still no national policy and no current guidelines or standards. In many situations haemoglobin transfusion triggers are high and surgical blood order equations and minimal blood order lists are not used (Kajja et al. 2010a, 2010b) .

In 2007, 120 countries (74%, including 46 developed, 48 transitional and 26 developing countries) identified and reported a total of 51,400 hospitals that perform blood transfusions, serving a population of around 3.6 billion. Not all countries were able to provide information on clinical practice (WHO 2010a). Data on hospitals performing transfusion provided by 96 countries (80%, including 38 developed countries, 40 transitional countries and 18 developing countries) illustrate the presence of a transfusion committee in 88% of these hospitals in developed countries, 33% in transitional and 25 % in developing countries. Mechanisms to monitor clinical transfusion practice (documentation) is present in 90% of the hospitals performing transfusion in developed countries, 52 % in transitional and 23 % in developing countries. However, a system for reporting adverse transfusion events (haemovigilance) in hospitals performing transfusion is found in 91% in developed countries, but only 46% in transitional and 23% in developing countries.

These 2007 WHO survey data illustrate a major gap in awareness and knowledge among policy makers and blood transfusion professionals, both in the procurement and the

WHO recommends that all donated blood to be used for transfusion should be screened at minimum for HIV, hepatitis B, hepatitis C and syphilis (WHO 2010). Complete and accurate data on the screening of donated blood are not available from many developing countries, particularly those where blood services are not coordinated. Many countries do not have reliable testing systems because of staff shortages, lack of basic laboratory services, poor quality test kits or their irregular supply. Of the 162 countries that provided data on screening for transfusion-transmissible infections including HIV, hepatitis B, hepatitis C and syphilis, 41 (25%) are not able to screen all donated blood for one or more of these infections (fig. 3). The other 121 countries provided data on whether blood donations were screened in a quality-assured manner (use of standard operating procedures and participation in an external quality assessment scheme or EQAS). Overall, 88% of the blood collected are screened following these basic quality procedures: 89% in developed countries, 87% in transitional countries and 48% in developing countries. For the blood donations collected in the remaining 41 countries, which account for 22% of the global donations reported to WHO, the use of these basic quality assurance procedures for laboratory screening is still unknown. Additionally there is still a widespread mix of test kits used within countries, both ELISA and rapid test depending on availability and supply. Quality of performance

Data on the clinical use of donated blood is limited, but studies suggest that transfusions are often given unnecessarily when simpler, less expensive treatments can provide equal or greater benefit. Not only is this a waste of a scarce resource but it also exposes patients to the risk of serious adverse transfusion reactions or infections transmitted through the blood. Hospital transfusion committees and a system for reporting adverse transfusion reactions should be established in each hospital to implement the national policy and guidelines and to monitor the safe and rational use of blood and blood products at the local level. However, in a substantial proportion of the transition and developing countries there is still no national policy and no current guidelines or standards. In many situations haemoglobin transfusion triggers are high and surgical blood order equations and minimal blood order

In 2007, 120 countries (74%, including 46 developed, 48 transitional and 26 developing countries) identified and reported a total of 51,400 hospitals that perform blood transfusions, serving a population of around 3.6 billion. Not all countries were able to provide information on clinical practice (WHO 2010a). Data on hospitals performing transfusion provided by 96 countries (80%, including 38 developed countries, 40 transitional countries and 18 developing countries) illustrate the presence of a transfusion committee in 88% of these hospitals in developed countries, 33% in transitional and 25 % in developing countries. Mechanisms to monitor clinical transfusion practice (documentation) is present in 90% of the hospitals performing transfusion in developed countries, 52 % in transitional and 23 % in developing countries. However, a system for reporting adverse transfusion events (haemovigilance) in hospitals performing transfusion is found in 91% in developed

These 2007 WHO survey data illustrate a major gap in awareness and knowledge among policy makers and blood transfusion professionals, both in the procurement and the

**1.1.3 Blood screening for transmissible infections** 

and reliability of test results remain a problem of considerable concern.

countries, but only 46% in transitional and 23% in developing countries.

**1.1.4 Clinical use of blood** 

lists are not used (Kajja et al. 2010a, 2010b) .

prescribing parts of the vein-to-vein blood transfusion chain in transitional (M-HDI) and even more prominent in developing (L-HDI) countries.

Fig. 3. Numbers of countries screening for HIV, HBV, HCV and syphilis Source: Global Database on Blood Safety (GDBS), 2007 survey (WHO 2010a)

## **1.2 Basics of the blood supply**

Since UN together with its health organization WHO became operational in 1948, universal principles have been laid down in the UN Declaration of Universal Human Rights (UN 1948). For the health care and blood transfusion chain art. 25.1 – Right of Health through securing food, clothing, shelter and health care, and art. 26 – Right of Education, elementary and access to vocational education, are paramount.

In1975 the WHA passed a Resolution 28.72 (Utilization and Supply of Human Blood and Blood Products), indicating that blood is a national resource, to be 'shared' voluntarily and altruistically and to be given as a social act of solidarity, and that human blood and tissue should never be subject to commerce (WHO 1978)

These principles have been worked out by e.g. the International Society of Blood Transfusion (ISBT) in the Code of Ethics (ISBT 2000), but also by the EU in the Directives related to blood transfusion (EU 2003, Directive 2002/98/EC).

Blood transfusion in its vein-to-vein structure should be seen as a part of a larger project to develop a safe, sustainable, high quality and efficacious blood supply and transfusion system that is fully integrated into the health care system. Ensuring the safety and availability of blood and blood products is an essential public health responsibility. Measures to ensure blood safety also play a major role in preventing the transmission of HIV, hepatitis viruses and other blood born pathogens in health care settings. The Ministry

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 589

The framework of such an integrated blood supply system could be based on the seven key

1. Organization and structure, including the necessary infrastructure to be strengthened and further developed. This element includes the development of an appropriate and implementable formal regulatory structure, development of a system of regional blood banks based on a sufficient economy of scale to become cost-effective. These institutions preferably should be part of a nationally coordinated blood transfusion service responsible for policy making, design of the necessary strategies, annual planning, the development of a national quality and quality management system based on internationally accepted standards and product specifications. Such quality and quality management system will have a uniform documentation system, which allows for the possibility of instituting a nation-wide ICT system for data management. The organization should have sufficient autonomy to operate its services. As the organization produces products (collection, processing and testing, storage and distribution) for clinical use, it is automatically product liable and should therefore operate independently from hospitals. Hospitals use the products for specific haemotherapy in patients and therefore have the legal obligation to protect consumer rights, which cannot be combined with product liability under the same final responsibility (conflict of interest). Another aspect of this first element is the need to develop appropriate and cGMP compliant working facilities, that guarantee a working

environment that allows high quality operations to be performed by staff.

key to the supplier-customer principle of quality operations (Kajja 2010).

specifications) will be part of the program.

2. Clinical use needs full attention to develop evidence based transfusion practices all over the country. That means assessment of the current clinical practices and development of an in-hospital transfusion quality and quality management system. Hospitals will be supplied by regional procurement centers (blood centres) with a working stock that will be based on an inventory of actual needs per discipline – paediatrics, obstetrics, surgery and traumatology and haemato-oncology. The development of a well functioning clinical interface will lead to the change from the currently prevalent supply driven system to a demand driven system, based on mutual respect and understanding and

3. Processing and testing of all units of blood collected will allow an efficient use of the blood collected and contribute to rational use of blood through component therapy. Testing for the key TTI markers (HIV, HBV, HCV and Syphilis) needs to be instituted with appropriate and standardized technology and methodology. Here, economies of scale are paramount to guarantee consistency of performance and cost containment. Where epidemiology indicates, additional tests can be considered such as brucellosis, Chagas or malaria. As screening tests focus on sensitivity, a system for confirmation needs to be developed at the national level – a reference laboratory that also could perform test kit and reagent validation before implementation is needed. Along with the development of component production, in-process quality control of the produced half and finished products (testing for standardized and uniform product

4. Collection of source material – human blood or plasma – from voluntary nonremunerated and preferably regular blood donors, motivated and mobilized from identified low-risk groups in the community. This requires development of public awareness based on social marketing. The currently prevalent supply driven system of

elements (figure 4) as follows:

of Health (MoH) should provide effective leadership and governance in developing a national blood system that is fully integrated into the health care system. First the foundation, then the construction of the organization and the necessary infrastructure (Quality System and Quality Management System, facilities, etc), will need to be developed. These will be followed by the development of the human capacity needed at all levels, including in the hospitals (medical and paramedical staff).

In principle, the approach for developing such an integrated nationally supported and organized country wide blood supply and transfusion system for the future, and in line with internationally accepted and advocated principles of operation, would then be as follows (fig. 4)

Fig. 4. Development scheme blood supply organization.

The set up should be based on a solid country specific legislative and regulatory system with sufficient authority to license operations according to international quality principles (cGMP, cGLP and cGCP)1 supported by appropriate and standardized management principles based on ISO9001:2008. It starts with a clinical needs assessment to be followed by the logistics of the procurement and supply chain that has its roots in the community (public awareness) (Smit Sibinga 2006, WHO 2008c, Smit Sibinga et al 2009a, ).

The implementation is not limited to public or private blood centres or establishments. The limitation is in the fragmentation with insufficient critical mass and economy of scale to guarantee quality and cost-effectiveness, nation wide access and affordability. National coordination and consistent and sustained governmental responsibility and support to protect citizens from unjustified and maleficent practices are the more important (Smit Sibinga 2000).

A nationally coordinated and integrated blood supply system needs competent and committed leadership and an appropriate budget to allow accessibility and affordability of haemotherapy, based on a proper and documented needs assessment. The financing system should be an integral part of a national health financing system based on cost recovery and a healthy insurance policy accessible and affordable for all citizens (WHO 2008, van Hulst et al. 2006).

<sup>1</sup> GMP = Good Manufacturing Practice, GLP = Good Laboratory Practice, GCP = Good Clinical Practice

of Health (MoH) should provide effective leadership and governance in developing a national blood system that is fully integrated into the health care system. First the foundation, then the construction of the organization and the necessary infrastructure (Quality System and Quality Management System, facilities, etc), will need to be developed. These will be followed by the development of the human capacity needed at all levels,

In principle, the approach for developing such an integrated nationally supported and organized country wide blood supply and transfusion system for the future, and in line with internationally accepted and advocated principles of operation, would then be as follows (fig. 4)

The set up should be based on a solid country specific legislative and regulatory system with sufficient authority to license operations according to international quality principles (cGMP, cGLP and cGCP)1 supported by appropriate and standardized management principles based on ISO9001:2008. It starts with a clinical needs assessment to be followed by the logistics of the procurement and supply chain that has its roots in the community (public

The implementation is not limited to public or private blood centres or establishments. The limitation is in the fragmentation with insufficient critical mass and economy of scale to guarantee quality and cost-effectiveness, nation wide access and affordability. National coordination and consistent and sustained governmental responsibility and support to protect citizens from unjustified and maleficent practices are the more important (Smit

A nationally coordinated and integrated blood supply system needs competent and committed leadership and an appropriate budget to allow accessibility and affordability of haemotherapy, based on a proper and documented needs assessment. The financing system should be an integral part of a national health financing system based on cost recovery and a healthy insurance policy accessible and affordable for all citizens (WHO 2008, van Hulst et

1 GMP = Good Manufacturing Practice, GLP = Good Laboratory Practice, GCP = Good Clinical Practice

including in the hospitals (medical and paramedical staff).

Fig. 4. Development scheme blood supply organization.

Sibinga 2000).

al. 2006).

awareness) (Smit Sibinga 2006, WHO 2008c, Smit Sibinga et al 2009a, ).

The framework of such an integrated blood supply system could be based on the seven key elements (figure 4) as follows:


Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 591

Each of these processes has a series of procedures and related documentation that needs to

1. The *blood ordering process* (ward/bedside) starts at the bedside with indication setting and decision making resulting in a standardized request and accompanying blood sample for compatibility testing. Traceability (documentation) is paramount to prevent adverse transfusion reactions due to clerical errors of identification (wrong blood in tube). It consists of six steps or procedures (diagnosis, indication, decision to transfuse or use alternatives, ordering, sample taking and transportation) and two operational

2. The *blood selection process* (laboratory) of blood components as requested and compatibility testing. It should be noted that compatibility testing is a laboratory diagnostic procedure. The blood selection process consists of four steps or procedures (reception and registration of request and sample, selection of blood, compatibility testing and transportation) and two operational documents (logbook and cross match

3. The *bedside transfusion process* (ward/bedside) of the selected units at the bedside, which needs careful identification of units and recipient (match), and the technical handling and observation of the transfusion, carried out by nursing staff and based on proper and uniform standard operating procedures with appropriate documentation to allow evaluation necessary to develop evidence based practice. It consists of two sub-

a. The preparation of the patient and the unit of blood before the transfusion – three steps or procedures (reception at the ward, patient and unit identification, vital

b. Transfusion and observation of the patient – four steps or procedures (connection to the patient, immediate observation, transfusion or discontinuation, observation

These processes are closely interrelated, though distinctly different. The following steps are

Clinicians and nursing staff need to be trained in these steps and the related quality assurance and documentation to develop a proper and standardized monitoring and evaluation evidence based transfusion practice. To create ownership among the prescribing

1. Ward – Ordering (indication/decision/alternatives)

2. Laboratory – Selection/compatibility

3. Ward – a. Preparation: ID & vital signs

b. Transfusion/observation

Fig. 5. In-hospital transfusion flow of steps.

documents (blood request form and sample label);

be developed:

form);

processes:

signs);

involved in the process:

of outcome).

the blood supply needs to be developed into a demand driven system, which means the availability of motivated potential donors willing to be mobilized to allow a balanced blood stock that is managed and the development of a contingency plan. Donor selection needs to be standardized and adjusted to internationally recommended minimum requirements for donor suitability.


#### **1.3 Basics of the clinical use of blood**

The clinical use of blood represents both the starting and the closing end of the demand and supply loop. Therefore, it does not make much sense to develop only the clinical interface if the basics of proper procurement (collection, processing and testing, storage and distribution), based on international principles (1948 UN Declaration of Universal Human Rights, 1975 WHA28/72 Utilization and Supply of Human Blood and Blood Products, International Red Cross and ISBT Code of Ethics) are not in place.

The in-hospital transfusion chain should include process analysis, process descriptions, related SOPs and operational documents such as a standard (national) blood request form, a standard compatibility test form, a transfusion outcome form, clinical guidelines and a haemovigilance report form (Kajja 2010).

The in-hospital transfusion chain consists of three distinctive processes, each containing a number of procedures, critical control points (CCPs/decisions) and documentation. (figure 5)

5. Education (teaching and training) is the cornerstone of capacity building. A national assessment and inventory of available education (institutions, curricula) needs to be carried out to allow the development of an effective approach towards capacity building and human resource development at all levels involved. The in-country approach will focus on leadership development (senior and middle management) and development of operational competencies (professional knowledge and skills) through

6. Monitoring and evaluation follows the implementation of a national quality and quality management system based on uniform documentation of what is being done, both at the management level (management information system) as well as at the operational level through an automated data processing system (ICT) with communication between all centres and the national Head Quarter and Ministry of Health. Use of simple statistical evaluation technology such as statistical process control (SPC) and application of Six Sigma (Gygi et al., 2005) will allow proper benchmarking focused on improvement through trend analysis. A nationwide compatible ICT system would allow proper quality management through coordinated monitoring and evaluation of

various education methodologies to allow larger groups of staff to benefit.

uniform data collected through regional centres and hospitals (vein-to-vein). 7. Sustainability is not only dependent on financial resources, but comprehensively relates to all six elements as described above – organizational structure and infrastructure, competent and adequate human resources, a reliable and regular voluntary blood donor panel, a standardized procurement process, evidence based rational use of blood components and alternatives, and quality assurance through proper monitoring of set indicators and their evaluation through benchmarking focused on improvement. This follows the principle of the Deming cycle of improvement – **plan** (policy and strategies), **do** (implementation of managerial and operational processes), **check** (monitoring of the indicators/specifications and accurate data collection through documentation), **act**

The clinical use of blood represents both the starting and the closing end of the demand and supply loop. Therefore, it does not make much sense to develop only the clinical interface if the basics of proper procurement (collection, processing and testing, storage and distribution), based on international principles (1948 UN Declaration of Universal Human Rights, 1975 WHA28/72 Utilization and Supply of Human Blood and Blood Products,

The in-hospital transfusion chain should include process analysis, process descriptions, related SOPs and operational documents such as a standard (national) blood request form, a standard compatibility test form, a transfusion outcome form, clinical guidelines and a

The in-hospital transfusion chain consists of three distinctive processes, each containing a number of procedures, critical control points (CCPs/decisions) and documentation. (figure 5)

(evaluation of the collected data and the benchmarking).

International Red Cross and ISBT Code of Ethics) are not in place.

**1.3 Basics of the clinical use of blood** 

haemovigilance report form (Kajja 2010).

minimum requirements for donor suitability.

the blood supply needs to be developed into a demand driven system, which means the availability of motivated potential donors willing to be mobilized to allow a balanced blood stock that is managed and the development of a contingency plan. Donor selection needs to be standardized and adjusted to internationally recommended Each of these processes has a series of procedures and related documentation that needs to be developed:

	- a. The preparation of the patient and the unit of blood before the transfusion three steps or procedures (reception at the ward, patient and unit identification, vital signs);
	- b. Transfusion and observation of the patient four steps or procedures (connection to the patient, immediate observation, transfusion or discontinuation, observation of outcome).

These processes are closely interrelated, though distinctly different. The following steps are involved in the process:


Fig. 5. In-hospital transfusion flow of steps.

Clinicians and nursing staff need to be trained in these steps and the related quality assurance and documentation to develop a proper and standardized monitoring and evaluation evidence based transfusion practice. To create ownership among the prescribing

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 593

transmission via transfusion are essential to mobilize a safe donor pool.

a. Community awareness about the need for blood and the risks of disease

b. Types of blood donors must be actively motivated, selected and screened for safety.

a. Education and staff competency: The basis for a quality assured and sustained

a. Applied research in the field of transfusion medicine through proper monitoring and evaluation (M&E) and continued statistical process control (SPC) can contribute to improved operations as well as global understanding of risks, barriers

**2. Principles and ethical aspects of blood donation and transfusion - How do** 

Like other medical specializations, the practice of transfusion medicine is bound by the ancient Greek Hippocratic mandate *Primum est non nocere* (first, do no harm). However, for transfusion specialists, this principle is not limited to the transfusion itself or to the recipient of the transfusion. Rather, it applies to a long chain of ethical decisions that stretches from the motivation of potential donors whose blood is used for transfusions to post-transfusion follow-up. This section will describe and explain how each link in this chain contributes to a

The ethical principles that govern the modern vein-to-vein transfusion system were developed relatively recently, that is to say, largely within the second half of the 20th century, when the science of transfusion medicine became an accepted and routine part of medical practice. (American College of Physicians [ACP], 1984) Indeed, from the 17th century, when physicians began experimenting with transfusing animal blood into humans, through the late 19th and early 20th century when blood groups were discovered and coagulation factors described, the field of transfusion medicine was marked by experimentation, trial and error, and few human subjects protections. (Feldschuh, 1990; McCullough, 1998; Kendrick, n.d.) The 1948 Nuremburg Code established a global framework for medical ethics following the atrocities committed by Nazi doctors during the Second World War. In Europe and North America, laws covering ethical concepts such as the requirement that patients give informed consent prior to medical procedures began to emerge in the 1950s and 1960s. (ACP, 1984) In the mid-1930s, the founding of the International Society of Blood Transfusion (ISBT), created a global forum for the development of specific ethical guidelines for the practice of blood transfusion. Two decades later, in 1955, the International Federation of Blood Donor Organizations (FIODS) was established to focus attention on ethical guidelines for the donation of blood and plasma. Both entities, as well as authors such as Richard Titmuss (The Gift Relationship: From Human Blood to Social Policy, 1971) (Titmuss, 1971), contributed to a body of ethical work that lead to the 1975 World Health Assembly resolution containing global recommendations

4. Collection of source material (community interface) –

and best practices (Smit Sibinga, 2009b).

system. (Smit Sibinga, 2009a)

**these elements promote blood safety?** 

safe blood supply and to safe transfusion practice.

*A brief history of blood donation and transfusion ethics* 

**2.1 Ethical aspects of blood donation** 

6. Monitoring and evaluation –

5. Education –

clinicians and nursing staff education should focus on consensus on items such as a uniform blood request form, terms of reference of a Hospital Transfusion Committee (HTC) and the outline of clinical guidelines (general and per prescribing discipline).

## **1.4 Gaps in the blood supply and clinical use**

In many developing countries blood transfusion in the vein-to-vein concept is still in its first or second generation stage. This means that blood is most often collected and transfused in the absence of a formal policy environment and without adequate regulatory controls or standards. In such systems, blood collection and utilization are fragmented, often dependent on independent factors limited to specific hospitals, such as the availability of trained and competent staff, funds for procurement, and a population of blood donors willing to come on a voluntary and regular basis.

Following the vein-to-vein transfusion chain, major gaps exist in the following areas:

	- a. Legal and regulatory frameworks are often outdated or do not exist.
	- b. Commitment of health authorities is lacking or isolated in fragmented centres.
	- c. Management capacity to sustain blood collection, storage, testing and transfusion services differs from routine hospital or laboratory management.
	- d. Organization and infrastructure for blood services requires national and facilityspecific assessments and inputs.
	- e. Chain of command and clear job descriptions contribute to quality control, stock management, and career development.
	- f. Quality culture and professional discipline are dependent on successful pre-service and on-going in-service training opportunities.
	- g. Poor hygiene and waste management may contribute to broader infection control problems within a facility and the local community.
	- a. Clinical awareness and accountability among clinicians is essential to avoid unnecessary transfusions and preserve limited blood stocks.
	- b. Improper indication setting and decision making may increase transfusion recipients' risk.
	- c. Informed consent of patients can create additional ethical and legal challenges for a facility when not obtained properly (Kajja et al. 2011)
	- d. Poor documentation and traceability contribute to wastage; may facilitate fraud, and; create barriers to appropriate epidemiological follow-up and tracing in the event of an adverse transfusion event.
	- e. Communication and understanding between suppliers and users is essential to ensure that suppliers (i.e., blood donors) contribute based on a humanitarian impulse, not one based on personal gain, and that users (patients and clinicians) recognize and consent to the risks related to transfusion.
	- a. Standards of processing and quality control are a crucial line of defense in patient safety and preventing unnecessary wastage.
	- b. Inconsistent supply logistics can interrupt quality-associated work routines, contribute to unnecessary wastage (out-dating and cold chain spoilage) and promote unequal service between regions or facilities (Kajja et al. 2010a, 2010b)

	- a. Community awareness about the need for blood and the risks of disease transmission via transfusion are essential to mobilize a safe donor pool.
	- b. Types of blood donors must be actively motivated, selected and screened for safety.

clinicians and nursing staff education should focus on consensus on items such as a uniform blood request form, terms of reference of a Hospital Transfusion Committee (HTC) and the

In many developing countries blood transfusion in the vein-to-vein concept is still in its first or second generation stage. This means that blood is most often collected and transfused in the absence of a formal policy environment and without adequate regulatory controls or standards. In such systems, blood collection and utilization are fragmented, often dependent on independent factors limited to specific hospitals, such as the availability of trained and competent staff, funds for procurement, and a population of blood donors

Following the vein-to-vein transfusion chain, major gaps exist in the following areas:

b. Commitment of health authorities is lacking or isolated in fragmented centres. c. Management capacity to sustain blood collection, storage, testing and transfusion

d. Organization and infrastructure for blood services requires national and facility-

e. Chain of command and clear job descriptions contribute to quality control, stock

f. Quality culture and professional discipline are dependent on successful pre-service

g. Poor hygiene and waste management may contribute to broader infection control

a. Clinical awareness and accountability among clinicians is essential to avoid

b. Improper indication setting and decision making may increase transfusion

c. Informed consent of patients can create additional ethical and legal challenges for a

d. Poor documentation and traceability contribute to wastage; may facilitate fraud, and; create barriers to appropriate epidemiological follow-up and tracing in the

e. Communication and understanding between suppliers and users is essential to ensure that suppliers (i.e., blood donors) contribute based on a humanitarian impulse, not one based on personal gain, and that users (patients and clinicians)

a. Standards of processing and quality control are a crucial line of defense in patient

b. Inconsistent supply logistics can interrupt quality-associated work routines, contribute to unnecessary wastage (out-dating and cold chain spoilage) and promote unequal service between regions or facilities (Kajja et al. 2010a, 2010b)

a. Legal and regulatory frameworks are often outdated or do not exist.

services differs from routine hospital or laboratory management.

outline of clinical guidelines (general and per prescribing discipline).

**1.4 Gaps in the blood supply and clinical use** 

willing to come on a voluntary and regular basis.

specific assessments and inputs.

management, and career development.

event of an adverse transfusion event.

safety and preventing unnecessary wastage.

and on-going in-service training opportunities.

problems within a facility and the local community.

facility when not obtained properly (Kajja et al. 2011)

recognize and consent to the risks related to transfusion.

unnecessary transfusions and preserve limited blood stocks.

1. Organization and infrastructure -

2. Clinical use –

recipients' risk.

3. Processing and testing –

	- a. Applied research in the field of transfusion medicine through proper monitoring and evaluation (M&E) and continued statistical process control (SPC) can contribute to improved operations as well as global understanding of risks, barriers and best practices (Smit Sibinga, 2009b).

## **2. Principles and ethical aspects of blood donation and transfusion - How do these elements promote blood safety?**

Like other medical specializations, the practice of transfusion medicine is bound by the ancient Greek Hippocratic mandate *Primum est non nocere* (first, do no harm). However, for transfusion specialists, this principle is not limited to the transfusion itself or to the recipient of the transfusion. Rather, it applies to a long chain of ethical decisions that stretches from the motivation of potential donors whose blood is used for transfusions to post-transfusion follow-up. This section will describe and explain how each link in this chain contributes to a safe blood supply and to safe transfusion practice.

## **2.1 Ethical aspects of blood donation**

#### *A brief history of blood donation and transfusion ethics*

The ethical principles that govern the modern vein-to-vein transfusion system were developed relatively recently, that is to say, largely within the second half of the 20th century, when the science of transfusion medicine became an accepted and routine part of medical practice. (American College of Physicians [ACP], 1984) Indeed, from the 17th century, when physicians began experimenting with transfusing animal blood into humans, through the late 19th and early 20th century when blood groups were discovered and coagulation factors described, the field of transfusion medicine was marked by experimentation, trial and error, and few human subjects protections. (Feldschuh, 1990; McCullough, 1998; Kendrick, n.d.) The 1948 Nuremburg Code established a global framework for medical ethics following the atrocities committed by Nazi doctors during the Second World War. In Europe and North America, laws covering ethical concepts such as the requirement that patients give informed consent prior to medical procedures began to emerge in the 1950s and 1960s. (ACP, 1984) In the mid-1930s, the founding of the International Society of Blood Transfusion (ISBT), created a global forum for the development of specific ethical guidelines for the practice of blood transfusion. Two decades later, in 1955, the International Federation of Blood Donor Organizations (FIODS) was established to focus attention on ethical guidelines for the donation of blood and plasma. Both entities, as well as authors such as Richard Titmuss (The Gift Relationship: From Human Blood to Social Policy, 1971) (Titmuss, 1971), contributed to a body of ethical work that lead to the 1975 World Health Assembly resolution containing global recommendations

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 595

2006b).2 In the developing world, national blood policies developed since 2000 increasingly reflect World Health Organization recommendations that call for blood donors to act on an altruistic impulse, not in exchange for money or other kinds of compensation, and for blood services to mobilize *voluntary, non-remunerated* donors. The WHO Aide-Mémoire on establishing national blood transfusion services considers this practice '*the foundation of a safe* 

**The ISBT Code of Ethics (2006 revision) Blood Centers: Donors and Donation**  (International Society for Blood Transfusion [ISBT], 2006a) 1. Blood donation including haematopoietic tissues for transplantation shall, in all circumstances, be voluntary and non-remunerated; no coercion should be brought to bear upon the donor. A donation is considered voluntary and non-remunerated if the person gives blood, plasma or cellular components of his/her own free will and receives no payment for it, either in the form of cash, or in kind which could be considered a substitute for money. This would include time off work other than that reasonable needed for the donation and travel. Small tokens, refreshments and reimbursements of direct travel costs are compatible with voluntary, non-remunerated donation. The donor should provide informed consent to the donation of blood or blood components and to the subsequent (legitimate) use of the blood by the

2. A profit motive should not be the basis for the establishment and running of a blood

3. The donor should be advised of the risks connected with the procedure; the donor's health and safety must be protected. Any procedures relating to the administration to a donor of any substance for increasing the concentration of specific blood components

4. Anonymity between donor and recipient must be ensured except in special situations

5. The donor should understand the risks to others of donating infected blood and his or

2 Exceptions exist to this general trend, most notably in paid plasma donations in the United States. Other developed countries provide financial or material compensation to donors, or have laws granting blood donors time off from work in exchange for donations. (European Commission, 2003, as cited in Farrugia et al., 2010; U.S. Food and Drug Administration, 2002) While the push for 100% voluntary, non-remunerated blood donations in developing countries has been shown to effectively screen out donors at high risk of infection with HIV or other transfusion-transmissible infections (Sarkodie et al., 2001), an emerging body of evidence suggests that some donors who act for reasons other than personal altruism – for instance, family members or others who donate in emergencies or to replace blood units – may present no greater risk to the blood supply than first-time volunteer donors (Allain et al., 2009; Diarra et al., 2009). Indeed, WHO and others stress the importance of motivating and retaining repeat donors '*who give blood regularly'*, as the best way to screen out potential donors with a high behavioural risk profile. Yet, despite regular reinforcement of this global guidance, many services continue to provide or experiment with some forms of remuneration for blood donors, e.g., cholesterol screening (Glynn et al., 2003), distribution of lottery ticket (Stutzer & Goette, 2010), or transportation to and from the donation clinic (ISBT, 2006). These divergent findings pose a substantial ethical challenge for blood service managers faced with a limited pool of willing blood donors and unmet demand for blood.

should be in compliance with internationally accepted standards.

and the confidentiality of donor information assured.

her ethical responsibility to the recipient.

*and adequate blood supply*.' (WHO, 2011c)

transfusion service.

service.

for ethical blood donations and transfusions (WHA 28.72). Those recommendations included the following key elements of transfusion ethics:


These recommendations seem especially prescient following the emergence of the HIV/AIDS epidemic in the 1980s, and the identification of blood transfusion as a significant route of HIV infection (US CDC, 1982). Between 1980 and 2000, the ISBT and WHO refined and adapted these original principles into a global code of ethics whose purpose was "*to define the ethical principles and rules to be observed in the field of Transfusion Medicine*." The ISBT code of ethics is discussed in detail below. Most countries worldwide have blood policies based on these fundamental principles (WHO, 2011a). Since 2000, these principles have guided numerous global resolutions related to HIV prevention and the emerging donorsupported field of 'blood safety'. (PEPFAR, 2005-2010; WHO, 2011b)

'*Safe blood starts with me*'. This commonly used blood donor motivation slogan captures one of the principal ethical issues in blood donation, namely that donors share an equal burden of responsibility with blood services to ensure the safety of the blood supply (Grainger et al., 1997). As the sole source of blood for transfusion, donors are indispensible. Yet, donors also have rights that must be respected and are, more critically, the principal vector for transfusion-transmissible infections. Ensuring the safety of donated blood, therefore, requires a balanced, combination approach, including active, education-based and noncoercive social mobilization practices by transfusion services and donation centres, and the *active and honest* participation of donors in the pre-donation screening process.

The ISBT Code of Ethics (2000, 2006 revision) contains 11 principles that expand on these concepts, especially as they relate to donor health and safety, donors' right to anonymity or confidentiality during and after donation, and donors' *ethical responsibility* not to donate if they believe their blood may be infected with HIV or another blood-borne pathogen.

The ISBT code can be collapsed into a chain with four basic links. This pre-donation chain describes the individual links that protect donors and the recipients of donated blood. As noted above, each of these links contributes to blood safety in a different way.

#### *Link 1: Mobilizing blood donors without coercion*

Identifying, mobilizing, educating, motivating and retaining an adequate pool of eligible and willing blood donors is the primary challenge faced by blood transfusion services worldwide. The problem is especially serious in the developing world, where public awareness of blood transfusion is low (Elhence, 2006), traditional or cultural beliefs about blood may serve as powerful disincentives to blood donation (Umeora et al., 2005), and high population prevalence rates for HIV and other TTIs may be a barrier to blood donor appeals to the general public (McFarland et al., 1998). In countries with serious blood shortages, the impulse to pay or coerce blood donors can be powerful (Parry, 1984). But since the 1980s, prompted largely by concerns about transfusion-transmitted hepatitis and HIV, blood services in the developed world have largely adopted policies promoting voluntary and anonymous blood donation and prohibiting or limiting the payment of donors (ISBT,

for ethical blood donations and transfusions (WHA 28.72). Those recommendations

3. Countries should develop legislation and supporting regulations to monitor and control the quality of blood collections, blood service laboratory operations (infectious disease screening, compatibility testing, production of blood products), and transfusion

These recommendations seem especially prescient following the emergence of the HIV/AIDS epidemic in the 1980s, and the identification of blood transfusion as a significant route of HIV infection (US CDC, 1982). Between 1980 and 2000, the ISBT and WHO refined and adapted these original principles into a global code of ethics whose purpose was "*to define the ethical principles and rules to be observed in the field of Transfusion Medicine*." The ISBT code of ethics is discussed in detail below. Most countries worldwide have blood policies based on these fundamental principles (WHO, 2011a). Since 2000, these principles have guided numerous global resolutions related to HIV prevention and the emerging donor-

'*Safe blood starts with me*'. This commonly used blood donor motivation slogan captures one of the principal ethical issues in blood donation, namely that donors share an equal burden of responsibility with blood services to ensure the safety of the blood supply (Grainger et al., 1997). As the sole source of blood for transfusion, donors are indispensible. Yet, donors also have rights that must be respected and are, more critically, the principal vector for transfusion-transmissible infections. Ensuring the safety of donated blood, therefore, requires a balanced, combination approach, including active, education-based and noncoercive social mobilization practices by transfusion services and donation centres, and the

The ISBT Code of Ethics (2000, 2006 revision) contains 11 principles that expand on these concepts, especially as they relate to donor health and safety, donors' right to anonymity or confidentiality during and after donation, and donors' *ethical responsibility* not to donate if

The ISBT code can be collapsed into a chain with four basic links. This pre-donation chain describes the individual links that protect donors and the recipients of donated blood. As

Identifying, mobilizing, educating, motivating and retaining an adequate pool of eligible and willing blood donors is the primary challenge faced by blood transfusion services worldwide. The problem is especially serious in the developing world, where public awareness of blood transfusion is low (Elhence, 2006), traditional or cultural beliefs about blood may serve as powerful disincentives to blood donation (Umeora et al., 2005), and high population prevalence rates for HIV and other TTIs may be a barrier to blood donor appeals to the general public (McFarland et al., 1998). In countries with serious blood shortages, the impulse to pay or coerce blood donors can be powerful (Parry, 1984). But since the 1980s, prompted largely by concerns about transfusion-transmitted hepatitis and HIV, blood services in the developed world have largely adopted policies promoting voluntary and anonymous blood donation and prohibiting or limiting the payment of donors (ISBT,

2. Countries should collect an adequate supply of blood to be self-sufficient.

supported field of 'blood safety'. (PEPFAR, 2005-2010; WHO, 2011b)

*active and honest* participation of donors in the pre-donation screening process.

noted above, each of these links contributes to blood safety in a different way.

*Link 1: Mobilizing blood donors without coercion* 

they believe their blood may be infected with HIV or another blood-borne pathogen.

included the following key elements of transfusion ethics: 1. Blood donations should be voluntary and unpaid.

practice.

2006b).2 In the developing world, national blood policies developed since 2000 increasingly reflect World Health Organization recommendations that call for blood donors to act on an altruistic impulse, not in exchange for money or other kinds of compensation, and for blood services to mobilize *voluntary, non-remunerated* donors. The WHO Aide-Mémoire on establishing national blood transfusion services considers this practice '*the foundation of a safe and adequate blood supply*.' (WHO, 2011c)

#### **The ISBT Code of Ethics (2006 revision)**

## **Blood Centers: Donors and Donation**

(International Society for Blood Transfusion [ISBT], 2006a)


<sup>2</sup> Exceptions exist to this general trend, most notably in paid plasma donations in the United States. Other developed countries provide financial or material compensation to donors, or have laws granting blood donors time off from work in exchange for donations. (European Commission, 2003, as cited in Farrugia et al., 2010; U.S. Food and Drug Administration, 2002) While the push for 100% voluntary, non-remunerated blood donations in developing countries has been shown to effectively screen out donors at high risk of infection with HIV or other transfusion-transmissible infections (Sarkodie et al., 2001), an emerging body of evidence suggests that some donors who act for reasons other than personal altruism – for instance, family members or others who donate in emergencies or to replace blood units – may present no greater risk to the blood supply than first-time volunteer donors (Allain et al., 2009; Diarra et al., 2009). Indeed, WHO and others stress the importance of motivating and retaining repeat donors '*who give blood regularly'*, as the best way to screen out potential donors with a high behavioural risk profile. Yet, despite regular reinforcement of this global guidance, many services continue to provide or experiment with some forms of remuneration for blood donors, e.g., cholesterol screening (Glynn et al., 2003), distribution of lottery ticket (Stutzer & Goette, 2010), or transportation to and from the donation clinic (ISBT, 2006). These divergent findings pose a substantial ethical challenge for blood service managers faced with a limited pool of willing blood donors and unmet demand for blood.

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 597

Pre-donation screening occurs after a donor has decided to make a donation, but before the blood is collected. The use of behavioural screening – also often referred to as self-exclusion screening – allows donors a confidential space in which to reflect on their behavioural risk profile and to weigh the consequences of a contaminated donation, especially donations that carry a high risk of infection with HIV. Behavioural questionnaires provide the blood service with information about lifestyle practices that could increase the donor's risk of carrying a TTI, and work-related information (e.g. do you operate heavy equipment?) that could create a safety hazard for the donor immediately after a donation. Questionnaires also provide information on medicines the donor is taking or other health conditions that could cause adverse reactions in the transfusion recipient or an adverse reaction for the donor (e.g.

In most countries, pre-donation screening includes a written questionnaire and a face-toface interview with a trained nurse or a donor counsellor. Questionnaires should ask donors simple, yet direct, questions about their general health and lifestyle, especially risky sexual practices. The following questions, drawn from the South African National Blood Service (SANBS) pre-donation questionnaire, are representative of the kinds of behavioural

 In the past six months have you had sexual activity with or without a condom: With more than one sex partner? With a regular sex partner excluding your spouse? With

 In the past six months have you: Had sexual activity with a prostitute or anyone else who takes money or drugs or other favours for sex? Received money, drugs or other

Male donors: In the past 6 months have you had oral or anal sex with another man with

In the past 12 months: Have you had a sexually transmitted disease (STD) e.g. syphilis,

Have you ever used needles to take drugs, steroids, or anything not prescribed by your

While the safety rationale justifies this kind of intrusive personal questioning, some automatic exclusion criteria, notably YES answers to questions about homosexual sex, have sparked ethical debates about the fairness of excluding donors on the basis of sexual

The WHO Aide Mémoire for National Blood Programmes encourages '*testing of all donated blood, including screening for transfusion-transmissible infections, blood grouping and compatibility testing.*' However, this WHO recommendation must not be viewed in isolation. Indeed, the Aide Mémoire and other WHO guidance stresses that laboratory screening must be part of an 'integrated strategy' that includes the mobilization of low behavioural risk voluntary, nonremunerated donors, a quality assurance system within the laboratory, and the reduction of unnecessary transfusions (WHO, 2011a). Research from high HIV prevalence countries in

*Link 3: Pre-donation counselling and behavioural risk screening* 

questions donors should be asked in confidence prior to a donation: Have you ever been refused as a blood donor, or told not to donate?

someone whose sexual background you do not know?

payment for sex? Been a victim of a sexual assault?

 Do you think your blood is safe for transfusion to a patient? To your knowledge does your sex partner have other sex partners?

gonorrhoea, genital ulcers, VD or 'drop'?

dizziness or fainting).

or without a condom?

doctor or a nurse?

orientation (Martucci, 2010). *Link 4: Laboratory screening* 


#### *Link 2: Education is key*

Worldwide, the public must be educated to understand that blood donation supports the collective good – that a unit donated today could save the life of a neighbour, a friend, a loved one, a stranger, or even the donor himself, tomorrow (*'today me, tomorrow you'*). But donors must also be educated about the risks associated with donation, both for the donor and for the recipient of donated blood. Education materials and programs should emphasize two main areas of risk and consent.

Risks to the donor and consent required prior to donation:


Risks to recipients of donated blood:


Social mobilization and donor education campaigns will differ depending on the target audience. In many developing countries, youth, especially high-school students, contribute a substantial proportion of the national blood supply (Jacobs et al., 1994). However, it should be noted that donation camps at schools usually are based on coercion through the school authorities. (Los et al., 2009) In addition to confirming the voluntary nature of school-based donations, blood services must also study the epidemiology of HIV and other transfusiontransmissible infections among school-aged donors to ensure that this group actually carries a lower risk of infection compared to the general population. Over the last 10 years, several successful models to promote blood donation among youth have been established worldwide. These include the Club 25 model created by the International Federation of Red Cross and Red Crescent Societies (See: http://www.ifrc.org/en/what-we-do/health/blood-services/ international-club-25-new-blood-for-the-world/) and the annual WHO-sponsored World Blood Donor Day on June 14, the birthday of Karl Landsteiner.

#### *Link 3: Pre-donation counselling and behavioural risk screening*

596 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

6. Blood donation must be based on regularly reviewed medical selection criteria and not entail discrimination of any kind, including gender, race, nationality or religion. Neither donor nor potential recipient has the right to require that any such discrimination be

7. Blood must be collected under the overall responsibility of a suitably qualified,

8. All matters related to whole blood donation and haemapheresis should be in compliance with appropriately defined and internationally accepted standards.

11. Wastage should be avoided in order to safeguard the interests of all potential recipients

Worldwide, the public must be educated to understand that blood donation supports the collective good – that a unit donated today could save the life of a neighbour, a friend, a loved one, a stranger, or even the donor himself, tomorrow (*'today me, tomorrow you'*). But donors must also be educated about the risks associated with donation, both for the donor and for the recipient of donated blood. Education materials and programs should emphasize two main

The potential for syncope (fainting), hyperventilation, bruising or damage to veins

 Since most countries test or strive to test 100% of donated blood for pathogens such as HIV, hepatitis B and C, and syphilis, donors must be informed of these tests and given an opportunity to receive their results with appropriate counselling. In South Africa, the South African National Blood Service (SANBS) includes a clear statement about testing and the potential emotional impact on donors: '*Every blood donation is tested for HIV/AIDS. Persons testing positive must be aware that this may have a psychological impact and profoundly* 

Other adverse transfusion events, e.g. circulatory overload, TRALI, mis-matched blood

Social mobilization and donor education campaigns will differ depending on the target audience. In many developing countries, youth, especially high-school students, contribute a substantial proportion of the national blood supply (Jacobs et al., 1994). However, it should be noted that donation camps at schools usually are based on coercion through the school authorities. (Los et al., 2009) In addition to confirming the voluntary nature of school-based donations, blood services must also study the epidemiology of HIV and other transfusiontransmissible infections among school-aged donors to ensure that this group actually carries a lower risk of infection compared to the general population. Over the last 10 years, several successful models to promote blood donation among youth have been established worldwide. These include the Club 25 model created by the International Federation of Red Cross and Red Crescent Societies (See: http://www.ifrc.org/en/what-we-do/health/blood-services/ international-club-25-new-blood-for-the-world/) and the annual WHO-sponsored World

*influence their lifestyle*.' (South African National Blood Service [SANBS], 2006)

9. Donors and recipients should be informed if they have been harmed. 10. Blood is a public resource and access should not be restricted.

Risks to the donor and consent required prior to donation:

Transmission of infectious pathogens, including HIV.

Blood Donor Day on June 14, the birthday of Karl Landsteiner.

during the veinipuncture process.

Risks to recipients of donated blood:

group, allogenic reactions.

practiced.

and the donor. *Link 2: Education is key* 

areas of risk and consent.

registered medical practitioner.

Pre-donation screening occurs after a donor has decided to make a donation, but before the blood is collected. The use of behavioural screening – also often referred to as self-exclusion screening – allows donors a confidential space in which to reflect on their behavioural risk profile and to weigh the consequences of a contaminated donation, especially donations that carry a high risk of infection with HIV. Behavioural questionnaires provide the blood service with information about lifestyle practices that could increase the donor's risk of carrying a TTI, and work-related information (e.g. do you operate heavy equipment?) that could create a safety hazard for the donor immediately after a donation. Questionnaires also provide information on medicines the donor is taking or other health conditions that could cause adverse reactions in the transfusion recipient or an adverse reaction for the donor (e.g. dizziness or fainting).

In most countries, pre-donation screening includes a written questionnaire and a face-toface interview with a trained nurse or a donor counsellor. Questionnaires should ask donors simple, yet direct, questions about their general health and lifestyle, especially risky sexual practices. The following questions, drawn from the South African National Blood Service (SANBS) pre-donation questionnaire, are representative of the kinds of behavioural questions donors should be asked in confidence prior to a donation:


While the safety rationale justifies this kind of intrusive personal questioning, some automatic exclusion criteria, notably YES answers to questions about homosexual sex, have sparked ethical debates about the fairness of excluding donors on the basis of sexual orientation (Martucci, 2010).

#### *Link 4: Laboratory screening*

The WHO Aide Mémoire for National Blood Programmes encourages '*testing of all donated blood, including screening for transfusion-transmissible infections, blood grouping and compatibility testing.*' However, this WHO recommendation must not be viewed in isolation. Indeed, the Aide Mémoire and other WHO guidance stresses that laboratory screening must be part of an 'integrated strategy' that includes the mobilization of low behavioural risk voluntary, nonremunerated donors, a quality assurance system within the laboratory, and the reduction of unnecessary transfusions (WHO, 2011a). Research from high HIV prevalence countries in

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 599

institutional ethics committees within hospitals and transfusion centres is recommended to educate staff about ethical issues; support ethical decision-making; develop ethics codes and policies, and; counsel staff and conduct ethical reviews (Perlin, 2001; Kajja et al. 2011). Ethical considerations continue even after a successful transfusion, most notably in cases where recipients become infected with a transfusion-transmissible infection, or are deemed at risk of infection because new information about the donor of the transfused unit comes to

The ISBT code of ethics for hospitals and patients contains seven key principles related to

**ISBT Code of Ethics for Hospitals and Patients**  (International Society for Blood Transfusion [ISBT], 2006a) 1. Patients should be informed of the known risks and benefits of blood transfusion and/or alternative therapies and have the right to accept or refuse the procedure. Any

2. In the event that the patient is unable to give prior informed consent, the basis for

3. Transfusion therapy must be given under the overall responsibility of a registered

6. As far as possible the patient should receive only those particular components (cells, plasma, or plasma derivatives) that are clinically appropriate and afford optimal

7. Blood transfusion practices established by national or international health bodies and other agencies competent and authorised to do so should be in compliance with this

It should be noted that these seven principles are predicated on an assumption that the ethical principles related to blood donors and the screening of blood for transfusiontransmissible infections have been respected. As with the ethical framework for blood donations, these principles can contribute to reduced risks of transfusion-transmissible

**3. Assessment techniques and methodologies: Identifying and addressing gaps and needs in blood safety programs and blood transfusion services** 

Understanding the roles and responsibilities associated with the various departments and job descriptions within a blood transfusion service is a complex task, involving layers of policy, science, human behaviour, risk, ethics, finances, and, ultimately, medical practice. Further identifying gaps, risks and needs within each (or all) of these layers, is an additional step that blood transfusion services must take in order to address weaknesses, strengthen services, recruit and/or retain staff, improve quality and evaluate the impact of services and products provided to transfusion centres or hospitals and patients. The ultimate goal of these objectives is to improve the safety of blood and blood products used for transfusion. The U.S. Food and Drug Administration cites the '*safety, purity, and potenc*y' of blood products as the main rationale for conducting blood service quality audits and assessments

infections by reducing or minimizing the number of inappropriate transfusions.

treatment by transfusion must be in the best interests of the patient.

4. Genuine clinical need should be the only basis for transfusion therapy. 5. There should be no financial incentive to prescribe a blood transfusion.

light (e.g. HIV sero-conversion in the donor).

the transfusion of blood and blood products.

medical practitioner.

safety.

code of ethics.

(Food and Drug Administration, 2010).

valid advance directive should be respected.

Africa has shown this integrated approach can have a positive impact on reducing the number of donations with incident or 'window period' HIV infections that the antigen/antibody assays used in most developing countries might not detect (Basavaraju, 2010).

The 2010 WHO Guidelines on Screening Donated Blood for Transfusion-Transmissible Infections recognize that operational limitations ('*lack of coordination ... inadequate infrastructure ... shortages of trained staff ... poor quality systems*') may prohibit some blood services from screening all donated units, or create barriers to the implementation of a coordinated, integrated laboratory screening program. The guidelines identify the following negative outcomes that may occur when laboratory screening systems do not exist or fail:


#### **2.2 Ethical aspects of blood transfusion**

As noted in section 1.2, Article 25 of the 1948 UN Declaration of Universal Human Rights (DUHR) makes reference to individuals' '*right to security in the event of ... sickness, disability ... or other lack of livelihood in circumstances beyond his control*.' The principle of obtaining patient consent prior to performing a blood transfusion or other medical procedure is derived from the broad concepts of *health* and *security ... in the event of sickness* described in the DUHR. Subsequent codes of medical ethics, including the Council of Europe's 2007 revision of its Guide to the Preparation, Use and Quality Assurance of Blood Components; these codes expanded on this basic definition of 'security' to cover all of the decisions preceding, during, and following a transfusion: From confirming the appropriate diagnosis and prescription order, to correct patient identification and adverse event monitoring during the transfusion itself. (Council of Europe, 2007) Occasionally, prescribers of blood will encounter patients who refuse a recommended transfusion on religious grounds. Clinicians may also face difficult decisions with patients who are minors and patients for whom a transfusion may extend life but not necessarily improve the quality of the patient's life; the creation of

Africa has shown this integrated approach can have a positive impact on reducing the number of donations with incident or 'window period' HIV infections that the antigen/antibody

The 2010 WHO Guidelines on Screening Donated Blood for Transfusion-Transmissible Infections recognize that operational limitations ('*lack of coordination ... inadequate infrastructure ... shortages of trained staff ... poor quality systems*') may prohibit some blood services from screening all donated units, or create barriers to the implementation of a coordinated, integrated laboratory screening program. The guidelines identify the following negative outcomes that may occur when laboratory screening systems do not exist or fail: Inefficient screening systems and wastage of resources owing to differing levels of

Unreliable, inconsistent supplies and transport conditions of test kits and reagents due

 Inadequate procedures for identification, leading to the misidentification of patient or donor blood samples, donations or processed units of blood and blood components

As noted in section 1.2, Article 25 of the 1948 UN Declaration of Universal Human Rights (DUHR) makes reference to individuals' '*right to security in the event of ... sickness, disability ... or other lack of livelihood in circumstances beyond his control*.' The principle of obtaining patient consent prior to performing a blood transfusion or other medical procedure is derived from the broad concepts of *health* and *security ... in the event of sickness* described in the DUHR. Subsequent codes of medical ethics, including the Council of Europe's 2007 revision of its Guide to the Preparation, Use and Quality Assurance of Blood Components; these codes expanded on this basic definition of 'security' to cover all of the decisions preceding, during, and following a transfusion: From confirming the appropriate diagnosis and prescription order, to correct patient identification and adverse event monitoring during the transfusion itself. (Council of Europe, 2007) Occasionally, prescribers of blood will encounter patients who refuse a recommended transfusion on religious grounds. Clinicians may also face difficult decisions with patients who are minors and patients for whom a transfusion may extend life but not necessarily improve the quality of the patient's life; the creation of

assays used in most developing countries might not detect (Basavaraju, 2010).

Lack of quality assurance and quality management systems

 Double standards due to a mix of technologies and methodologies Incorrect storage or inappropriate use of test kits and reagents

Inaccuracies in the recording or transcription of test results.

Unnecessary hold time due to poor access to confirmatory tests

 Blood shortages and use of unscreened blood in urgent situations Incorrect donor notification and stigmatization. (WHO, 2009)

operation at multiple sites

to poor logistics Equipment failure

 Technical failure in testing Misinterpretation of test results

 Higher error rates in test results Increased risk of failure to detect TTIs

Unnecessary discard of non-reactive blood

**2.2 Ethical aspects of blood transfusion** 

Use of poor quality test kits and reagents

Variations in laboratory procedures and practices

institutional ethics committees within hospitals and transfusion centres is recommended to educate staff about ethical issues; support ethical decision-making; develop ethics codes and policies, and; counsel staff and conduct ethical reviews (Perlin, 2001; Kajja et al. 2011).

Ethical considerations continue even after a successful transfusion, most notably in cases where recipients become infected with a transfusion-transmissible infection, or are deemed at risk of infection because new information about the donor of the transfused unit comes to light (e.g. HIV sero-conversion in the donor).

The ISBT code of ethics for hospitals and patients contains seven key principles related to the transfusion of blood and blood products.

#### **ISBT Code of Ethics for Hospitals and Patients**

### (International Society for Blood Transfusion [ISBT], 2006a)


It should be noted that these seven principles are predicated on an assumption that the ethical principles related to blood donors and the screening of blood for transfusiontransmissible infections have been respected. As with the ethical framework for blood donations, these principles can contribute to reduced risks of transfusion-transmissible infections by reducing or minimizing the number of inappropriate transfusions.

## **3. Assessment techniques and methodologies: Identifying and addressing gaps and needs in blood safety programs and blood transfusion services**

Understanding the roles and responsibilities associated with the various departments and job descriptions within a blood transfusion service is a complex task, involving layers of policy, science, human behaviour, risk, ethics, finances, and, ultimately, medical practice. Further identifying gaps, risks and needs within each (or all) of these layers, is an additional step that blood transfusion services must take in order to address weaknesses, strengthen services, recruit and/or retain staff, improve quality and evaluate the impact of services and products provided to transfusion centres or hospitals and patients. The ultimate goal of these objectives is to improve the safety of blood and blood products used for transfusion. The U.S. Food and Drug Administration cites the '*safety, purity, and potenc*y' of blood products as the main rationale for conducting blood service quality audits and assessments (Food and Drug Administration, 2010).

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 601

The GDBS questionnaire contains 253 process, outcome and output indicators clustered

Since its launch, WHO has received and compiled three reports (1998-1999; 2001-2002; 2004-

The identification of blood transfusion as a significant vector for HIV transmission in Africa in the 1990s (Colbunders, 1991) led to increasing attention and financing for blood safety programmes via global health programmes focused on HIV prevention.3 As noted above, the epidemiology of transfusion-transmitted HIV also drove the passage of World Health Assembly (WHA) resolutions on the blood safety, and the development, over the last decade, of WHO's catalogue of blood safety guidelines and recommendations. In many countries this increased attention to blood safety as part of a comprehensive HIV prevention strategy has strengthened the whole national blood service – from vein-to-vein – in addition to reducing the transmission of HIV through transfusion. Still, despite progress, transfusion systems remain weak in many countries, especially those in the lower income strata. The most recent GDBS report (2004-2005) highlighted a number of these weaknesses, including: Less than 50% of countries report collecting blood exclusively from voluntary, non-

40% of the 172 countries surveyed, reported having national haemovigilance systems.

80% of the world's population live in countries that collect only 45% of the global blood

Experience and evidence from the field over the last decade has shown that blood services in countries with high prevalence HIV have been able to systematically reduce the prevalence of HIV in donated blood units by identifying and addressing gaps and weaknesses in their operations and structures. In 2008, the U.S. Centers for Disease Control and Prevention (CDC) presented data from the PEPFAR blood safety program that showed substantial gaps in the legislative and policy frameworks in 14 countries in sub-Saharan

Using indicators adapted from the WHO GDBS, CDC asked countries if a national blood policy was in place or if the national blood transfusion service (NBTS) was supported by a 'legislative framework' (e.g. laws and regulations). In 2003, only six of the 14 countries

3 Half of the 101 countries that responded to a GDBS question about external support for their blood services indicated that they were receiving some kind of international assistance in 2004-2005.

53% reported having national regulatory bodies for blood transfusion.

around eight operational and technical areas (WHO, 2011d) :

6. Blood Component Preparation, Storage and Transportation

2005); data collection for a fourth report was begun in 2008.

**3.1.1 Mind the gaps – Recent GDBS findings** 

7. Hospital Transfusion Process and Clinical Use of Blood & Blood Components

4. Screening for Transfusion-Transmissible Infections 5. Blood Group Serology Testing of Blood Donations

1. Administrative Information 2. Organization and Management 3. Blood Donors and Blood Collection

8. Fractionated Plasma Products

remunerated blood donors.

**3.1.2 Addressing gaps – Achieving change** 

Africa and the Caribbean (US CDC, 2008).

supply.

To accomplish assessment and evaluation objectives, blood services may use a number of assessment and evaluation tools, many of which are drawn from business practices (e.g. Six Sigma, Total Quality Management, SWOT analyses) or the field of risk analysis. International organizations (WHO, ISBT, the IFRCRCS), national blood transfusion services, regulatory agencies, and Red Cross/Red Crescent Societies, as well as multilateral and bilateral donors (e.g. the European Union, the U.S. President's Emergency Plan for AIDS Relief, the Japan International Cooperation Agency) have also developed assessment tools and indicators to assist with the development, implementation and monitoring of blood safety projects and programs.

The field of evaluation has evolved and expanded substantially in the last 20 years. A recent PubMed literature search found nearly 250,000 papers dedicated to public health evaluations or assessments within the last decade. Beyond the scientific literature, thousands of programme reports, guides and other documents in the 'gray literature' are published each year. This massive diversity of material includes many different methodologies, some of which have been used by blood transfusion services to monitor, evaluate, assess or audit (Chevrolle et al., 2000) human resource needs (Ferrera et al., 2001), blood banking, stock management, laboratory and transfusion practices (Fretz, 2003; Dosunmu & Dada, 2005), training curricula (Wehrli, 2011), epidemiological surveillance (Roussel et al; Linden & Bianco, 2001 ), and quality systems (Berte, 1997; Mintz, 1995; Smit Sibinga, 2001).

This chapter will review the basic elements these tools are designed off to assess, monitor and evaluate. Examples derived from specific tools and indicators, such as the WHO Global Database on Blood Safety, will be presented to highlight the utility of assessment and evaluation in the development of strong blood transfusion services, especially in areas with high burdens of HIV and other transfusion-transmissible infections.

As mentioned above in section 1.2, blood services worldwide are built around a framework with seven basic components, each of which can be evaluated through techniques such as SWOT analyses (Strengths-Weaknesses-Opportunities-Threats), and addressed with the principles of the Deming cycle of improvement (Plan-Do-Check-Act):


Within each of these elements, WHO and other blood safety technical assistance programs have developed assessment indicators to help blood services identify needs, gaps and risks.

#### **3.1 The WHO global database on blood safety**

A good place to begin to make sense of the diversity of available materials is the WHO Global Database on Blood Safety (GDBS). The GDBS was developed by WHO with expert input through the Global Collaboration on Blood Safety (GCBS) and launched in 1998. WHO member countries are asked to submit data to the GDBS every two years. The indicators collected by the GDBS are periodically revised and increasingly reflect collaborative work between WHO and development partners supporting blood safety programmes in countries.

The GDBS questionnaire contains 253 process, outcome and output indicators clustered around eight operational and technical areas (WHO, 2011d) :

1. Administrative Information

600 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

To accomplish assessment and evaluation objectives, blood services may use a number of assessment and evaluation tools, many of which are drawn from business practices (e.g. Six Sigma, Total Quality Management, SWOT analyses) or the field of risk analysis. International organizations (WHO, ISBT, the IFRCRCS), national blood transfusion services, regulatory agencies, and Red Cross/Red Crescent Societies, as well as multilateral and bilateral donors (e.g. the European Union, the U.S. President's Emergency Plan for AIDS Relief, the Japan International Cooperation Agency) have also developed assessment tools and indicators to assist with the development, implementation and monitoring of blood

The field of evaluation has evolved and expanded substantially in the last 20 years. A recent PubMed literature search found nearly 250,000 papers dedicated to public health evaluations or assessments within the last decade. Beyond the scientific literature, thousands of programme reports, guides and other documents in the 'gray literature' are published each year. This massive diversity of material includes many different methodologies, some of which have been used by blood transfusion services to monitor, evaluate, assess or audit (Chevrolle et al., 2000) human resource needs (Ferrera et al., 2001), blood banking, stock management, laboratory and transfusion practices (Fretz, 2003; Dosunmu & Dada, 2005), training curricula (Wehrli, 2011), epidemiological surveillance (Roussel et al; Linden & Bianco, 2001 ), and quality systems (Berte, 1997; Mintz, 1995; Smit

This chapter will review the basic elements these tools are designed off to assess, monitor and evaluate. Examples derived from specific tools and indicators, such as the WHO Global Database on Blood Safety, will be presented to highlight the utility of assessment and evaluation in the development of strong blood transfusion services, especially in areas with

As mentioned above in section 1.2, blood services worldwide are built around a framework with seven basic components, each of which can be evaluated through techniques such as SWOT analyses (Strengths-Weaknesses-Opportunities-Threats), and addressed with the

Within each of these elements, WHO and other blood safety technical assistance programs have developed assessment indicators to help blood services identify needs, gaps and risks.

A good place to begin to make sense of the diversity of available materials is the WHO Global Database on Blood Safety (GDBS). The GDBS was developed by WHO with expert input through the Global Collaboration on Blood Safety (GCBS) and launched in 1998. WHO member countries are asked to submit data to the GDBS every two years. The indicators collected by the GDBS are periodically revised and increasingly reflect collaborative work between WHO and development partners supporting blood safety

high burdens of HIV and other transfusion-transmissible infections.

principles of the Deming cycle of improvement (Plan-Do-Check-Act):

safety projects and programs.

1. Structure and organization 2. Clinical use of blood 3. Processing and testing 4. Blood collections 5. Education and Training 6. Monitoring and Evaluation

**3.1 The WHO global database on blood safety** 

7. Sustainability

programmes in countries.

Sibinga, 2001).


Since its launch, WHO has received and compiled three reports (1998-1999; 2001-2002; 2004- 2005); data collection for a fourth report was begun in 2008.

### **3.1.1 Mind the gaps – Recent GDBS findings**

The identification of blood transfusion as a significant vector for HIV transmission in Africa in the 1990s (Colbunders, 1991) led to increasing attention and financing for blood safety programmes via global health programmes focused on HIV prevention.3 As noted above, the epidemiology of transfusion-transmitted HIV also drove the passage of World Health Assembly (WHA) resolutions on the blood safety, and the development, over the last decade, of WHO's catalogue of blood safety guidelines and recommendations. In many countries this increased attention to blood safety as part of a comprehensive HIV prevention strategy has strengthened the whole national blood service – from vein-to-vein – in addition to reducing the transmission of HIV through transfusion. Still, despite progress, transfusion systems remain weak in many countries, especially those in the lower income strata. The most recent GDBS report (2004-2005) highlighted a number of these weaknesses, including:


#### **3.1.2 Addressing gaps – Achieving change**

Experience and evidence from the field over the last decade has shown that blood services in countries with high prevalence HIV have been able to systematically reduce the prevalence of HIV in donated blood units by identifying and addressing gaps and weaknesses in their operations and structures. In 2008, the U.S. Centers for Disease Control and Prevention (CDC) presented data from the PEPFAR blood safety program that showed substantial gaps in the legislative and policy frameworks in 14 countries in sub-Saharan Africa and the Caribbean (US CDC, 2008).

Using indicators adapted from the WHO GDBS, CDC asked countries if a national blood policy was in place or if the national blood transfusion service (NBTS) was supported by a 'legislative framework' (e.g. laws and regulations). In 2003, only six of the 14 countries

 3 Half of the 101 countries that responded to a GDBS question about external support for their blood services indicated that they were receiving some kind of international assistance in 2004-2005.

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 603

During the same four year period, all 14 countries reported lower or stable rates of HIV

Although a strict causal association cannot be derived (Noumsi et al., 2008) from these data, this report suggests a positive relationship between progress toward addressing policy and other operational gaps and improvements in the safety of donated blood for supportive

In the majority of economically restricted countries the transfusion chain from vein-to-vein is determined by what happens to be available. The supply drives the system. When a clinical need occurs, either the scarce hospital or blood bank stock is being used and exhausted or family is urged to search for blood donors, whether family related, friends or what the market offers. Often that results in under-treatment of patients, unjustified use or no treatment at all. The data available for mother and infant death due to shortages illustrate

Most of these donors are seriously coerced, time pressure stimulates poor handling and the serious and realistic effect of transmission of infections such as HIV, HBV and HCV. Besides, it has been observed and documented that hidden stocks are being kept or just grow due to shortage in organization and poor logistics of the supply (Kajja I et al., 2010a). The chain quite often is interrupted at the clinical interface side, with a serious paucity of communication between producer/supplier and prescriber/consumer of blood and blood components. The root cause of this paucity is in limited and focused knowledge and related practices on either side of the chain. When regular need assessments are being done a better idea would grow about the epidemiology of blood transfusion in the hospitals, which then could lead to balanced and evidence based logistics of supply of human blood in

As a consequence the blood supply and clinical use should be firmly embedded in the health care system with major involvement of the community to allow such anticipatory strategies. Community involvement means community education to understand why a continuous and not an incidental and *ad hoc* support is needed (Los & Smit Sibinga, 2001). It is the principle of '*today me, tomorrow you*' as a social act of solidarity. When the blood supply becomes a community issue, awareness and responsibility to support with healthy blood on a sharing principle, rather than being dragged into blood donation because of urgent needs of family and relatives who might die if you would not donate immediately (Los & Smit Sibinga, 2001). Questionnaires and testing, whether rapid or ELISA then move towards the edge of becoming a farce, seriously jeopardizing the safety of blood transfusion. To find out what the knowledge, attitudes and practices of a community are in relation to blood donation and transfusion, a KAP (knowledge, attitudes, practices) study could certainly be beneficial. KAP studies can be done broad, focused on the community by and large or target specific groups, such as presumed low risk categories, known or registered blood donors, and non-donors. Each such KAP study will need a careful analysis to unravel the underlying anthropological and psychological information needed to understand how the mind is set of those who participated and how that relates to community feelings and behaviour as a whole. KAP studies should not be incidental, but be part of a mechanism to

**4. Evidence based strategies to move from a supply-driven to a demand-**

prevalence in donated units (Table 2).

**driven blood transfusion system** 

this situation (WHO et al. 2010).

anticipation of the needs.

**4.1 Community specifics for tailor made solutions** 

haemotherapy.

reported having a national blood policy; the same year only four of the 14 countries reported having a 'legislative framework' to support NBTS activities. By 2007, all 14 countries had national blood policies in place or in development, and 10 of 14 countries had established or were developing 'legislative frameworks' based on WHO blood safety guidelines. (Table 1)


Table 1. Standards of national blood transfusion policies and legislative frameworks, number of whole blood units collected, and number collected per 1,000 population – U.S. President's Emergency Plan for AIDS Relief, 14 countries, 2003-2007


Table 2. Estimated percentage of persons aged 15-49 years with human immunodeficiency virus (HIV) infection, percentage of blood collections reactive for HIV, and percentage of collections from voluntary, non-remunerated donors – U.S. President's Emergency Plan for AIDS Relief, 14 countries, 2003-2007

reported having a national blood policy; the same year only four of the 14 countries reported having a 'legislative framework' to support NBTS activities. By 2007, all 14 countries had national blood policies in place or in development, and 10 of 14 countries had established or were developing 'legislative frameworks' based on WHO blood safety

Table 1. Standards of national blood transfusion policies and legislative frameworks, number of whole blood units collected, and number collected per 1,000 population – U.S.

Table 2. Estimated percentage of persons aged 15-49 years with human immunodeficiency virus (HIV) infection, percentage of blood collections reactive for HIV, and percentage of collections from voluntary, non-remunerated donors – U.S. President's Emergency Plan for

AIDS Relief, 14 countries, 2003-2007

President's Emergency Plan for AIDS Relief, 14 countries, 2003-2007

guidelines. (Table 1)

During the same four year period, all 14 countries reported lower or stable rates of HIV prevalence in donated units (Table 2).

Although a strict causal association cannot be derived (Noumsi et al., 2008) from these data, this report suggests a positive relationship between progress toward addressing policy and other operational gaps and improvements in the safety of donated blood for supportive haemotherapy.

### **4. Evidence based strategies to move from a supply-driven to a demanddriven blood transfusion system**

#### **4.1 Community specifics for tailor made solutions**

In the majority of economically restricted countries the transfusion chain from vein-to-vein is determined by what happens to be available. The supply drives the system. When a clinical need occurs, either the scarce hospital or blood bank stock is being used and exhausted or family is urged to search for blood donors, whether family related, friends or what the market offers. Often that results in under-treatment of patients, unjustified use or no treatment at all. The data available for mother and infant death due to shortages illustrate this situation (WHO et al. 2010).

Most of these donors are seriously coerced, time pressure stimulates poor handling and the serious and realistic effect of transmission of infections such as HIV, HBV and HCV. Besides, it has been observed and documented that hidden stocks are being kept or just grow due to shortage in organization and poor logistics of the supply (Kajja I et al., 2010a). The chain quite often is interrupted at the clinical interface side, with a serious paucity of communication between producer/supplier and prescriber/consumer of blood and blood components. The root cause of this paucity is in limited and focused knowledge and related practices on either side of the chain. When regular need assessments are being done a better idea would grow about the epidemiology of blood transfusion in the hospitals, which then could lead to balanced and evidence based logistics of supply of human blood in anticipation of the needs.

As a consequence the blood supply and clinical use should be firmly embedded in the health care system with major involvement of the community to allow such anticipatory strategies. Community involvement means community education to understand why a continuous and not an incidental and *ad hoc* support is needed (Los & Smit Sibinga, 2001). It is the principle of '*today me, tomorrow you*' as a social act of solidarity. When the blood supply becomes a community issue, awareness and responsibility to support with healthy blood on a sharing principle, rather than being dragged into blood donation because of urgent needs of family and relatives who might die if you would not donate immediately (Los & Smit Sibinga, 2001). Questionnaires and testing, whether rapid or ELISA then move towards the edge of becoming a farce, seriously jeopardizing the safety of blood transfusion. To find out what the knowledge, attitudes and practices of a community are in relation to blood donation and transfusion, a KAP (knowledge, attitudes, practices) study could certainly be beneficial. KAP studies can be done broad, focused on the community by and large or target specific groups, such as presumed low risk categories, known or registered blood donors, and non-donors. Each such KAP study will need a careful analysis to unravel the underlying anthropological and psychological information needed to understand how the mind is set of those who participated and how that relates to community feelings and behaviour as a whole. KAP studies should not be incidental, but be part of a mechanism to

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 605

raised relates to the risks for contracting infectious diseases such as HIV/AIDS, hepatitis, malaria and tuberculosis. Additionally these infectious diseases may be spread through a variety of contacts, e.g. the blood supply. Education provides knowledge through information, which is stored in the brains. A major question and related process is how to convert the acquired knowledge into appropriate action. The process depends highly on how the information is presented and how the knowledge is perceived. The perception

Education and vocational institutes do play a paramount role in the presentation of information and the way the acquired knowledge is perceived individually and collectively, leading to individual behaviour and collective or group behaviour – the moral and ethics of a community. To bridge the existing knowledge gap, analysis is needed of both the way, the environment and the contents of the information offered, and the intellectual mechanisms of the perception of the knowledge necessary for the triggering of appropriate action (Los &

Potential teachers and parents therefore need to be educated on how to pack and present the information and how to monitor and evaluate the perception of the knowledge. This continuum should have a high rank on the priority list of any nation, filling in one of the key universal human rights – the right of education. Competence is the intimate twinning through matching of acquiring knowledge and developing skills to act appropriately, whatever is concerned. When the community or public understands the need for a healthy life style, for sharing regularly a bit of healthy blood with those in need, by donating blood on an altruistic and regular basis, when the professionals in the health care understand the need to appropriately deal with the collection, processing, testing, storage and distribution of human blood as a transplant and at the clinical side with the in-hospital processes of prescription and ordering, selection and compatibility testing, and the ultimate transfusion and its monitoring and evaluation, the gap will be substantially narrowed and shallowed. However, without a

proper understanding of the policy makers, the gap will not be bridged completely.

Evidence-based strategies for blood safety and availability have been successfully implemented in most developed countries and some transitional and developing nations. However, despite the proven effectiveness of these strategies, many countries are making slow progress towards their implementation. There is ample evidence that a nationally supported blood supply and clinical use of human blood, well regulated and professionally implemented on an adequate economy of scale, leads to a significant reduction in risk of

Such nationally supported approach covers the entire nation and is based on education of all parties involved, understanding the importance and relevance of the necessary and ongoing

Such systems recognize and address the potential weaknesses and gaps as listed above in the 6 major areas of transfusion medicine - 1. Organization and structure; 2. Clinical use (clinical interface); 3. Processing and testing; 4. Collection of source material (community

Such systems are based on the needs of the community to be met by the supply through anticipation, proper planning and adequate logistics (Smit Sibinga, 2000). The demand then

Over the past few decades, since the outbreak of the HIV/AIDS epidemic, much work has been done to provide a better understanding of the routing of transmission of the virus. There

interface); 5. Education; 6. Monitoring and evaluation (research and development).

ultimately triggers the action needed (WI Thomas & Thomas DS, 1928).

Smit Sibinga, 2009; Kajja, 2010).

transmission of infectious diseases.

provision of information and related actions.

will drive the supply and no longer the other way around.

**5. Directions for improvement – Values and realities** 

follow up and study the changes in mind set and behaviour of the community. Only then will it provide a useful tool for benchmarking progress in attitude and related practices (Los & Smit Sibinga, 2009; Los et al. 2009).

#### **4.2 Prerequisites – Leadership, awareness, willingness, environment/climate, access**

Unsafe blood transfusions have contributed to the enormous burden of HIV infections in various developing parts of the world, in particular in sub-Saharan Africa and the Central Asian region (World Bank et al., 2008), and still continue to add to this burden. The risk of HIV, HCV and HBV infection through unsafe blood and blood products is exceptionally high (95–100%) compared to other common routes of exposure: For example, 11–32% for mother-to-child transmission of HIV and HBV and 0.1%–10% for sexual contact. Sub-Saharan Africa has a particularly high level of transfusion-associated HIV compared with other developing regions due to a higher risk of infected blood being transfused. This results from a combination of factors: High rates of transfusion in some groups of patients (particularly women during labour, and children in the malaria Season), a higher incidence and prevalence of HIV infection, dependence on unsafe blood donors and inadequate or even absence of testing of blood for HIV in some countries (WHO 2008a, 2010a, 2010b). However, also the poor education level and poverty among larger groups in the community play an important role. Women and children account for a disproportionate number of HIV, HBV and HCV infections through unsafe blood because they are the main groups of patients receiving blood transfusion. In developing countries around 50% of the blood is transfused to women and 25% to children, largely under the age of 5 years. Up to 20% of maternal mortality and 15% of child deaths have been attributed to severe anaemia due to malaria. Timely access to safe blood transfusion is a life-saving measure in many of these clinical conditions and can also prevent serious illness in these patients.

Besides the need for identified, competent and designated leadership (Smit Sibinga 2009a, 2009b), there is the holistic need for awareness – politicians and policy makers, community in all its diversity, health professionals and related stakeholders such as hospital managers, religious leaders and educators. The government is final responsible for the well being of the community and should create the environment and climate for education and professional infrastructure to allow awareness and willingness to grow and sustain. The organization of the health care should guarantee access and affordability to all in need, and the blood supply and clinical prescribers should use and optimize the professional and social climate and environment to allow proper, safe and justified practices of procurement and clinical use of blood and blood components to be developed and implemented.

It has been demonstrated that a well organized and structured nationally supported blood supply and transfusion system yields a better and safer transfusion practice with a minimum residual risk for transmission of blood born infections, in particular HIV/AIDS, as compared to a non-cohesive and fragmented blood supply. Any structure should find its anchor in an appropriate legal framework – documented principles of blood donation and transfusion, adequate regulations and an operational system for audit and inspection of compliance with the principles and related operational standards and technical requirements (Hollan et al., 1990)

#### **4.3 Role of education and vocational institutes**

As mentioned in section 2.1 the key factor is competent human capacity at all levels, which means education of the community to create public awareness, the professionals to create professional awareness and politicians to create political awareness. The awareness to be

follow up and study the changes in mind set and behaviour of the community. Only then will it provide a useful tool for benchmarking progress in attitude and related practices (Los

**4.2 Prerequisites – Leadership, awareness, willingness, environment/climate, access**  Unsafe blood transfusions have contributed to the enormous burden of HIV infections in various developing parts of the world, in particular in sub-Saharan Africa and the Central Asian region (World Bank et al., 2008), and still continue to add to this burden. The risk of HIV, HCV and HBV infection through unsafe blood and blood products is exceptionally high (95–100%) compared to other common routes of exposure: For example, 11–32% for mother-to-child transmission of HIV and HBV and 0.1%–10% for sexual contact. Sub-Saharan Africa has a particularly high level of transfusion-associated HIV compared with other developing regions due to a higher risk of infected blood being transfused. This results from a combination of factors: High rates of transfusion in some groups of patients (particularly women during labour, and children in the malaria Season), a higher incidence and prevalence of HIV infection, dependence on unsafe blood donors and inadequate or even absence of testing of blood for HIV in some countries (WHO 2008a, 2010a, 2010b). However, also the poor education level and poverty among larger groups in the community play an important role. Women and children account for a disproportionate number of HIV, HBV and HCV infections through unsafe blood because they are the main groups of patients receiving blood transfusion. In developing countries around 50% of the blood is transfused to women and 25% to children, largely under the age of 5 years. Up to 20% of maternal mortality and 15% of child deaths have been attributed to severe anaemia due to malaria. Timely access to safe blood transfusion is a life-saving measure in many of these

clinical conditions and can also prevent serious illness in these patients.

Besides the need for identified, competent and designated leadership (Smit Sibinga 2009a, 2009b), there is the holistic need for awareness – politicians and policy makers, community in all its diversity, health professionals and related stakeholders such as hospital managers, religious leaders and educators. The government is final responsible for the well being of the community and should create the environment and climate for education and professional infrastructure to allow awareness and willingness to grow and sustain. The organization of the health care should guarantee access and affordability to all in need, and the blood supply and clinical prescribers should use and optimize the professional and social climate and environment to allow proper, safe and justified practices of procurement

and clinical use of blood and blood components to be developed and implemented.

It has been demonstrated that a well organized and structured nationally supported blood supply and transfusion system yields a better and safer transfusion practice with a minimum residual risk for transmission of blood born infections, in particular HIV/AIDS, as compared to a non-cohesive and fragmented blood supply. Any structure should find its anchor in an appropriate legal framework – documented principles of blood donation and transfusion, adequate regulations and an operational system for audit and inspection of compliance with the principles and related operational standards and technical

As mentioned in section 2.1 the key factor is competent human capacity at all levels, which means education of the community to create public awareness, the professionals to create professional awareness and politicians to create political awareness. The awareness to be

& Smit Sibinga, 2009; Los et al. 2009).

requirements (Hollan et al., 1990)

**4.3 Role of education and vocational institutes** 

raised relates to the risks for contracting infectious diseases such as HIV/AIDS, hepatitis, malaria and tuberculosis. Additionally these infectious diseases may be spread through a variety of contacts, e.g. the blood supply. Education provides knowledge through information, which is stored in the brains. A major question and related process is how to convert the acquired knowledge into appropriate action. The process depends highly on how the information is presented and how the knowledge is perceived. The perception ultimately triggers the action needed (WI Thomas & Thomas DS, 1928).

Education and vocational institutes do play a paramount role in the presentation of information and the way the acquired knowledge is perceived individually and collectively, leading to individual behaviour and collective or group behaviour – the moral and ethics of a community. To bridge the existing knowledge gap, analysis is needed of both the way, the environment and the contents of the information offered, and the intellectual mechanisms of the perception of the knowledge necessary for the triggering of appropriate action (Los & Smit Sibinga, 2009; Kajja, 2010).

Potential teachers and parents therefore need to be educated on how to pack and present the information and how to monitor and evaluate the perception of the knowledge. This continuum should have a high rank on the priority list of any nation, filling in one of the key universal human rights – the right of education. Competence is the intimate twinning through matching of acquiring knowledge and developing skills to act appropriately, whatever is concerned. When the community or public understands the need for a healthy life style, for sharing regularly a bit of healthy blood with those in need, by donating blood on an altruistic and regular basis, when the professionals in the health care understand the need to appropriately deal with the collection, processing, testing, storage and distribution of human blood as a transplant and at the clinical side with the in-hospital processes of prescription and ordering, selection and compatibility testing, and the ultimate transfusion and its monitoring and evaluation, the gap will be substantially narrowed and shallowed. However, without a proper understanding of the policy makers, the gap will not be bridged completely.

Evidence-based strategies for blood safety and availability have been successfully implemented in most developed countries and some transitional and developing nations. However, despite the proven effectiveness of these strategies, many countries are making slow progress towards their implementation. There is ample evidence that a nationally supported blood supply and clinical use of human blood, well regulated and professionally implemented on an adequate economy of scale, leads to a significant reduction in risk of transmission of infectious diseases.

Such nationally supported approach covers the entire nation and is based on education of all parties involved, understanding the importance and relevance of the necessary and ongoing provision of information and related actions.

Such systems recognize and address the potential weaknesses and gaps as listed above in the 6 major areas of transfusion medicine - 1. Organization and structure; 2. Clinical use (clinical interface); 3. Processing and testing; 4. Collection of source material (community interface); 5. Education; 6. Monitoring and evaluation (research and development).

Such systems are based on the needs of the community to be met by the supply through anticipation, proper planning and adequate logistics (Smit Sibinga, 2000). The demand then will drive the supply and no longer the other way around.

#### **5. Directions for improvement – Values and realities**

Over the past few decades, since the outbreak of the HIV/AIDS epidemic, much work has been done to provide a better understanding of the routing of transmission of the virus. There

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 607

4. to build human resource capacity through the provision of initial and continuing education (teaching and training) of staff to ensure quality of blood services and blood

5. to enhance the quality of evaluation and regulatory actions in the area of blood products and associated medical devices, including in vitro diagnostic devices; 6. to establish or strengthen systems for the safe and rational use of blood products and to provide education (teaching and training) for all staff involved in clinical transfusion, to implement potential solutions in order to minimize transfusion errors and promote patient safety, to promote the availability of transfusion alternatives including, where

7. to ensure the reliability of mechanisms for reporting serious or unexpected adverse reactions to blood and plasma donation and to the receipt of blood components and plasma derived medicinal products, including transmissions of pathogens

The red thread through all these resolutions is the prevention of further spread of HIV/AIDS through contaminated blood transfusions and improving patient care,

The global need for blood safety and availability has been highlighted in the following WHA and Executive Board (EB) resolutions and regional resolutions (PAHO and AFRO) that provide specific direction on strategies and activities within individual regions:

1975: WHA Resolution WHA28.72: Utilization and Supply of Human Blood and Blood

1999: DC-PAHO/AMRO Resolution CD41.R15: Strengthening Blood Banks in the

2001: RC-AFRO Resolution AFR/RC51/R2: Blood Safety Strategy for the African

2003: WHA Resolution WHA56.30: Global Health Sector Strategy for HIV/AIDS 2005: WHA Resolution WHA58.13: Blood Safety: Proposal to Establish World Blood

WHA Resolution WHA60.24: Health Promotion in a Globalized World

WHA Resolution WHA63:19: WHO HIV/AIDS strategy for 2011–2015 WHA Resolution WHA63:20: Chagas Disease: Control and Elimination

WHA Resolution WHA63.12: Availability, Safety and Quality of Blood Products

2000: WHA Resolution WHA53.14: HIV/AIDS: Confronting the Epidemic

2002: WHA Resolution WHA55.18: Quality of Care: Patient Safety

WHA Resolution WHA60.29: Health Technologies

WHA Resolution WHA63.10: Partnerships

WHA Resolution WHA63:18: Viral Hepatitis

Table 3. WHA Resolutions related to blood safety.

appropriate, autologous transfusion and patient blood management;

products;

(haemovigilance);

Products

Region

Donor Day

2007:

2010:

addressing the major knowledge gaps.

Region of the Americas

1987: EB Resolution EB79.R1: Blood and Blood Products 1995: WHA Resolution WHA48.27: Paris AIDS Summit

are prominent differences in the various cultures in the perception of the risks related to behaviour, personal and collective. That relates to different standards of moral and ethics, of values of life and realities of human attitudes and behaviour. Education remains a key factor in the provision of knowledge and related perception needed for action to prevent transmission, both vertical and horizontal. Blood transfusion in the vein-to-vein concept lacks behind in its development despite the continuum of initiatives developed by organizations such as the World Health Organization (WHO), the International Federation of Red Cross and Red Crescent Societies (IRC), the International Society of Blood Transfusion (ISBT) and the World Federation of Hemophilia (WFH) (Smit Sibinga, 2002). The WHO Blood Transfusion Safety Programme at WHO-HQ, Geneva, evolved from the WHO Global Programme on AIDS and the Global Blood Safety Initiative (GBSI) of the late 1980s. The leadership role of WHO has become visible through the development of a number of tools for education, collecting data, and providing guiding documents such as the series of *Aide Mémoires* to support and advise Governments in their attempts to structure national blood supply systems on a cost-effective, safe and sustainable basis. The Global Blood Safety Initiative started to map the situation of the blood supply and clinical use in the world and provide a series of expert advises, including two documents on education in transfusion medicine (WHO 1992a, 1992b).

#### **5.1 WHA resolutions**

With the goal of ensuring universal access to safe blood, WHO has been at the forefront of the movement to improve blood safety as mandated by successive World Health Assembly resolutions. In 2007 an important global meeting took place in Ottawa, Canada, addressing in a global consultation crucial aspects of a universal access to safe blood all part of the identified gaps (WHO, 2008a). More than 30 years after the first World Health Assembly resolution (WHA28.72) addressed the issue of blood safety, equitable access to safe blood and blood products and their safe and rational use still remain major challenges throughout the world. While the demand for blood is growing in the advanced world with longevity of life and increasingly sophisticated clinical procedures, national blood supplies are rarely sufficient to meet existing requirements in the restricted economy part of the world with some 80% of the global population.

Since that first World Health Assembly Resolution, a series of Resolutions has been created, endorsed and signed by the Member State representatives in an attempt to stimulate implementation at national level (Table 3). A recent one, WHA63.12 on Availability, Safety and Quality of Blood Products, was endorsed in May 2010 and urges Member States –


are prominent differences in the various cultures in the perception of the risks related to behaviour, personal and collective. That relates to different standards of moral and ethics, of values of life and realities of human attitudes and behaviour. Education remains a key factor in the provision of knowledge and related perception needed for action to prevent transmission, both vertical and horizontal. Blood transfusion in the vein-to-vein concept lacks behind in its development despite the continuum of initiatives developed by organizations such as the World Health Organization (WHO), the International Federation of Red Cross and Red Crescent Societies (IRC), the International Society of Blood Transfusion (ISBT) and the World Federation of Hemophilia (WFH) (Smit Sibinga, 2002). The WHO Blood Transfusion Safety Programme at WHO-HQ, Geneva, evolved from the WHO Global Programme on AIDS and the Global Blood Safety Initiative (GBSI) of the late 1980s. The leadership role of WHO has become visible through the development of a number of tools for education, collecting data, and providing guiding documents such as the series of *Aide Mémoires* to support and advise Governments in their attempts to structure national blood supply systems on a cost-effective, safe and sustainable basis. The Global Blood Safety Initiative started to map the situation of the blood supply and clinical use in the world and provide a series of expert advises, including

With the goal of ensuring universal access to safe blood, WHO has been at the forefront of the movement to improve blood safety as mandated by successive World Health Assembly resolutions. In 2007 an important global meeting took place in Ottawa, Canada, addressing in a global consultation crucial aspects of a universal access to safe blood all part of the identified gaps (WHO, 2008a). More than 30 years after the first World Health Assembly resolution (WHA28.72) addressed the issue of blood safety, equitable access to safe blood and blood products and their safe and rational use still remain major challenges throughout the world. While the demand for blood is growing in the advanced world with longevity of life and increasingly sophisticated clinical procedures, national blood supplies are rarely sufficient to meet existing requirements in the restricted economy part of the world with

Since that first World Health Assembly Resolution, a series of Resolutions has been created, endorsed and signed by the Member State representatives in an attempt to stimulate implementation at national level (Table 3). A recent one, WHA63.12 on Availability, Safety and Quality of Blood Products, was endorsed in May 2010 and urges Member States – 1. to take all the necessary steps to establish, implement and support nationallycoordinated, efficiently-managed and sustainable blood and plasma programmes according to the availability of resources, with the aim of achieving self-sufficiency,

2. to take all the necessary steps to update their national regulations on donor assessment and deferral, the collection, testing, processing, storage, transportation and use of blood products, and operation of regulatory authorities in order to ensure that regulatory control in the area of quality and safety of blood products across the entire transfusion

3. to establish quality systems, for the processing of whole blood and blood components, good manufacturing practices for the production of plasma-derived medicinal products and appropriate regulatory control, including the use of diagnostic devices to prevent

transfusion transmissible diseases with highest sensitivity and specificity;

two documents on education in transfusion medicine (WHO 1992a, 1992b).

**5.1 WHA resolutions** 

some 80% of the global population.

unless special circumstances preclude it;

chain meets internationally recognized standards;


The red thread through all these resolutions is the prevention of further spread of HIV/AIDS through contaminated blood transfusions and improving patient care, addressing the major knowledge gaps.



Table 3. WHA Resolutions related to blood safety.

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 609

knowledge, attitude and practice of these health workers. When certain tools were audited, the compliance was found to be 38.1 percent among the assessed hospitals, though the auditing was limited to seven (7) major hospitals. This shows the intervention has made an

When blood and blood components utilization comparison was made before (2006) and after the intervention (2008), demand for whole blood had decreased whereas the demands for all blood components had increased significantly (except FFP which remained

This shows the progress made in Eritrea through focused education in addressing safe

*Malawi* (courtesy Dr. Jean C. Emmanuel) – Malawi (population of ± 11 million) is a Low Human Development Index (L-HDI) country. The European Union EC EDF VIII Project document set out to develop an independent and sustainable National Malawi Blood Transfusion Service (MBTS) following the recommendations and guidelines of the World Health Organisation (WHO), International Federation of Red Cross and Red Crescent Societies (IFRCRCS) and the International Society of Blood Transfusion (ISBT). The MBTS project plan was based on sustainable and effectively managed and organised independent National Blood Services. The platform for development was the establishment of a Finance and Administration department, with an experienced chartered cost accountant (CPA) as Director; with facilities and trained staff. Effective collaborative networks have been established with Ministry of Health (MoH) and Ministry of Finance (MoF), ensuring incorporation of a sustainable budget into the national annual fiscal budget, negotiated 'fee for service' from the private health insurance schemes for the private sector, and an equitable career structure for all staff with social benefits to ensure continuous capacity building and retention of staff. MBTS Trust Board appointed an experienced CEO; Finance

In February 2000 a financing agreement, MAI/7001/002, was signed between the Republic of Malawi and the European Commission (EC) for € 7.8m in order to support the Malawi MoH to establish an independent National MBTS under a formally constituted and independent Malawi Blood Transfusion Service Trust. Project funding was increased with a further € 1.3m following a successful mid-term review (MTR). The Project Manager was appointed in March 2003 and development commenced. The Board of Trustees is responsible for the effective operation of MBTS and drafted appropriate legal frameworks, comprising the Constitution for the Board of Trustees and Legislation of the Service. MBTS is an officially registered Non Government Organisation (NGO) with a legal seal. MBTS is managed and organised by a competent Chief Executive Officer (CEO) who has internationally recognised qualifications, a Finance and Administrative Director and Medical Director with a Deputy; together form the Senior Management Team reporting directly to the Board. Developing collaborative working partnerships with the relevant NGOs, stakeholders and bodies in the private and public sector in Malawi is an important

The overall objective of MBTS is to provide safe blood and blood products, reduce the incidence of HIV, and other diseases transmissible by blood, ensuring equitable access and availability of blood and promoting appropriate clinical use of blood. The goal was achieved within the planned project timeframe a sustainable, national blood transfusion service providing a safe, adequate and accessible supply for all those in need in recognised health care establishments from 100% voluntary non-remunerated safe blood donors, which

transfusion practice, and the measurable improvements in that practice.

impact when compared with the pre-intervention status.

& Administration Director and Medical Director.

and ongoing strategy.

unchanged).

## **5.2 Millennium development goals**

The United Nations Millennium Development Goals (MDG) are eight goals that in 2000 all 191 UN Member States have agreed to try to achieve by the year 2015 (UN, 2000). The United Nations Millennium Declaration, signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women, all essential parts of the original 1948 UN Declaration of Universal Human Rights.

The eight MDGs are derived from this UN Millennium Declaration.


All eight goals have specific targets and indicators. Of these eight goals, the numbers 4, 5 and 6, and eight of the 18 targets relate directly to health and safe blood transfusion. The number 2 relates to education and the number 8 to the role of partnership for development, equally important to the development of safe and efficacious blood transfusion practices.

Some developing countries have made impressive progress in achieving the health-related Millennium Development Goals, targets and indicators. However, many more are still falling behind. Progress is particularly slow in sub-Saharan Africa but also in other developing and transition countries such as a number of the Newly Independent States (NIS), where knowledge gaps remain a major issue to address.

#### **5.3 Success stories**

There is a steadily growing number of success stories on bridging the knowledge gap and improving on the safety of the blood supply. We present just a few recent examples, largely from the African continent.

*Eritrea* (Baraki et al., 2010) - In 2006, despite the production of blood components in the National Blood Transfusion Centre (NBTC), about 90% of blood requests were for whole blood, an evidence of inappropriate use of blood and blood components in Eritrea. This could be the result of absence of proper and up to date guidelines and lack of training in appropriate use of blood and blood components, and alternatives. To change, the NBTC adapted clinical guidelines from the WHO document on appropriate use of blood (WHO, 2001). Copies of this document were distributed to all hospital staff in the country followed by training to the guidelines.

Objective of this Swiss Red Cross and Academic Institute IDTM (Groningen, NL) supported project was to assess the impact of distributing clinical guidelines and training (interventions) on knowledge, attitude and practice (KAP) of clinical prescribers in blood transfusion before and after the interventions. Correctly responded knowledge, attitude and practice (KAP) questions were collectively considered. Baseline: 3.8 percent of respondents correctly answered all KAP questions, which increased to 6.1 percent after the intervention. Of the total KAP questions, the average correct responses were 15.86 in the baseline and 17.45 in the follow-up assessment. The difference was positive and statistically significant (p<0.000) demonstrating the intervention had a major impact in changing the overall

The United Nations Millennium Development Goals (MDG) are eight goals that in 2000 all 191 UN Member States have agreed to try to achieve by the year 2015 (UN, 2000). The United Nations Millennium Declaration, signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women, all essential parts of the original 1948 UN Declaration of

All eight goals have specific targets and indicators. Of these eight goals, the numbers 4, 5 and 6, and eight of the 18 targets relate directly to health and safe blood transfusion. The number 2 relates to education and the number 8 to the role of partnership for development, equally important to the development of safe and efficacious blood transfusion practices. Some developing countries have made impressive progress in achieving the health-related Millennium Development Goals, targets and indicators. However, many more are still falling behind. Progress is particularly slow in sub-Saharan Africa but also in other developing and transition countries such as a number of the Newly Independent States

There is a steadily growing number of success stories on bridging the knowledge gap and improving on the safety of the blood supply. We present just a few recent examples, largely

*Eritrea* (Baraki et al., 2010) - In 2006, despite the production of blood components in the National Blood Transfusion Centre (NBTC), about 90% of blood requests were for whole blood, an evidence of inappropriate use of blood and blood components in Eritrea. This could be the result of absence of proper and up to date guidelines and lack of training in appropriate use of blood and blood components, and alternatives. To change, the NBTC adapted clinical guidelines from the WHO document on appropriate use of blood (WHO, 2001). Copies of this document were distributed to all hospital staff in the country followed

Objective of this Swiss Red Cross and Academic Institute IDTM (Groningen, NL) supported project was to assess the impact of distributing clinical guidelines and training (interventions) on knowledge, attitude and practice (KAP) of clinical prescribers in blood transfusion before and after the interventions. Correctly responded knowledge, attitude and practice (KAP) questions were collectively considered. Baseline: 3.8 percent of respondents correctly answered all KAP questions, which increased to 6.1 percent after the intervention. Of the total KAP questions, the average correct responses were 15.86 in the baseline and 17.45 in the follow-up assessment. The difference was positive and statistically significant (p<0.000) demonstrating the intervention had a major impact in changing the overall

The eight MDGs are derived from this UN Millennium Declaration.

**5.2 Millennium development goals** 

1. to eradicate extreme poverty and hunger; 2. to achieve universal primary education;

7. to ensure environmental sustainability;

3. to promote gender equality and empower women;

6. to combat HIV/AIDS, malaria, and other diseases;

8. to develop a global partnership for development.

(NIS), where knowledge gaps remain a major issue to address.

Universal Human Rights.

4. to reduce child mortality; 5. to improve maternal health;

**5.3 Success stories** 

from the African continent.

by training to the guidelines.

knowledge, attitude and practice of these health workers. When certain tools were audited, the compliance was found to be 38.1 percent among the assessed hospitals, though the auditing was limited to seven (7) major hospitals. This shows the intervention has made an impact when compared with the pre-intervention status.

When blood and blood components utilization comparison was made before (2006) and after the intervention (2008), demand for whole blood had decreased whereas the demands for all blood components had increased significantly (except FFP which remained unchanged).

This shows the progress made in Eritrea through focused education in addressing safe transfusion practice, and the measurable improvements in that practice.

*Malawi* (courtesy Dr. Jean C. Emmanuel) – Malawi (population of ± 11 million) is a Low Human Development Index (L-HDI) country. The European Union EC EDF VIII Project document set out to develop an independent and sustainable National Malawi Blood Transfusion Service (MBTS) following the recommendations and guidelines of the World Health Organisation (WHO), International Federation of Red Cross and Red Crescent Societies (IFRCRCS) and the International Society of Blood Transfusion (ISBT). The MBTS project plan was based on sustainable and effectively managed and organised independent National Blood Services. The platform for development was the establishment of a Finance and Administration department, with an experienced chartered cost accountant (CPA) as Director; with facilities and trained staff. Effective collaborative networks have been established with Ministry of Health (MoH) and Ministry of Finance (MoF), ensuring incorporation of a sustainable budget into the national annual fiscal budget, negotiated 'fee for service' from the private health insurance schemes for the private sector, and an equitable career structure for all staff with social benefits to ensure continuous capacity building and retention of staff. MBTS Trust Board appointed an experienced CEO; Finance & Administration Director and Medical Director.

In February 2000 a financing agreement, MAI/7001/002, was signed between the Republic of Malawi and the European Commission (EC) for € 7.8m in order to support the Malawi MoH to establish an independent National MBTS under a formally constituted and independent Malawi Blood Transfusion Service Trust. Project funding was increased with a further € 1.3m following a successful mid-term review (MTR). The Project Manager was appointed in March 2003 and development commenced. The Board of Trustees is responsible for the effective operation of MBTS and drafted appropriate legal frameworks, comprising the Constitution for the Board of Trustees and Legislation of the Service. MBTS is an officially registered Non Government Organisation (NGO) with a legal seal. MBTS is managed and organised by a competent Chief Executive Officer (CEO) who has internationally recognised qualifications, a Finance and Administrative Director and Medical Director with a Deputy; together form the Senior Management Team reporting directly to the Board. Developing collaborative working partnerships with the relevant NGOs, stakeholders and bodies in the private and public sector in Malawi is an important and ongoing strategy.

The overall objective of MBTS is to provide safe blood and blood products, reduce the incidence of HIV, and other diseases transmissible by blood, ensuring equitable access and availability of blood and promoting appropriate clinical use of blood. The goal was achieved within the planned project timeframe a sustainable, national blood transfusion service providing a safe, adequate and accessible supply for all those in need in recognised health care establishments from 100% voluntary non-remunerated safe blood donors, which

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 611

place. Almost exclusively whole blood is being transfused and adverse events are poorly observed. In 2009, in close collaboration with World Health Organization and the Academic Institute IDTM (Groningen, NL), a project to improve quality in blood transfusion through an appropriate quality management system was established, focused on the creation of a solid national blood supply and transfusion framework. Objectives were to review existing quality management programme and identify gaps, assist in the development of a draft national quality policy and develop a plan for quality improvement including capacity building. Through a series of field visits to main blood transfusion centres in three main States, the establishment of a National Steering Committee to create full ownership, capacity building through basic education in quality management and clinical transfusion medicine (quality culture) and enhancement of a voluntary blood donation programme strategy, the

3. 50 senior blood bank quality managers from 10 States educated in the basics of quality management. Committees from these trainers have worked on developing a draft

4. 6 seminars for prescribers conducted in 3 States, to improve clinical blood transfusion

This demonstrates that international collaboration (WHO/IDTM) can generate major achievements in establishing a national framework and improving quality blood transfusion services in developing countries to achieve the goals of safe and adequate blood supplies

*Uganda* (Kyeyune et al., 2010) - In 1957, a centralized transfusion service - the Uganda Blood Transfusion Service (UBTS), was started at Nakasero. This supplied blood to the entire country for the following 20 years. The period from 1977 to 1987 saw political unrest disrupt national infrastructures and aggravated the human resource crisis in the health sector. This resulted into reversion to the original unregulated hospital based transfusion service nationwide. Like any other low HDI country, Uganda is still challenged by a low availability of voluntary non-remunerated blood donors (VNRBD); insufficient transport and storage facilities; low capacities in testing of donated blood and quality assurance in testing laboratories. Through a step-by-step approach these problems are being reversed using locally and internationally sourced technical and financial support. In May 1987, Uganda with the assistance of the Global Programme on AIDS (GPA) of the World Health Organization (WHO) held a financial donor conference in Kampala. As a result, the Uganda AIDS Control Programme (UACP) was formed. The European Commission (EC) through its AIDS Task Force (ATF) made a pledge of 1.5 million Euros to rehabilitate the central blood bank at Nakasero and the collection, processing and distribution of 10,000 units of whole blood to be supplied to hospitals within 100 kms from Nakasero Blood Bank. In the period 1989-2004, further funding from EC together with adequate technical advice and support enabled the UBTS to improve its infrastructure by opening four regional blood banks in Mbarara, Fort-Portal, Gulu, Mbale and two satellites in Arua and Kitovu. This was accompanied by development and adoption of a National Blood Transfusion Policy, and organization and coordination of a national safe blood transfusion service based on voluntary non-remunerated blood donors. This period saw significant reduction of HIV and hepatitis B sero-prevalence among donors. A quality assurance programme was instituted in the UBTS establishment, and opportunities for human resource development in-service

1. Endorsed National Blood Transfusion Policy (Ministry of Health); 2. Voluntary Blood Donor Association established and registered;

knowledge and practice (in-hospital transfusion chain).

and clinical awareness and knowledge at national level.

following goals were reached –

national quality manual;

meets the needs of all hospitals in Malawi through the three centres specifically designed and built within the project framework.

The five-year project ended 2007. An independent Mid Term Review (MTR) Team contracted by European Commission (EC), concluded that the project had been successfully implemented. As a result EC agreed to an extension to the funding of € 1.3m through EDF IX, for the construction of 3 Blood Centres.

Key achievements of the project:


*Sudan* (Hassan Ali et al., 2010) - In Sudan blood transfusion services were fragmented hospital based with 85% of blood collected from family and replacement donors. More than 300 hospital blood banks practice blood collection and transfusion; 40% are rural hospitals with transfusion rate of 5-100 units of blood per month besides large central and specialized urban hospitals with transfusion rate of 100-300 units of blood per month. About 300,000 units of blood are collected annually; 56% is screened using rapid tests and 44% by ELISA technique, with a TTI marker prevalence of HIV - 2%, HBV - 6%, HCV - 2% and syphilis - 5%. Apart from a few solitary guidelines and SOP-like instructions no quality system was in

meets the needs of all hospitals in Malawi through the three centres specifically designed

The five-year project ended 2007. An independent Mid Term Review (MTR) Team contracted by European Commission (EC), concluded that the project had been successfully implemented. As a result EC agreed to an extension to the funding of € 1.3m through EDF












*Sudan* (Hassan Ali et al., 2010) - In Sudan blood transfusion services were fragmented hospital based with 85% of blood collected from family and replacement donors. More than 300 hospital blood banks practice blood collection and transfusion; 40% are rural hospitals with transfusion rate of 5-100 units of blood per month besides large central and specialized urban hospitals with transfusion rate of 100-300 units of blood per month. About 300,000 units of blood are collected annually; 56% is screened using rapid tests and 44% by ELISA technique, with a TTI marker prevalence of HIV - 2%, HBV - 6%, HCV - 2% and syphilis - 5%. Apart from a few solitary guidelines and SOP-like instructions no quality system was in



and built within the project framework.

IX, for the construction of 3 Blood Centres.

implementing quality systems;

beginning July 2006 to present;

training ended 31 March 2007;

blood products for blood transfusion;

facilitated by respective senior staff;

Paediatric Transfusion Guidelines;

all public and private hospitals;

Materials (every technician has a personal copy);

for service" through private medical insurance.

and future MBTS staff;

Key achievements of the project:

place. Almost exclusively whole blood is being transfused and adverse events are poorly observed. In 2009, in close collaboration with World Health Organization and the Academic Institute IDTM (Groningen, NL), a project to improve quality in blood transfusion through an appropriate quality management system was established, focused on the creation of a solid national blood supply and transfusion framework. Objectives were to review existing quality management programme and identify gaps, assist in the development of a draft national quality policy and develop a plan for quality improvement including capacity building. Through a series of field visits to main blood transfusion centres in three main States, the establishment of a National Steering Committee to create full ownership, capacity building through basic education in quality management and clinical transfusion medicine (quality culture) and enhancement of a voluntary blood donation programme strategy, the following goals were reached –


This demonstrates that international collaboration (WHO/IDTM) can generate major achievements in establishing a national framework and improving quality blood transfusion services in developing countries to achieve the goals of safe and adequate blood supplies and clinical awareness and knowledge at national level.

*Uganda* (Kyeyune et al., 2010) - In 1957, a centralized transfusion service - the Uganda Blood Transfusion Service (UBTS), was started at Nakasero. This supplied blood to the entire country for the following 20 years. The period from 1977 to 1987 saw political unrest disrupt national infrastructures and aggravated the human resource crisis in the health sector. This resulted into reversion to the original unregulated hospital based transfusion service nationwide. Like any other low HDI country, Uganda is still challenged by a low availability of voluntary non-remunerated blood donors (VNRBD); insufficient transport and storage facilities; low capacities in testing of donated blood and quality assurance in testing laboratories. Through a step-by-step approach these problems are being reversed using locally and internationally sourced technical and financial support. In May 1987, Uganda with the assistance of the Global Programme on AIDS (GPA) of the World Health Organization (WHO) held a financial donor conference in Kampala. As a result, the Uganda AIDS Control Programme (UACP) was formed. The European Commission (EC) through its AIDS Task Force (ATF) made a pledge of 1.5 million Euros to rehabilitate the central blood bank at Nakasero and the collection, processing and distribution of 10,000 units of whole blood to be supplied to hospitals within 100 kms from Nakasero Blood Bank. In the period 1989-2004, further funding from EC together with adequate technical advice and support enabled the UBTS to improve its infrastructure by opening four regional blood banks in Mbarara, Fort-Portal, Gulu, Mbale and two satellites in Arua and Kitovu. This was accompanied by development and adoption of a National Blood Transfusion Policy, and organization and coordination of a national safe blood transfusion service based on voluntary non-remunerated blood donors. This period saw significant reduction of HIV and hepatitis B sero-prevalence among donors. A quality assurance programme was instituted in the UBTS establishment, and opportunities for human resource development in-service

Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 613

in which lack of education (knowledge) plays a major role. When a safe and professional environment for the vein-to-vein use of blood and blood components is created, the risk for transmissible and transfusion related diseases will be reduced. At the same time there should be developed a sustainable and integrated health care system by building competent leadership, management and operational capacity in the methodologies and technologies involved in the procurement and clinical use of blood and blood components as

That could only be achieved sustainably when enabling policies and an institutional environment are developed through appropriate national drug and blood policies (legal and regulatory framework), with all partners involved in the health technologies and within the framework of national health policies (integrated), which generate a common vision and a

The authors would like to acknowledge Dr. Yifdeamlak E. Baraki from Eritrea, Dr. Jean C. Emmanuel from Malawi, Dr. Abdul Hassan Ali from Sudan, Dr. Dorothy Kyeyune from Uganda and Dr. Mayya Makhmudova from Uzbekistan for their invaluable contribution to

Adriani WPA, Smit Sibinga CTh. *How to develop a practical Quality Management System in resource limited countries,* Vox Sanguinis, Vol. 95, Issue 241 (Suppl), pp. 501 Allain JP, Sarkodie F, Asenso-Mensah K, Owusu-Ofori S. (2009). *Relative safety of first-time volunteer and replacement donors in west Africa,* Transfusion, Vol. 50, pp. 340-3 American College of Physicians Ad Hoc Committee on Medical Ethics (Eds.). (1984).

Baraki Y, Swiss Red Cross, Smit Sibinga CTh. (2010). *The Impact of Introduction of Clinical* 

Basavaraju S et al. (2010). *Reduced risk of transfusion-transmitted HIV in Kenya through centrally* 

*American College of Physicians Ethics Manual Part I: History of Medical Ethics, The Physician and the Patient, The Physician's Relationship to Other Physicians, The Physician and Society, Annals of Internal Medicine*, Vol. 101, Issue 1 (July 1984), pp.

*Guidelines and Training in Appropriate Use of Blood and Blood Products (AUB) on Knowledge, Attitude and Practice of Blood Prescribers in Eritrea*. Transfusion, 2010;50

*co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening*, Vox Sanguinis, Vol. 99, Issue 3 (October 2010), pp. 212–219 Berte LM. (1997). *Tools for improving quality in the transfusion service*, American Journal of Clinical Pathology, Vol. 107, Issue 4 Suppl 1 (April 1997), pp. S36-42 Chevrolle F et al. (2000). *Blood transfusion audit methodology: the auditors, reference systems and audit guidelines*, Transfus Clin Biol, Vol. 7, Issue 6, (December 2000), pp. 559-62 Colebunders R et al. (1991). *Seroconversion rate, mortality, and clinical manifestations associated* 

*with the receipt of a human immunodeficiency virus-infected blood transfusion in Kinshasa,* 

*Zaire*, Journal of Infectious Diseases, Vol. 164, pp. 450–6

fundamental elements of a sustainable health care system.

realistic and feasible plan for action.

**6. Acknowledgement** 

129-137

(2S):187A

the success stories.

**7. References** 

training were initiated. The EC fund was phased out in 2004 amidst increasing demands for safe blood for an increasing population. From 2004 to date UBTS has enjoyed technical (TA provision) and financial support from the US PEPFAR project, focused on strengthening of the national blood transfusion service. This has been followed by renovation of existing and establishment of new facilities, increased blood collection from 107,000 units in 2004 to 165,500 units in 2009. Blood testing for hepatitis C was started in 2005 in addition to HIV, Hepatitis B and syphilis testing. Hospital transfusion committees to oversee clinical use of blood are being created, and a major emphasis is on quality system essentials and capacity building in the regional blood banks.

*Uzbekistan* (Makhmudova & Smit Sibinga, 2008) - Project focus: development of a Republican Blood Supply and Transfusion System based on international standards – safe, efficacious, sustainable and affordable.

The Government of Uzbekistan initiated measures to reform the Health Care System. Government and Asian Development Bank (ADB) signed a Loan Agreement (2004) for a major project: Woman and Child Health Development (WCHD); part is used to improve blood services. The blood services situation requires radical improvement: Donated blood is not safe, majority is collected from paid donors with serious risk of HIV, HCV and HBV transmission. The country lacks a national blood safety policy, strategic plan, appropriate legislative and regulatory framework. The Blood Safety Program (component 3) of WCHD comprises a nationwide blood supply system, initiated in 2004 and substantiated in 2006, based on WHO and Red Cross principles. The programme is public health oriented, addressing the need for a nationally supported system, cost-effective, motivation and mobilization of the community to convert the current paid and replacement system into a truly voluntary and regular blood donor system, upgrading procurement operations (regional and economy-of-scale). It addresses the need for equitable access of safe blood to all citizens, appropriate clinical practices, and a national budget system to allow sustained and continuous operations. Using public education and social marketing campaigns with the support of NGOs, a voluntary and regular donor programme will be implemented stepwise. Another major point is in establishing appropriate clinical transfusion practices. With support of international expertise, MoH has created a Republican reform plan to reduce the number of inadequate hospital based blood transfusion units. The plan focuses on consolidation of core activities - blood collection, processing and testing, storage and distribution in 6 regional centres, strategically spread over the country to be able to handle logistics of demand and supply, and provide cost-effective operations. Implementation is in phases to allow proper adaptation and guarantee of continued supply of blood over the transition period. The WCHD conducts training needs assessments, develops training modules based on WHO guidelines and provides education for clinicians and transfusion medicine specialists (capacity building). Another example of how to bridge the knowledge gap.

This demonstrates that donor funding when appropriately utilized and supported by adequate provision of guidance and technical advice can improve blood transfusion programmes in the low human development index countries.

#### **5.4 Lessons learned**

To reduce the burden of morbidity and mortality through HIV infected blood transfusions of particularly the poor and marginalized populations, the focus should be on an increasing access to clinical and diagnostic technology, safe blood, blood components and medical devices. This could be achieved through reducing the leading risk factors to human health in which lack of education (knowledge) plays a major role. When a safe and professional environment for the vein-to-vein use of blood and blood components is created, the risk for transmissible and transfusion related diseases will be reduced. At the same time there should be developed a sustainable and integrated health care system by building competent leadership, management and operational capacity in the methodologies and technologies involved in the procurement and clinical use of blood and blood components as fundamental elements of a sustainable health care system.

That could only be achieved sustainably when enabling policies and an institutional environment are developed through appropriate national drug and blood policies (legal and regulatory framework), with all partners involved in the health technologies and within the framework of national health policies (integrated), which generate a common vision and a realistic and feasible plan for action.

## **6. Acknowledgement**

The authors would like to acknowledge Dr. Yifdeamlak E. Baraki from Eritrea, Dr. Jean C. Emmanuel from Malawi, Dr. Abdul Hassan Ali from Sudan, Dr. Dorothy Kyeyune from Uganda and Dr. Mayya Makhmudova from Uzbekistan for their invaluable contribution to the success stories.

## **7. References**

612 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

training were initiated. The EC fund was phased out in 2004 amidst increasing demands for safe blood for an increasing population. From 2004 to date UBTS has enjoyed technical (TA provision) and financial support from the US PEPFAR project, focused on strengthening of the national blood transfusion service. This has been followed by renovation of existing and establishment of new facilities, increased blood collection from 107,000 units in 2004 to 165,500 units in 2009. Blood testing for hepatitis C was started in 2005 in addition to HIV, Hepatitis B and syphilis testing. Hospital transfusion committees to oversee clinical use of blood are being created, and a major emphasis is on quality system essentials and capacity

*Uzbekistan* (Makhmudova & Smit Sibinga, 2008) - Project focus: development of a Republican Blood Supply and Transfusion System based on international standards – safe,

The Government of Uzbekistan initiated measures to reform the Health Care System. Government and Asian Development Bank (ADB) signed a Loan Agreement (2004) for a major project: Woman and Child Health Development (WCHD); part is used to improve blood services. The blood services situation requires radical improvement: Donated blood is not safe, majority is collected from paid donors with serious risk of HIV, HCV and HBV transmission. The country lacks a national blood safety policy, strategic plan, appropriate legislative and regulatory framework. The Blood Safety Program (component 3) of WCHD comprises a nationwide blood supply system, initiated in 2004 and substantiated in 2006, based on WHO and Red Cross principles. The programme is public health oriented, addressing the need for a nationally supported system, cost-effective, motivation and mobilization of the community to convert the current paid and replacement system into a truly voluntary and regular blood donor system, upgrading procurement operations (regional and economy-of-scale). It addresses the need for equitable access of safe blood to all citizens, appropriate clinical practices, and a national budget system to allow sustained and continuous operations. Using public education and social marketing campaigns with the support of NGOs, a voluntary and regular donor programme will be implemented stepwise. Another major point is in establishing appropriate clinical transfusion practices. With support of international expertise, MoH has created a Republican reform plan to reduce the number of inadequate hospital based blood transfusion units. The plan focuses on consolidation of core activities - blood collection, processing and testing, storage and distribution in 6 regional centres, strategically spread over the country to be able to handle logistics of demand and supply, and provide cost-effective operations. Implementation is in phases to allow proper adaptation and guarantee of continued supply of blood over the transition period. The WCHD conducts training needs assessments, develops training modules based on WHO guidelines and provides education for clinicians and transfusion medicine specialists (capacity building). Another example of how to

This demonstrates that donor funding when appropriately utilized and supported by adequate provision of guidance and technical advice can improve blood transfusion

To reduce the burden of morbidity and mortality through HIV infected blood transfusions of particularly the poor and marginalized populations, the focus should be on an increasing access to clinical and diagnostic technology, safe blood, blood components and medical devices. This could be achieved through reducing the leading risk factors to human health

programmes in the low human development index countries.

building in the regional blood banks.

efficacious, sustainable and affordable.

bridge the knowledge gap.

**5.4 Lessons learned** 


Transmission of HIV Through Blood – How To Bridge the Knowledge Gap 615

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**24** 

*Brazil* 

**Molecular Epidemiology of HIV-1 Infection** 

Antonio Carlos Rosário Vallinoto, Luiz Fernando Almeida Machado,

No other group of infectious agents has received increased attention from scientists in recent years than that of retroviruses. This reflects not only their importance as pathogens of humans and animals, but also its great value in studying the interactions between pathogens

The family *Retroviridae* comprises a large number of viruses that have the ability to insert its genome into the host cell and infect primarily vertebrates, despite having been described

Viruses pathogenic to humans which cause infections worldwide can be divided into two main groups: the transformants and the cytopathic. The first, induce changes in the control of cell division and can lead to tumors, such as Human T-lymphotropic virus (HTLV), belonging to the genus *Deltaretrovirus* and is linked to neurological and hematological. Cytopathic retroviruses are members of the *Lentivirus* genus, such as the Human immunodeficiency virus (HIV), and are related to severe immunodeficiency condictions. The ubiquotous conditions, now known by the name of acquired immunodeficiency syndrome (AIDS) is caused by HIV and was first recognized in the summer of 1981. The spread of an emerging virus in all regions of the world, caused great losses both in terms of

HIV infection results in a profound disorder in the host immune system, which is characterized by a decrease in the number of lymphocytes with the CD4 glycoprotein on their surface, especially helper T lymphocytes (ATL), with subsequent reversal of the ratio of

In Brazil, the HIV-1 dissemination reflects the grandeur and diversity sociogeographic of the country and its regional heterogeneity. The first cases of HIV/AIDS in Brazil, dates from 1982 and were originated the Southeast individual, which today still has the highest number of reported cases of the disease. Subtypes B, F, C and D, in addition to samples of virus recombinants and dual infections in different geographical areas. In the present chapter, we describe the molecular epidemiology of HIV-1 infection in the Brazilian Amazon region, emphasizing its impact in the city of Belem, Capital of the Para State, which is the main port of entry into the Amazon, highlighting the occurrence of the circulating subtypes and the

infections in other animals such as snails and insects.

human lives as well as in the economic point of view.

genetic profile of the host which is associated with the infection.

CD4+ or CD8+ T lymphocytes.

**1. Introduction** 

and host.

*Federal University of Para, Institute of Biological Sciences, Virus Laboratory,* 

Marluísa de Oliveira Guimarães Ishak and Ricardo Ishak

**in the Amazon Region** 


http://www.who.int/bloodsafety/transfusion\_services/nat\_blood\_pol/en/

World Health Organization. (2011b). World Health Assembly/Executive Board Resolutions on Blood Safety, In: Blood transfusion safety documentation centre, Accessed March 23, 2011, Available from:

http://www.who.int/bloodsafety/publications/en/index.html


## **Molecular Epidemiology of HIV-1 Infection in the Amazon Region**

Antonio Carlos Rosário Vallinoto, Luiz Fernando Almeida Machado, Marluísa de Oliveira Guimarães Ishak and Ricardo Ishak *Federal University of Para, Institute of Biological Sciences, Virus Laboratory, Brazil* 

## **1. Introduction**

618 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

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2001, Geneva, CH

2008 Geneva, CH

CH

*Services in Central Asian Health Systems: A clear and present danger of spreading HIV/AIDS and other infectious diseases*. The International Bank for Reconstruction

> No other group of infectious agents has received increased attention from scientists in recent years than that of retroviruses. This reflects not only their importance as pathogens of humans and animals, but also its great value in studying the interactions between pathogens and host.

> The family *Retroviridae* comprises a large number of viruses that have the ability to insert its genome into the host cell and infect primarily vertebrates, despite having been described infections in other animals such as snails and insects.

> Viruses pathogenic to humans which cause infections worldwide can be divided into two main groups: the transformants and the cytopathic. The first, induce changes in the control of cell division and can lead to tumors, such as Human T-lymphotropic virus (HTLV), belonging to the genus *Deltaretrovirus* and is linked to neurological and hematological. Cytopathic retroviruses are members of the *Lentivirus* genus, such as the Human immunodeficiency virus (HIV), and are related to severe immunodeficiency condictions.

> The ubiquotous conditions, now known by the name of acquired immunodeficiency syndrome (AIDS) is caused by HIV and was first recognized in the summer of 1981. The spread of an emerging virus in all regions of the world, caused great losses both in terms of human lives as well as in the economic point of view.

> HIV infection results in a profound disorder in the host immune system, which is characterized by a decrease in the number of lymphocytes with the CD4 glycoprotein on their surface, especially helper T lymphocytes (ATL), with subsequent reversal of the ratio of CD4+ or CD8+ T lymphocytes.

> In Brazil, the HIV-1 dissemination reflects the grandeur and diversity sociogeographic of the country and its regional heterogeneity. The first cases of HIV/AIDS in Brazil, dates from 1982 and were originated the Southeast individual, which today still has the highest number of reported cases of the disease. Subtypes B, F, C and D, in addition to samples of virus recombinants and dual infections in different geographical areas. In the present chapter, we describe the molecular epidemiology of HIV-1 infection in the Brazilian Amazon region, emphasizing its impact in the city of Belem, Capital of the Para State, which is the main port of entry into the Amazon, highlighting the occurrence of the circulating subtypes and the genetic profile of the host which is associated with the infection.

Molecular Epidemiology of HIV-1 Infection in the Amazon Region 621

reported having only primary and secondary education, as well as those with a heterosexual behavior. There was no statistically correlation between sex, educational level, sexual

Subtype C was identified in Belem and phylogenetic analysis supports the hypothesis that the virus was imported from the Southeast and Southern Brazil. Additionally, the recombinant CRF02\_AG subtype, circulating in Belém-PA probably was reported for the first time in the Amazon region and reinforces the importance of epidemiological

In Belem four subtypes were described in relation to *env*: B (88.3%), F (8.3%), D (1.7%), and C (1.7%); subtype B was the only one found in Macapa. In relation to the *pro* segment, there were four distinct subtypes in Belem: B (88.3%), F (9.3%), D (1.2%), and CRF02\_AG (1.2%). In Macapa, subtypes B (97.1%) and F (2.9%) were detected. Six strains were characterized as mosaics: two were Benv/Fpro (1.6%), two Fenv/Bpro (1.6%), one Cenv/Bpro (0.85%), and one

When compared to the State of Amazonas, there is a higher concentration of cases of disease in Manaus (capital), which holds approximately 90% of cases (Fundação de Medicina Tropical do Amazonas, 2006). Manaus has greater human genetic diversity because of their indigenous origin and sociocultural strong influence of migration from the Northeast region of Brazil since the 1800's when colonization occurred more intensely because of the business cycles of the rubber extractive exploratory projects, settlement of forest areas its transformation into an industrial area (Carneiro Filho,

There is evidence that the HIV / AIDS in the city of Manaus evolved with different patterns of distribution and expansion, whose characteristics define its consolidation in the initially affected districts still in the emergency epidemic, spreading later to other spaces receptive

In Manaus, it was found almost equal proportions of HIV-1 strains belonging to subtype B (51.6%) and F (48.4%), a finding that differs from previous results from studies conducted in

**Region State Subtypes Gene(s) References** 

*env* 

Machado *et al*., 2009

Machado *et al*., 2009

Machado *et al*., 2009

Machado *et al*., 2009

Machado *et al*., 2009

Vicente *et al*., 2000

*pro* 

*env* 

*pro* 

*env* 

B, F, D e C

B, F, D, CRF02\_AG

Benv/Fpro, Fenv/Bpro, Cenv/Bpro, Benv/Dpro

B

B e F

B, F e B/F

Table 1. Geographic distribution of subtypes of HIV-1 in northern Brazil.

orientation and risk behavior for HIV-1, with subtypes B and F infection.

surveillance for the virus in the country.

Benv/Dpro (0.8%) (Machado et al., 2009).

urban areas of southeastern Brazil (Vicente et al., 2000).

1998).

City (Silva et al., 2009).

**North** Pará

Pará

Pará

Amapá

Amapá

Amazonas

Currently HIV-1 genetic heterogeneity is classified into four phylogenetic groups: M, N, O and P, which may reflect four interspecific transmission events from chimpanzees (Plantier et al., 2009). Group M (major) is the most frequently involves with human infectious worldwide and is composed of nine genetically distinct subtypes, named A, B, C, D, F, G, H, J and K, whose gene sequences differ approximately 20% (Taylor et al., 2008).

In Brazil, HIV-1 is characterized by the occurrence of several subtypes of the M group, and includes subtype B, the most prevalent in the majority of the regions, followed by subtypes F, C, and D, (Monteiro et al., 2009) although some cities present a distinct pattern of distribution of these subtypes (Vicente et al., 2000; Soares et al., 2003). This diversity of subtypes could represent more than one port of entry of HIV-1 in the country, with the emergence of the epidemic occurring, probably in the late 1970's or early 1980's (Morgado et al., 1998).

The circulating recombinant forms of HIV (CRFs) have an important role in regional and global epidemics of the virus, particularly in regions where multiple subtypes circulate simultaneously. Currently over 40 CRFs are recognized worldwide (http://www.hiv.lanl. gov), and five have been described in Brazil, designated as CRF28\_BF, CRF29\_BF, CRF39\_BF, CRF40\_BF e CRF31\_BC (Sanabani et al., 2006; De Sá Filho et al., 2006, http://www.hiv.lanl.gov/content/sequence/HIV/CRFs/CRFs.html), where CRF\_BC represents 11% of the HIV-1 viruses circulating in the Southern region of the country (Santos et al., 2006).

In addition to the CRF, a large number of unique recombinant forms (URFs) have been characterized worldwide (McCutchan, 2006). Notoriously, a recombination is a potentially important mechanism that significantly contributes to HIV genetic variability with serious implications for diagnosis, drug treatment and optimal vaccine development (Sanabani et al., 2010).

## **2. HIV-1 infection in the Brazilian Amazon region**

The molecular epidemiology of HIV-1 strains circulating in the Northern region of Brazil is poorly known (Table 1). The State of Para has 43.3% of the cases. Until June 2006, there were 5919 infected individuals, in which 80.4% were men and 19.6% were women (Brasil, 2008). The prevalence of the infection in the State of Amapa is still low, although the region borders French Guiana and a great number of indigenous populations move freely between the two countries. The cities of Belem (State of Para), Manaus (State of Amazonas) and Macapa (State of Amapa) can be considered as the main entry of HIV-1 in northern Brazil. The city of Belem has one of the largest ports in the Brazilian Amazon and receives a great input of tourists throughout the year, while the city of Macapa is located next to several Indian tribes and borders countries such as Guyana, which generates a large population movement between two locations. The city of Belem shows the highest diversity of subtypes of HIV-1 in Brazil, having been identified the subtypes B, F, D, C and recombinant CRF02\_AG subtype reflecting in this way, the same epidemiological profile found in almost all regions of Brazil (Sabino et al., 1996; Morgado et al., 1998; Ramos et al., 1999, Tanuri et al., 1999; Vicente et al., 2000) and from South America (Marquina et al., 1996; Navas et al., 1999; Avila et al., 2002; Castro et al., 2003).

The population group studied presented epidemiological characteristics which indicated that the heterosexual transmission of HIV-1 associated with sexual promiscuity, was the main way of virus dissemination. HIV-1 occurred mostly in the group of individuals who

Currently HIV-1 genetic heterogeneity is classified into four phylogenetic groups: M, N, O and P, which may reflect four interspecific transmission events from chimpanzees (Plantier et al., 2009). Group M (major) is the most frequently involves with human infectious worldwide and is composed of nine genetically distinct subtypes, named A, B, C, D, F, G, H,

In Brazil, HIV-1 is characterized by the occurrence of several subtypes of the M group, and includes subtype B, the most prevalent in the majority of the regions, followed by subtypes F, C, and D, (Monteiro et al., 2009) although some cities present a distinct pattern of distribution of these subtypes (Vicente et al., 2000; Soares et al., 2003). This diversity of subtypes could represent more than one port of entry of HIV-1 in the country, with the emergence of the epidemic occurring, probably in the late 1970's or early 1980's (Morgado et

The circulating recombinant forms of HIV (CRFs) have an important role in regional and global epidemics of the virus, particularly in regions where multiple subtypes circulate simultaneously. Currently over 40 CRFs are recognized worldwide (http://www.hiv.lanl. gov), and five have been described in Brazil, designated as CRF28\_BF, CRF29\_BF, CRF39\_BF, CRF40\_BF e CRF31\_BC (Sanabani et al., 2006; De Sá Filho et al., 2006, http://www.hiv.lanl.gov/content/sequence/HIV/CRFs/CRFs.html), where CRF\_BC represents 11% of the HIV-1 viruses circulating in the Southern region of the country (Santos

In addition to the CRF, a large number of unique recombinant forms (URFs) have been characterized worldwide (McCutchan, 2006). Notoriously, a recombination is a potentially important mechanism that significantly contributes to HIV genetic variability with serious implications for diagnosis, drug treatment and optimal vaccine development (Sanabani et

The molecular epidemiology of HIV-1 strains circulating in the Northern region of Brazil is poorly known (Table 1). The State of Para has 43.3% of the cases. Until June 2006, there were 5919 infected individuals, in which 80.4% were men and 19.6% were women (Brasil, 2008). The prevalence of the infection in the State of Amapa is still low, although the region borders French Guiana and a great number of indigenous populations move freely between the two countries. The cities of Belem (State of Para), Manaus (State of Amazonas) and Macapa (State of Amapa) can be considered as the main entry of HIV-1 in northern Brazil. The city of Belem has one of the largest ports in the Brazilian Amazon and receives a great input of tourists throughout the year, while the city of Macapa is located next to several Indian tribes and borders countries such as Guyana, which generates a large population movement between two locations. The city of Belem shows the highest diversity of subtypes of HIV-1 in Brazil, having been identified the subtypes B, F, D, C and recombinant CRF02\_AG subtype reflecting in this way, the same epidemiological profile found in almost all regions of Brazil (Sabino et al., 1996; Morgado et al., 1998; Ramos et al., 1999, Tanuri et al., 1999; Vicente et al., 2000) and from South America (Marquina et al., 1996; Navas et al., 1999;

The population group studied presented epidemiological characteristics which indicated that the heterosexual transmission of HIV-1 associated with sexual promiscuity, was the main way of virus dissemination. HIV-1 occurred mostly in the group of individuals who

**2. HIV-1 infection in the Brazilian Amazon region** 

Avila et al., 2002; Castro et al., 2003).

J and K, whose gene sequences differ approximately 20% (Taylor et al., 2008).

al., 1998).

et al., 2006).

al., 2010).

reported having only primary and secondary education, as well as those with a heterosexual behavior. There was no statistically correlation between sex, educational level, sexual orientation and risk behavior for HIV-1, with subtypes B and F infection.

Subtype C was identified in Belem and phylogenetic analysis supports the hypothesis that the virus was imported from the Southeast and Southern Brazil. Additionally, the recombinant CRF02\_AG subtype, circulating in Belém-PA probably was reported for the first time in the Amazon region and reinforces the importance of epidemiological surveillance for the virus in the country.

In Belem four subtypes were described in relation to *env*: B (88.3%), F (8.3%), D (1.7%), and C (1.7%); subtype B was the only one found in Macapa. In relation to the *pro* segment, there were four distinct subtypes in Belem: B (88.3%), F (9.3%), D (1.2%), and CRF02\_AG (1.2%). In Macapa, subtypes B (97.1%) and F (2.9%) were detected. Six strains were characterized as mosaics: two were Benv/Fpro (1.6%), two Fenv/Bpro (1.6%), one Cenv/Bpro (0.85%), and one Benv/Dpro (0.8%) (Machado et al., 2009).

When compared to the State of Amazonas, there is a higher concentration of cases of disease in Manaus (capital), which holds approximately 90% of cases (Fundação de Medicina Tropical do Amazonas, 2006). Manaus has greater human genetic diversity because of their indigenous origin and sociocultural strong influence of migration from the Northeast region of Brazil since the 1800's when colonization occurred more intensely because of the business cycles of the rubber extractive exploratory projects, settlement of forest areas its transformation into an industrial area (Carneiro Filho, 1998).

There is evidence that the HIV / AIDS in the city of Manaus evolved with different patterns of distribution and expansion, whose characteristics define its consolidation in the initially affected districts still in the emergency epidemic, spreading later to other spaces receptive City (Silva et al., 2009).

In Manaus, it was found almost equal proportions of HIV-1 strains belonging to subtype B (51.6%) and F (48.4%), a finding that differs from previous results from studies conducted in urban areas of southeastern Brazil (Vicente et al., 2000).


Table 1. Geographic distribution of subtypes of HIV-1 in northern Brazil.

Molecular Epidemiology of HIV-1 Infection in the Amazon Region 623

Avila, M.M., Pando, M.A., Carrion, G., Peralta, L.M., Salomon, H., Carrillo, M.G., Sanchez,

Brasil. Ministério da Saúde. *Boletim Epidemiológico* (2008). AIDS, 12: 1–57, http://portal.saude.gov.br/portal/svs/visualizar\_texto.cfm?idtxt=21168. Carneiro Filho, A (1998). Manaus: fortaleza extrativismo-cidade, uma história da dinâmica

Castro, E., Echeverría, G., Deibis, L., González de Salmen, B., Dos Santos Moreira, A.,

Cohen, O.J., Kinter, A. & Fauci, A.S. (1997). Host factors in the pathogenesis of HIV disease.

De Sa Filho, D.J., Sucupira, M.C., Caseiro, M.M., Sabino, E.C., Diaz, R.S. & Janini, L.M.

Drogari-Apiranthitou, M., Fijen, C.A.P., Thiel, S., Platonov, A., Jensen, L., Dankert, J. &

Garred, P., Richter, C., Andersen, A.B., Madsen, H.O., Mtoni, I., Svejgaard, A. & Shao, J.

Hibberd, M.L., Sumiya, M., Summerfield, J.A., Booy, R. & Levin, M. (1999). Association of

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**4. References** 

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## **3. Genetic background of HIV-1 infected subjects**

The pathogenesis of human immunodeficiency virus 1 infection is very complex and of course influenced by both viral and host factors (Cohen et al., 1997). Studies have focused the attention about the role of *MBL* gene variants and its serum concentration on the progression of AIDS in HIV-1-infected subjects (Garred et al., 1997; Prohászka et al., 1997).

Mannose-binding lectin (MBL) is a liver-derived pluripotent serum lectin that has a role in the host's innate immune system (Turner, 2003) by binding with high affinity to mannose or other carbohydrate components existent in viruses, bacteria and yeast (Kuipers et al*.*, 2003). However, MBL function is directly associated with its serum concentrations which are determined by the interplay between promoter and structural gene mutations (Madsen et al*.*, 1995; Jüliger et al., 2000).

Three mutations have been described in the structural region of the molecule (codons 52, 54 and 57) from which are derived three allelic variants named *MBL\*D*, *MBL\*B* and *MBL\*C*, respectively. On the other hand, the wild allele is called *MBL\*A* (Madsen et al., 1994). The occurrence of these variants have been associated with MBL serum deficiency and consequently to susceptibility/resistance to infection by various pathogens, including HIV-1 (Drogari-Apiranthitou et al., 1997; Garred et al., 1997; Prohászka et al*.*, 1997; Luty et al., 1998; Hibberd et al., 1999; Peterslund et al., 2001; Klabunde et al., 2002; Roy et al., 2002; Song et al., 2003).

It was investigated the association between *MBL* gene polymorphism and the susceptibility to HIV-1 infection (Vallinoto et al., 2006). The study of 145 HIV-1-infected subjects and 99 healthy controls showed the presence of alleles *MBL\*A*, *MBL\*B* and *MBL\*D*, whose frequencies were 69%, 22% and 09% among patients and 71%, 13% and 16% among healthy controls, respectively. The presence of the variant *MBL\*B* was associated with higher plasma viral load levels, suggesting the importance of the *MBL* gene polymorphism in the clinical evolution of HIV-1-infected patients.

The prevalence of mutations in the -550 (H/L) and -221 (X/Y) mannose-binding lectin (MBL) gene promoter regions and their impact on infection by human immunodeficiency virus 1 (HIV-1) was investigated in a population of 128 HIV-1 seropositive and 97 seronegative patients (Vallinoto et al, 2008). The allele identification was performed through the sequence-specific primer polymerase chain reaction method, using primer sequences specific to each polymorphism. The evolution of the infection was evaluated through CD4+ T-lymphocyte counts and plasma viral load. The allele and haplotype frequencies among HIV-1-infected patients and seronegative healthy control patients did not show significant differences. CD4+ T-lymphocyte counts showed lower levels among seropositive patients carrying haplotypes LY, LX and HX, as compared to those carrying the HY haplotype. Mean plasma viral load was higher among seropositive patients with haplotypes LY, LX and HX than among those carrying the HY haplotype. When promoter and exon 1 mutations were matched, it was possible to identify a significantly higher viral load among HIV-1 infected individuals carrying haplotypes correlated to low serum levels of MBL. The current study shows that haplotypes related to medium and low MBL serum levels might directly influence the evolution of viral progression in patients. Therefore, it is suggested that the identification of haplotypes within the promoter region of the MBL gene among HIV-1 infected persons should be further evaluated as a prognostic tool for AIDS progression.

#### **4. References**

622 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

The pathogenesis of human immunodeficiency virus 1 infection is very complex and of course influenced by both viral and host factors (Cohen et al., 1997). Studies have focused the attention about the role of *MBL* gene variants and its serum concentration on the progression of AIDS in HIV-1-infected subjects (Garred et al., 1997; Prohászka et al.,

Mannose-binding lectin (MBL) is a liver-derived pluripotent serum lectin that has a role in the host's innate immune system (Turner, 2003) by binding with high affinity to mannose or other carbohydrate components existent in viruses, bacteria and yeast (Kuipers et al*.*, 2003). However, MBL function is directly associated with its serum concentrations which are determined by the interplay between promoter and structural gene mutations (Madsen et

Three mutations have been described in the structural region of the molecule (codons 52, 54 and 57) from which are derived three allelic variants named *MBL\*D*, *MBL\*B* and *MBL\*C*, respectively. On the other hand, the wild allele is called *MBL\*A* (Madsen et al., 1994). The occurrence of these variants have been associated with MBL serum deficiency and consequently to susceptibility/resistance to infection by various pathogens, including HIV-1 (Drogari-Apiranthitou et al., 1997; Garred et al., 1997; Prohászka et al*.*, 1997; Luty et al., 1998; Hibberd et al., 1999; Peterslund et al., 2001; Klabunde et al., 2002; Roy et al., 2002; Song et al.,

It was investigated the association between *MBL* gene polymorphism and the susceptibility to HIV-1 infection (Vallinoto et al., 2006). The study of 145 HIV-1-infected subjects and 99 healthy controls showed the presence of alleles *MBL\*A*, *MBL\*B* and *MBL\*D*, whose frequencies were 69%, 22% and 09% among patients and 71%, 13% and 16% among healthy controls, respectively. The presence of the variant *MBL\*B* was associated with higher plasma viral load levels, suggesting the importance of the *MBL* gene polymorphism in the clinical

The prevalence of mutations in the -550 (H/L) and -221 (X/Y) mannose-binding lectin (MBL) gene promoter regions and their impact on infection by human immunodeficiency virus 1 (HIV-1) was investigated in a population of 128 HIV-1 seropositive and 97 seronegative patients (Vallinoto et al, 2008). The allele identification was performed through the sequence-specific primer polymerase chain reaction method, using primer sequences specific to each polymorphism. The evolution of the infection was evaluated through CD4+ T-lymphocyte counts and plasma viral load. The allele and haplotype frequencies among HIV-1-infected patients and seronegative healthy control patients did not show significant differences. CD4+ T-lymphocyte counts showed lower levels among seropositive patients carrying haplotypes LY, LX and HX, as compared to those carrying the HY haplotype. Mean plasma viral load was higher among seropositive patients with haplotypes LY, LX and HX than among those carrying the HY haplotype. When promoter and exon 1 mutations were matched, it was possible to identify a significantly higher viral load among HIV-1 infected individuals carrying haplotypes correlated to low serum levels of MBL. The current study shows that haplotypes related to medium and low MBL serum levels might directly influence the evolution of viral progression in patients. Therefore, it is suggested that the identification of haplotypes within the promoter region of the MBL gene among HIV-1 infected persons should be further evaluated as a

**3. Genetic background of HIV-1 infected subjects** 

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prognostic tool for AIDS progression.


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**25** 

**HIV Screening** 

*1,2United Kingdom* 

*3Scotland* 

H. Blake1, P. Leighton2 and S. Sharma3

*Queen's Medical Centre, NG7 2UH, Nottingham* 

*Medical Centre, NG7 2HA, Nottingham,* 

**Saliva Testing as a Practical Tool for Rapid** 

*1Division of Nursing, University of Nottingham, B Floor (South Block Link), Queen's* 

*3Department of Psychology, University of Strathclyde, G1 1XQ, Glasgow,* 

*2Division of Primary Care, University of Nottingham, Room 2104, C Floor South 3Block,* 

Whilst the annual number of new HIV infections is steadily declining, levels of new infections overall are high and the number of people living with HIV has increased worldwide. An estimated 73,000 people in the UK are living with HIV, of which it is estimated that 24,000 are undiagnosed or unaware of their HIV status (Health Protection Agency, 2007). The prevalence of undiagnosed HIV infection would therefore seem a key driver for increased and routine HIV testing, both to lessen the potential for unwitting transmission of HIV and to support early detection and timely access to medical care in those infected. It has been shown that late diagnosis of HIV infection, resulting in delayed patient management, is associated with poorer survival (Losina et al., 2009). In the UK, the National Strategy for Sexual Health and HIV (Department of Health, 2001) aims to reduce

This is a rapidly advancing field and whilst it is beyond the scope of this chapter to encapsulate all the current evidence in this field, a brief overview is presented of saliva testing as a diagnostic tool, the benefits and the caveats. The contexts in which saliva testing for HIV are currently conducted is considered both in the UK and internationally. The evidence for the sensitivity and specificity of this method will be considered. Attitudes of recipients towards rapid HIV screening, in particular saliva testing, are considered together

HIV screening is undertaken for a number of purposes, the UNAIDS/WHO summarise these as i) testing for screening blood, ii) testing for epidemiological surveillance and iii) testing for diagnosing infected individuals (UNAIDS, 1997). A variety of specific tests might be used to these ends. The British HIV Association (BHIVA) states that, "a potentially important mechanism for limiting the HIV epidemic is the widespread use of HIV testing in

the prevalence of undiagnosed HIV by increasing screening.

with attitudes towards the contexts in which testing is undertaken.

**1. Introduction** 

**2. Diagnosis of HIV/AIDs** 

the mannose-binding lectin gene promoter among human immunodeficiency virus 1 infected subjects. *Mem Inst Oswaldo Cruz*, 103: 645–649, ISSN:1678-8060

Vicente, A.C., Otsuki, K., Silva, N.B., Castilho, M.C., Barros, F.S., Pieniazek, D., et al. (2000). The HIV epidemic in the Amazon Basin is driven by prototypic and recombinant HIV-1 subtypes B and F. *Journal of Acquired Immune Deficiency Syndrome*, 23: 327– 331, ISSN:1525-4135.

## **Saliva Testing as a Practical Tool for Rapid HIV Screening**

H. Blake1, P. Leighton2 and S. Sharma3

*1Division of Nursing, University of Nottingham, B Floor (South Block Link), Queen's Medical Centre, NG7 2HA, Nottingham, 2Division of Primary Care, University of Nottingham, Room 2104, C Floor South 3Block, Queen's Medical Centre, NG7 2UH, Nottingham 3Department of Psychology, University of Strathclyde, G1 1XQ, Glasgow, 1,2United Kingdom 3Scotland* 

## **1. Introduction**

626 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

1 infected subjects. *Mem Inst Oswaldo Cruz*, 103: 645–649, ISSN:1678-8060 Vicente, A.C., Otsuki, K., Silva, N.B., Castilho, M.C., Barros, F.S., Pieniazek, D., et al. (2000).

331, ISSN:1525-4135.

the mannose-binding lectin gene promoter among human immunodeficiency virus

The HIV epidemic in the Amazon Basin is driven by prototypic and recombinant HIV-1 subtypes B and F. *Journal of Acquired Immune Deficiency Syndrome*, 23: 327–

> Whilst the annual number of new HIV infections is steadily declining, levels of new infections overall are high and the number of people living with HIV has increased worldwide. An estimated 73,000 people in the UK are living with HIV, of which it is estimated that 24,000 are undiagnosed or unaware of their HIV status (Health Protection Agency, 2007). The prevalence of undiagnosed HIV infection would therefore seem a key driver for increased and routine HIV testing, both to lessen the potential for unwitting transmission of HIV and to support early detection and timely access to medical care in those infected. It has been shown that late diagnosis of HIV infection, resulting in delayed patient management, is associated with poorer survival (Losina et al., 2009). In the UK, the National Strategy for Sexual Health and HIV (Department of Health, 2001) aims to reduce the prevalence of undiagnosed HIV by increasing screening.

> This is a rapidly advancing field and whilst it is beyond the scope of this chapter to encapsulate all the current evidence in this field, a brief overview is presented of saliva testing as a diagnostic tool, the benefits and the caveats. The contexts in which saliva testing for HIV are currently conducted is considered both in the UK and internationally. The evidence for the sensitivity and specificity of this method will be considered. Attitudes of recipients towards rapid HIV screening, in particular saliva testing, are considered together with attitudes towards the contexts in which testing is undertaken.

## **2. Diagnosis of HIV/AIDs**

HIV screening is undertaken for a number of purposes, the UNAIDS/WHO summarise these as i) testing for screening blood, ii) testing for epidemiological surveillance and iii) testing for diagnosing infected individuals (UNAIDS, 1997). A variety of specific tests might be used to these ends. The British HIV Association (BHIVA) states that, "a potentially important mechanism for limiting the HIV epidemic is the widespread use of HIV testing in

Saliva Testing As a Practical Tool for Rapid HIV Screening 629

evidence for screening programmes reducing the transmission of HIV is unclear (Paltiel, 2006), a range of studies indicate that those who are aware of their HIV status amend their behaviour so as to limit the risk of HIV transmission to others (Marks et al., 2005; Crepaz et

In the United States (U.S.) in 2006, in an effort to improve the identification of HIV-positive individuals, the Center for Diseases Control and Prevention (CDC) released their current HIV testing guidelines. These recommended routine testing for those age 13 to 64 years regardless of risk factors, unless testing is specifically declined by the individual (opt-out testing) (Branson et al., 2006). In the U.S. the following criteria apply: opt-out HIV screening is recommended for patients in all healthcare settings, with people at high risk for HIV infection screened for HIV at least annually. Here, separate written consent for HIV testing is not required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Finally, prevention counselling should not be required with HIV diagnostic testing or as part of HIV screening programmes in healthcare settings (Branson et al., 2006). Although one-third of people with HIV infection in the UK remain undiagnosed, current UK guidelines recommend opt-out testing only for pregnant women

HIV testing involves the detection of antibodies produced by the body in an unsuccessful attempt to fight HIV infection, such antibodies being more easily detected than the virus itself. Testing can be carried out on whole blood, plasma, serum, urine, dried blood spots and saliva samples, but might only be carried out after a 3-8 week period following infection (Schopper & Vercauteren, 1996). During this 3-8 week window the HIV antigen is rarely identified - bar in exceptional circumstances at the peak of high circulation of virus particles

Initial developments in HIV screening centred upon the need to ensure that donated blood remained free of the HIV virus. A *testing paradigm* thus emerged to protect the supply of donated blood, a paradigm marked by "tests with high sensitivity, suitable for batch processing of high volumes of specimens in centralised laboratories with specialised equipment." (Branson, 2000a). The enzyme-linked immunosorbent assay (ELISA) was indicative of this; a screening test for blood, efficient in large-scale hospital settings and reliant upon specialist laboratory equipment. The ELISA is the most appropriate, and most commonly used, screening test for samples greater than 100 per day; the ELISA is most appropriate for population level surveillance of HIV infection (UNAIDS, 1997). Performed by trained medical staff the ELISA test is reliable, but incurs substantial costs and might only offer results a few days after testing. Whilst this cost and delay are less important in

During the late 1980s and early 1990s the benefits of *voluntary counselling and testing* were increasingly recognised and other testing algorithms were developed to meet this end (Branson, 2000a). Concerns about false positives from the ELISA test led the U.S. Public Health Service recommending secondary testing with the Western Blot (WB) to ensure accuracy. Although once again, the significant time delay associated with this combination of tests, of up to 2 weeks before test results are returned to patients, was a significant barrier. Also ELISA both in isolation and in combination with the WB test has limited suitability for remote or smaller clinical settings where resources are limited and access to adequate

screening donated blood, for other forms of testing they might act as a barrier.

and people attending genitourinary clinics (Hamill et al., 2007).

al., 2006; Chou et al., 2005).

**2.2 HIV tests** 

(Carne, 1988; Chin, et al., 2007).

a variety of clinical settings," but provides no specific guidance on how the testing should be done (BHVA, 2005). The selection of the most appropriate test, and testing protocol, should not only be informed by test sensitivity and specificity, but also by a number of economic and logistic factors (Branson, 2003). The following sections outline some key information relating to procedures for HIV testing, categories of HIV testing, and HIV testing guidelines, and consider technical and process issues relating to HIV testing.

## **2.1 Testing for HIV**

HIV testing has evolved from initial concerns, in the mid/early 1980s, for screening the supply of donated blood, to now reflect a broader range of concerns which include clinical diagnosis and strategic public health intervention (Branson, 2000a, 2000b). UNAIDS/WHO have identified four distinct categories of HIV testing: Diagnostic testing, Voluntary counselling and testing (VCT), Routinised testing in specific setting, and Mandatory testing. Diagnostic HIV testing is testing undertaken where signs and symptoms related to an HIV infection are observed in any individual. Testing is carried out to ensure timely clinical diagnosis, and to ensure the provision of adequate clinical support and services. People with certain diseases, such as tuberculosis and any other sexually transmitted disease, are also tested for HIV infection on a regular basis to this end.

Voluntary counselling and testing, also referred to as 'client focused testing', categorises those programmes of HIV testing which are designed to promote HIV awareness and to broaden access to HIV testing. Such testing is carried out in the absence of individual symptoms and is combined with group and individual counselling around HIV issues to raise awareness and educate in relevant health, and health behaviour, areas. This kind of testing programme is often undertaken with those who are perceived to be at high-risk of exposure to the HIV virus, or those who are concerned that they have been recently exposed to HIV. Testing is provided in local health and community settings, and pre and post-test counselling is offered to all those being testing. Pre-test counselling is often delivered in group settings, with post-test and follow-up counselling delivered on a one-to-one basis. UNAIDS/WHO identify VCT as the most effective approach to testing for achieving behaviour change to prevent HIV transmission in public settings.

Routine HIV testing of those accessing clinical or medical services is often carried out in those settings where high risk client groups are prevalent. Such testing is carried out with the purpose of early (asymptomatic) identification, with associated benefits for reduced risk of unwitting transmission of the virus. Carried out in community health centres, specialist clinics or hospitals settings such testing includes that undertaken in sexual health clinics with people who are undergoing diagnostic testing for other sexually transmitted diseases. It also incorporates the testing of intravenous drug users in primary and secondary care settings. Routine testing of this kind often utilises rapid HIV tests, which are described in more detail in section 3.

Mandatory HIV testing may be carried out for all donors prior to procedures involving transfusion of blood, bodily fluids or any organ transplant. In some countries, HIV testing is compulsorily carried out at the time of immigration, pregnancy and during routine medical check-ups of military personnel.

The individual, and health service cost, benefits associated with early detection and early medical intervention in cases of HIV infection offer a strong argument for routine testing, even amongst those populations where the incidence of HIV is low (Paltiel, 2006). Whilst evidence for screening programmes reducing the transmission of HIV is unclear (Paltiel, 2006), a range of studies indicate that those who are aware of their HIV status amend their behaviour so as to limit the risk of HIV transmission to others (Marks et al., 2005; Crepaz et al., 2006; Chou et al., 2005).

In the United States (U.S.) in 2006, in an effort to improve the identification of HIV-positive individuals, the Center for Diseases Control and Prevention (CDC) released their current HIV testing guidelines. These recommended routine testing for those age 13 to 64 years regardless of risk factors, unless testing is specifically declined by the individual (opt-out testing) (Branson et al., 2006). In the U.S. the following criteria apply: opt-out HIV screening is recommended for patients in all healthcare settings, with people at high risk for HIV infection screened for HIV at least annually. Here, separate written consent for HIV testing is not required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Finally, prevention counselling should not be required with HIV diagnostic testing or as part of HIV screening programmes in healthcare settings (Branson et al., 2006). Although one-third of people with HIV infection in the UK remain undiagnosed, current UK guidelines recommend opt-out testing only for pregnant women and people attending genitourinary clinics (Hamill et al., 2007).

#### **2.2 HIV tests**

628 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

a variety of clinical settings," but provides no specific guidance on how the testing should be done (BHVA, 2005). The selection of the most appropriate test, and testing protocol, should not only be informed by test sensitivity and specificity, but also by a number of economic and logistic factors (Branson, 2003). The following sections outline some key information relating to procedures for HIV testing, categories of HIV testing, and HIV

HIV testing has evolved from initial concerns, in the mid/early 1980s, for screening the supply of donated blood, to now reflect a broader range of concerns which include clinical diagnosis and strategic public health intervention (Branson, 2000a, 2000b). UNAIDS/WHO have identified four distinct categories of HIV testing: Diagnostic testing, Voluntary counselling and testing (VCT), Routinised testing in specific setting, and Mandatory testing. Diagnostic HIV testing is testing undertaken where signs and symptoms related to an HIV infection are observed in any individual. Testing is carried out to ensure timely clinical diagnosis, and to ensure the provision of adequate clinical support and services. People with certain diseases, such as tuberculosis and any other sexually transmitted disease, are also

Voluntary counselling and testing, also referred to as 'client focused testing', categorises those programmes of HIV testing which are designed to promote HIV awareness and to broaden access to HIV testing. Such testing is carried out in the absence of individual symptoms and is combined with group and individual counselling around HIV issues to raise awareness and educate in relevant health, and health behaviour, areas. This kind of testing programme is often undertaken with those who are perceived to be at high-risk of exposure to the HIV virus, or those who are concerned that they have been recently exposed to HIV. Testing is provided in local health and community settings, and pre and post-test counselling is offered to all those being testing. Pre-test counselling is often delivered in group settings, with post-test and follow-up counselling delivered on a one-to-one basis. UNAIDS/WHO identify VCT as the most effective approach to testing for achieving

Routine HIV testing of those accessing clinical or medical services is often carried out in those settings where high risk client groups are prevalent. Such testing is carried out with the purpose of early (asymptomatic) identification, with associated benefits for reduced risk of unwitting transmission of the virus. Carried out in community health centres, specialist clinics or hospitals settings such testing includes that undertaken in sexual health clinics with people who are undergoing diagnostic testing for other sexually transmitted diseases. It also incorporates the testing of intravenous drug users in primary and secondary care settings. Routine testing of this kind often utilises rapid HIV tests, which are described in

Mandatory HIV testing may be carried out for all donors prior to procedures involving transfusion of blood, bodily fluids or any organ transplant. In some countries, HIV testing is compulsorily carried out at the time of immigration, pregnancy and during routine medical

The individual, and health service cost, benefits associated with early detection and early medical intervention in cases of HIV infection offer a strong argument for routine testing, even amongst those populations where the incidence of HIV is low (Paltiel, 2006). Whilst

testing guidelines, and consider technical and process issues relating to HIV testing.

tested for HIV infection on a regular basis to this end.

behaviour change to prevent HIV transmission in public settings.

**2.1 Testing for HIV** 

more detail in section 3.

check-ups of military personnel.

HIV testing involves the detection of antibodies produced by the body in an unsuccessful attempt to fight HIV infection, such antibodies being more easily detected than the virus itself. Testing can be carried out on whole blood, plasma, serum, urine, dried blood spots and saliva samples, but might only be carried out after a 3-8 week period following infection (Schopper & Vercauteren, 1996). During this 3-8 week window the HIV antigen is rarely identified - bar in exceptional circumstances at the peak of high circulation of virus particles (Carne, 1988; Chin, et al., 2007).

Initial developments in HIV screening centred upon the need to ensure that donated blood remained free of the HIV virus. A *testing paradigm* thus emerged to protect the supply of donated blood, a paradigm marked by "tests with high sensitivity, suitable for batch processing of high volumes of specimens in centralised laboratories with specialised equipment." (Branson, 2000a). The enzyme-linked immunosorbent assay (ELISA) was indicative of this; a screening test for blood, efficient in large-scale hospital settings and reliant upon specialist laboratory equipment. The ELISA is the most appropriate, and most commonly used, screening test for samples greater than 100 per day; the ELISA is most appropriate for population level surveillance of HIV infection (UNAIDS, 1997). Performed by trained medical staff the ELISA test is reliable, but incurs substantial costs and might only offer results a few days after testing. Whilst this cost and delay are less important in screening donated blood, for other forms of testing they might act as a barrier.

During the late 1980s and early 1990s the benefits of *voluntary counselling and testing* were increasingly recognised and other testing algorithms were developed to meet this end (Branson, 2000a). Concerns about false positives from the ELISA test led the U.S. Public Health Service recommending secondary testing with the Western Blot (WB) to ensure accuracy. Although once again, the significant time delay associated with this combination of tests, of up to 2 weeks before test results are returned to patients, was a significant barrier. Also ELISA both in isolation and in combination with the WB test has limited suitability for remote or smaller clinical settings where resources are limited and access to adequate

Saliva Testing As a Practical Tool for Rapid HIV Screening 631

at home, in the highest uptake in rural areas, in young people and groups with low educational attainment; this has resulted in substantial reductions in existing inequalities in accessing such services (Mutale et al., 2010). However, there are serious caveats associated with home testing which must be considered and balanced against any perceived benefits. Firstly, there is a potential that such kits may be fraudulent (e.g. Kurtzweil, 1999) or less accurate than those administered by trained staff. Secondly, there may be a risk of abuse if individuals are forced to take tests against their will. Finally, there a need for immediate confirmation of results and also access to counselling for those with a positive test result. In the UK little HIV testing is currently performed outside GUM and antenatal settings (Tweed

The introduction of rapid and 'point of care' testing in HIV was primarily to increase identification of HIV infected individuals, to enable inexpensive and convenient methods of testing amongst rural, outreach and at-risk populations, and to improve consumer experience of the testing procedure (Holt, 2009). Such rapid tests use finger-stick capillary whole blood (FSB) or oral fluid (OF), thus avoiding the need for venous blood sampling and centrifugation (Pavie et al., 2010). Specific benefits associated with rapid testing include immediate communication of test results (in standard tests between 25% and 33% of those tested do not return to receive their results), and advantages in immediate medical staff awareness of HIV status so as to limit the potential for HIV transmission during medical

Rapid tests modified to use oral fluid samples obviate the need for either venepuncture or finger prick blood analysis (Hamill et al., 2007). Oral fluid HIV tests offer additional advantages due to their non-invasive nature, can be performed anywhere, do not require specialist phlebotomy training or equipment, and reduce biohazardous risk (Delaney et al., 2006). Rapid, reliable and affordable tests, requiring no equipment and minimal training, are now also available for HIV infection in developing countries (Peeling & Mabey, 2010).

In recent decades, a number of rapid test assays have been developed that enable HIV antibody status to be determined quickly, efficiently and less invasively than traditional forms of testing. Most rapid tests can be conveniently carried out 'on site' by someone with basic training and for this reason these are often referred to as 'point-of-care testing' (Kendrick et al., 2005). These tests are designed to detect antibodies in several different body fluids including whole blood from finger-prick blood, plasma, urine, or saliva. Rapid tests are simple to perform, can be conducted in rural settings without laboratory equipment, and remove the need to process and store specimens and transport them from the field (Pascoe

Rapid tests rely on samples of blood taken from fingertip or saliva sample obtained by rubbing an absorbent pad across the lower and upper gums in the mouth. Obtained blood or saliva sample is then transferred into a plastic device already containing a developer solution, followed by the insertion of an assay test strip into the device. After a brief waiting period of approximately 15-20 minutes the appearance of two lines on the test strip is interpreted as a positive test result, indicating the presence of HIV-1 antibodies; however, a

single line indicates a negative test result, and no visible lines imply an invalid test.

et al., 2010).

et al., 2009).

**3. Rapid testing and saliva testing** 

procedures (Kane, 1999; Branson, 2000a).

**3.1 Nature of rapid testing and saliva testing** 

facilities is restricted (McCarthy et al., 1993; Owens et al., 1996). With particular concern for testing in the developing world, and to reflect a growing number of simple and rapid assays, the UN/WHO offers an informative typology of testing combinations (UNAIDS, 1997; Branson, 2000a, 2003).

For blood screening, population surveillance (of high risk groups) and diagnosis of individuals from high risk populations (who are displaying signs/symptoms of HIV infection) a single screening assay is adequate; and, a reactive test should be considered sufficient for a HIV positive diagnosis. For population surveillance (low and mid-risk groups), asymptomatic individual diagnosis (high risk group) and symptomatic diagnosis (low and mid-risk social group) a second screening assay should follow an initial reactive test; if both initial and second assays are reactive then the specimen is considered positive. For asymptomatic diagnosis (low and mid-risk social group) a third screening assay should be carried out following initial and second reactive tests; the specimen is considered positive if the third test is also reactive.

## **2.3 Technical and process issues**

Above all, HIV testing should be carried in accordance with ethical principles designed to protect human rights. Testing should be carried out in a confidential manner and the person being tested should be fully informed about the nature and procedures of the test. Tests should be undertaken with caution since clinicians may be both civilly and criminally liable if they take a blood sample for HIV testing without disclosing to the patient (i) the nature of the test, (ii) the possible consequences of a positive result, and (iii) without obtaining informed consent (Sherrad & Gatt, 1987).

Further, where a positive HIV test manifests, appropriate psychological counselling should be provided to the diagnosed individual (WHO, 2004). Other technical and process issues include consideration of the cost-effectiveness of testing, of the quality of tests and testing procedures, and of the potential for home testing and the associated benefits and caveats.

#### *Cost-effectiveness*

Evidence from the U.S. suggests that routine, voluntary HIV testing is not only of crucial public health importance but is also economically justified (Walensky et al., 2007). The cost of HIV testing kits is variable, although this expenditure accounts for a substantial portion of the budget in national AIDS programmes. Selecting the most appropriate and cost-effective products for each particular setting therefore includes careful consideration of a range of factors including cost of test kit, storage, equipment maintenance and training of personnel.

#### *Quality of testing procedures*

Ensuring that quality is maintained and standard operating procedures are followed is critical to the generation of reliable results. The majority of HIV diagnostic products perform very well when used according to specific instructions. However, there is a risk that kits may be produced that do not meet exacting standards for quality, or make fraudulent claims for endorsement by WHO or the U.S. Food and Drink Administration (Kurtzweil, 1999). This remains an ongoing challenge.

#### *Home testing*

Home testing has positive implications for offering an alternative to people who might otherwise not seek testing in traditional health care facilities. For example, in some countries, a high uptake has been achieved by delivering both HIV counselling and testing

facilities is restricted (McCarthy et al., 1993; Owens et al., 1996). With particular concern for testing in the developing world, and to reflect a growing number of simple and rapid assays, the UN/WHO offers an informative typology of testing combinations (UNAIDS,

For blood screening, population surveillance (of high risk groups) and diagnosis of individuals from high risk populations (who are displaying signs/symptoms of HIV infection) a single screening assay is adequate; and, a reactive test should be considered sufficient for a HIV positive diagnosis. For population surveillance (low and mid-risk groups), asymptomatic individual diagnosis (high risk group) and symptomatic diagnosis (low and mid-risk social group) a second screening assay should follow an initial reactive test; if both initial and second assays are reactive then the specimen is considered positive. For asymptomatic diagnosis (low and mid-risk social group) a third screening assay should be carried out following initial and second reactive tests; the specimen is considered positive

Above all, HIV testing should be carried in accordance with ethical principles designed to protect human rights. Testing should be carried out in a confidential manner and the person being tested should be fully informed about the nature and procedures of the test. Tests should be undertaken with caution since clinicians may be both civilly and criminally liable if they take a blood sample for HIV testing without disclosing to the patient (i) the nature of the test, (ii) the possible consequences of a positive result, and (iii) without obtaining

Further, where a positive HIV test manifests, appropriate psychological counselling should be provided to the diagnosed individual (WHO, 2004). Other technical and process issues include consideration of the cost-effectiveness of testing, of the quality of tests and testing procedures, and of the potential for home testing and the associated benefits and caveats.

Evidence from the U.S. suggests that routine, voluntary HIV testing is not only of crucial public health importance but is also economically justified (Walensky et al., 2007). The cost of HIV testing kits is variable, although this expenditure accounts for a substantial portion of the budget in national AIDS programmes. Selecting the most appropriate and cost-effective products for each particular setting therefore includes careful consideration of a range of factors including cost of test kit, storage, equipment maintenance and training of personnel.

Ensuring that quality is maintained and standard operating procedures are followed is critical to the generation of reliable results. The majority of HIV diagnostic products perform very well when used according to specific instructions. However, there is a risk that kits may be produced that do not meet exacting standards for quality, or make fraudulent claims for endorsement by WHO or the U.S. Food and Drink Administration (Kurtzweil, 1999).

Home testing has positive implications for offering an alternative to people who might otherwise not seek testing in traditional health care facilities. For example, in some countries, a high uptake has been achieved by delivering both HIV counselling and testing

1997; Branson, 2000a, 2003).

if the third test is also reactive.

*Cost-effectiveness* 

*Home testing* 

*Quality of testing procedures* 

This remains an ongoing challenge.

**2.3 Technical and process issues** 

informed consent (Sherrad & Gatt, 1987).

at home, in the highest uptake in rural areas, in young people and groups with low educational attainment; this has resulted in substantial reductions in existing inequalities in accessing such services (Mutale et al., 2010). However, there are serious caveats associated with home testing which must be considered and balanced against any perceived benefits. Firstly, there is a potential that such kits may be fraudulent (e.g. Kurtzweil, 1999) or less accurate than those administered by trained staff. Secondly, there may be a risk of abuse if individuals are forced to take tests against their will. Finally, there a need for immediate confirmation of results and also access to counselling for those with a positive test result. In the UK little HIV testing is currently performed outside GUM and antenatal settings (Tweed et al., 2010).

## **3. Rapid testing and saliva testing**

The introduction of rapid and 'point of care' testing in HIV was primarily to increase identification of HIV infected individuals, to enable inexpensive and convenient methods of testing amongst rural, outreach and at-risk populations, and to improve consumer experience of the testing procedure (Holt, 2009). Such rapid tests use finger-stick capillary whole blood (FSB) or oral fluid (OF), thus avoiding the need for venous blood sampling and centrifugation (Pavie et al., 2010). Specific benefits associated with rapid testing include immediate communication of test results (in standard tests between 25% and 33% of those tested do not return to receive their results), and advantages in immediate medical staff awareness of HIV status so as to limit the potential for HIV transmission during medical procedures (Kane, 1999; Branson, 2000a).

Rapid tests modified to use oral fluid samples obviate the need for either venepuncture or finger prick blood analysis (Hamill et al., 2007). Oral fluid HIV tests offer additional advantages due to their non-invasive nature, can be performed anywhere, do not require specialist phlebotomy training or equipment, and reduce biohazardous risk (Delaney et al., 2006). Rapid, reliable and affordable tests, requiring no equipment and minimal training, are now also available for HIV infection in developing countries (Peeling & Mabey, 2010).

#### **3.1 Nature of rapid testing and saliva testing**

In recent decades, a number of rapid test assays have been developed that enable HIV antibody status to be determined quickly, efficiently and less invasively than traditional forms of testing. Most rapid tests can be conveniently carried out 'on site' by someone with basic training and for this reason these are often referred to as 'point-of-care testing' (Kendrick et al., 2005). These tests are designed to detect antibodies in several different body fluids including whole blood from finger-prick blood, plasma, urine, or saliva. Rapid tests are simple to perform, can be conducted in rural settings without laboratory equipment, and remove the need to process and store specimens and transport them from the field (Pascoe et al., 2009).

Rapid tests rely on samples of blood taken from fingertip or saliva sample obtained by rubbing an absorbent pad across the lower and upper gums in the mouth. Obtained blood or saliva sample is then transferred into a plastic device already containing a developer solution, followed by the insertion of an assay test strip into the device. After a brief waiting period of approximately 15-20 minutes the appearance of two lines on the test strip is interpreted as a positive test result, indicating the presence of HIV-1 antibodies; however, a single line indicates a negative test result, and no visible lines imply an invalid test.

Saliva Testing As a Practical Tool for Rapid HIV Screening 633

Rapid tests have been used for more than two decades to test serum and plasma, particularly in developing countries and for emergency diagnosis. They are simple to use and have high specificity, however, false positives do occur and they have been criticised in previous years for lacking in sensitivity relative to reference enzyme immunoassays (EIA/ELISA), particularly during primary HIV infection and infection by variant strains (Makuwa et al., 2002). There is, however, research evidence to indicate that rapid HIV tests produce results of comparable sensitivity and specificity to the ELISA test (Franco-Paredes et al., 2006; Greenwald et al., 2006; Branson, 2000a). Laboratory testing of 1266 specimens at rural peripheral laboratories of varied combinations of seven rapid HIV tests even showed a specificity of 100% (Stetler et al., 1997). Empirical studies have shown promising findings in a range of settings and populations including HIV positive individuals (DeBattista et al., 2007), HIV negative individuals (Makasso, 2005), sexual health clinic attenders (DeBattista et al., 2007), pregnant adult women in Namibia (Hamers et al., 2008), acute care (Lee et al, 2011) and adults presenting for voluntary testing elsewhere in the developing world (Pascoe

Furthermore, whilst some early work has suggested that salivary testing should be recommended only for epidemiological studies (Mortimer & Parry, 1992), more recent studies have continued to demonstrate that rapid oral fluid tests show a high standard of sensitivity and specificity (e.g. Debattista et al., 2007; Hamers et al., 2008; Delaney et al., 2006). Independent performance data for 4 FDA approved rapid HIV tests (Franco-Paredes et al., 2006) and a wider range of rapid tests (Branson, 2000a) highlight product testing with both sensitivity and specificity outcomes of 100% (Oraquick and Retrocell HIV-1/2) (Branson, 2000a). Data from 2006 showed that in testing, sensitivity and specificity exceeded 99% in 4 FDA approved tests (with the exception of Reveal G2 Plasma test where specificity is 98.6%) (Franco-Paredes et al., 2006). Comparisons between rapid HIV tests are inconsistent. It has been suggested that there may be differences in diagnostic accuracy, with tests being less sensitive on oral fluid than on finger-stick whole blood and less sensitive on finger-stick whole blood than on serum (Pavie et al., 2010). More recently, in a direct comparison of the performance of all 6 tests currently approved by the FDA for use in the U.S. (using whole blood, oral fluid, serum, and plasma specimens), it has been shown that *all* rapid tests have statistically equivalent performance characteristics, based on overlapping confidence intervals for sensitivity and specificity, compared with conventional ELISA

It should be noted that although rapid tests using saliva have been shown to have high sensitivity and specificity parameters (Delaney et al., 2011), these are essentially brief screening tests and it has long been recognised that in cases where the first screening test utilised saliva, the diagnosis should be reconfirmed through a rapid test that involves blood testing (Andersson et al., 1997). In fact, it is now generally accepted that a second confirmatory test which detects the presence of a specific type of antibody to HIV 1/2 *must* follow (Franco-Paredes, et al., 2006). WHO recommends that for diagnostic purposes, two assays be used with a third test for discrepant results (Strategy II and III); the first test must have the highest sensitivity and the second test a similar or higher specificity (UNAIDS/WHO, 2004). Accuracy may be altered in pregnancy, and to improve diagnostic accuracy and to reduce false-positive results it may be necessary to use two rapid tests during labour and delivery (Pai et al., 2007). Some further limitations have been identified with oral fluid assays (e.g. unlikely to detect those in early stages of HIV infection or with reduced viral load) these limitations also apply to other rapid assays (Pascoe et al., 2009).

et al., 2009).

(Delaney et al., 2011).

The speed with which test results can be produced make rapid HIV tests very popular and extremely useful particularly in public outreach settings (Spielberg et al., 2005). In such settings there may be limited access to a HIV test centre and furthermore, there may be a reluctance to be assessed for HIV infection amongst certain groups (e.g. sex-workers, druginjectors). Moreover, it is not uncommon that individuals who have agreed to take a HIV test, do not return for their conventional laboratory blood test results and thus remain unaware of their HIV virus carrier status, presenting a danger to society as potential HIV transmitters (Galvan et al., 2004). Use of rapid saliva tests also have the potential to prevent HIV infections occurring in health workers due to handling of blood during standard ELISA, WB or rapid blood tests.

The unique features manifested by all rapid tests are their non-invasive testing procedure and the immediacy of producing results. Another advanced characteristic of rapid tests is the level of anonymity offered since the saliva, blood or urine specimen can be collected at home, sent to the laboratory for testing and results declared via the telephone, without a need to visit the clinic in person.

#### **3.2 Diagnostic accuracy of HIV rapid tests**

All diagnostic tests have limitations and sometimes their use may produce erroneous or questionable results. The accuracy of tests is often described in terms of 'sensitivity' (the percentage of results that will be positive when HIV is not present) and 'specificity' (the percentage of results that will be negative when HIV is not present). False positives occur when the test incorrectly indicates that HIV is present in a non-infected person. Conversely, false negatives occur when the test incorrectly indicates that HIV is absent in an infected person.

In a review of the risks and benefits of HIV screening, the U.S. Preventive Services Task Force concluded in 2005 that, "…the use of repeatedly reactive enzyme immunoassay followed by confirmatory Western blot or immunoflourescent assay remains the standard method for diagnosing HIV-1 infection. A large study of HIV testing in 725 U.S. laboratories reported a sensitivity of 99.7% and a specificity of 98.5% for enzyme immunoassay, and studies in U.S. blood donors reported specificities of 99.8% and greater than 99.99%. With confirmatory Western blot, the chance of a false-positive identification in a low-prevalence setting is about 1 in 250,000 (95% CI, 1 in 173,000 to 1 in 379,000)" (Chou et al., 2005).

The specificity rate outlined above for enzyme immunoassay screening tests indicates that, in every 1,000 positive HIV test results, there will be around 15 false positive results. However, confirming the test result (e.g. repeating the test, if this option is available) may reduce the likelihood of a false positive to just 1 result in every 250,000 tests. The sensitivity rating outlined above indicates that, in every 1,000 negative HIV test results, there will be 3 false negative results. Nevertheless, the high negative predictive value of these tests is extremely high, meaning that a negative test result will be correct more than 9,997 times in 10,000 (99.97% of the time). Due to the high negative predictive value of HIV screening tests, the CDC recommends that a negative test results be considered conclusive evidence that an individual does not have HIV.

Non-specific reactions, hypergammaglobulinemia, or the presence of antibodies directed to other infectious agents that may be antigenically similar to HIV can produce false positive results. Auto-immune diseases, such as systemic lupus erythematosus, have also rarely caused false positive results. Most false negative results are due to the window period; other factors, such as post-exposure prophylaxis, can rarely produce false negatives (Hare et al., 2004).

The speed with which test results can be produced make rapid HIV tests very popular and extremely useful particularly in public outreach settings (Spielberg et al., 2005). In such settings there may be limited access to a HIV test centre and furthermore, there may be a reluctance to be assessed for HIV infection amongst certain groups (e.g. sex-workers, druginjectors). Moreover, it is not uncommon that individuals who have agreed to take a HIV test, do not return for their conventional laboratory blood test results and thus remain unaware of their HIV virus carrier status, presenting a danger to society as potential HIV transmitters (Galvan et al., 2004). Use of rapid saliva tests also have the potential to prevent HIV infections occurring in health workers due to handling of blood during standard

The unique features manifested by all rapid tests are their non-invasive testing procedure and the immediacy of producing results. Another advanced characteristic of rapid tests is the level of anonymity offered since the saliva, blood or urine specimen can be collected at home, sent to the laboratory for testing and results declared via the telephone, without a

All diagnostic tests have limitations and sometimes their use may produce erroneous or questionable results. The accuracy of tests is often described in terms of 'sensitivity' (the percentage of results that will be positive when HIV is not present) and 'specificity' (the percentage of results that will be negative when HIV is not present). False positives occur when the test incorrectly indicates that HIV is present in a non-infected person. Conversely, false negatives occur when the test incorrectly indicates that HIV is absent in an infected

In a review of the risks and benefits of HIV screening, the U.S. Preventive Services Task Force concluded in 2005 that, "…the use of repeatedly reactive enzyme immunoassay followed by confirmatory Western blot or immunoflourescent assay remains the standard method for diagnosing HIV-1 infection. A large study of HIV testing in 725 U.S. laboratories reported a sensitivity of 99.7% and a specificity of 98.5% for enzyme immunoassay, and studies in U.S. blood donors reported specificities of 99.8% and greater than 99.99%. With confirmatory Western blot, the chance of a false-positive identification in a low-prevalence

The specificity rate outlined above for enzyme immunoassay screening tests indicates that, in every 1,000 positive HIV test results, there will be around 15 false positive results. However, confirming the test result (e.g. repeating the test, if this option is available) may reduce the likelihood of a false positive to just 1 result in every 250,000 tests. The sensitivity rating outlined above indicates that, in every 1,000 negative HIV test results, there will be 3 false negative results. Nevertheless, the high negative predictive value of these tests is extremely high, meaning that a negative test result will be correct more than 9,997 times in 10,000 (99.97% of the time). Due to the high negative predictive value of HIV screening tests, the CDC recommends that a negative test results be considered conclusive evidence that an

Non-specific reactions, hypergammaglobulinemia, or the presence of antibodies directed to other infectious agents that may be antigenically similar to HIV can produce false positive results. Auto-immune diseases, such as systemic lupus erythematosus, have also rarely caused false positive results. Most false negative results are due to the window period; other factors, such as post-exposure prophylaxis, can rarely produce false negatives (Hare et al., 2004).

setting is about 1 in 250,000 (95% CI, 1 in 173,000 to 1 in 379,000)" (Chou et al., 2005).

ELISA, WB or rapid blood tests.

need to visit the clinic in person.

individual does not have HIV.

person.

**3.2 Diagnostic accuracy of HIV rapid tests** 

Rapid tests have been used for more than two decades to test serum and plasma, particularly in developing countries and for emergency diagnosis. They are simple to use and have high specificity, however, false positives do occur and they have been criticised in previous years for lacking in sensitivity relative to reference enzyme immunoassays (EIA/ELISA), particularly during primary HIV infection and infection by variant strains (Makuwa et al., 2002). There is, however, research evidence to indicate that rapid HIV tests produce results of comparable sensitivity and specificity to the ELISA test (Franco-Paredes et al., 2006; Greenwald et al., 2006; Branson, 2000a). Laboratory testing of 1266 specimens at rural peripheral laboratories of varied combinations of seven rapid HIV tests even showed a specificity of 100% (Stetler et al., 1997). Empirical studies have shown promising findings in a range of settings and populations including HIV positive individuals (DeBattista et al., 2007), HIV negative individuals (Makasso, 2005), sexual health clinic attenders (DeBattista et al., 2007), pregnant adult women in Namibia (Hamers et al., 2008), acute care (Lee et al, 2011) and adults presenting for voluntary testing elsewhere in the developing world (Pascoe et al., 2009).

Furthermore, whilst some early work has suggested that salivary testing should be recommended only for epidemiological studies (Mortimer & Parry, 1992), more recent studies have continued to demonstrate that rapid oral fluid tests show a high standard of sensitivity and specificity (e.g. Debattista et al., 2007; Hamers et al., 2008; Delaney et al., 2006). Independent performance data for 4 FDA approved rapid HIV tests (Franco-Paredes et al., 2006) and a wider range of rapid tests (Branson, 2000a) highlight product testing with both sensitivity and specificity outcomes of 100% (Oraquick and Retrocell HIV-1/2) (Branson, 2000a). Data from 2006 showed that in testing, sensitivity and specificity exceeded 99% in 4 FDA approved tests (with the exception of Reveal G2 Plasma test where specificity is 98.6%) (Franco-Paredes et al., 2006). Comparisons between rapid HIV tests are inconsistent. It has been suggested that there may be differences in diagnostic accuracy, with tests being less sensitive on oral fluid than on finger-stick whole blood and less sensitive on finger-stick whole blood than on serum (Pavie et al., 2010). More recently, in a direct comparison of the performance of all 6 tests currently approved by the FDA for use in the U.S. (using whole blood, oral fluid, serum, and plasma specimens), it has been shown that *all* rapid tests have statistically equivalent performance characteristics, based on overlapping confidence intervals for sensitivity and specificity, compared with conventional ELISA (Delaney et al., 2011).

It should be noted that although rapid tests using saliva have been shown to have high sensitivity and specificity parameters (Delaney et al., 2011), these are essentially brief screening tests and it has long been recognised that in cases where the first screening test utilised saliva, the diagnosis should be reconfirmed through a rapid test that involves blood testing (Andersson et al., 1997). In fact, it is now generally accepted that a second confirmatory test which detects the presence of a specific type of antibody to HIV 1/2 *must* follow (Franco-Paredes, et al., 2006). WHO recommends that for diagnostic purposes, two assays be used with a third test for discrepant results (Strategy II and III); the first test must have the highest sensitivity and the second test a similar or higher specificity (UNAIDS/WHO, 2004). Accuracy may be altered in pregnancy, and to improve diagnostic accuracy and to reduce false-positive results it may be necessary to use two rapid tests during labour and delivery (Pai et al., 2007). Some further limitations have been identified with oral fluid assays (e.g. unlikely to detect those in early stages of HIV infection or with reduced viral load) these limitations also apply to other rapid assays (Pascoe et al., 2009).

Saliva Testing As a Practical Tool for Rapid HIV Screening 635

including MSM, high-risk heterosexual populations and injecting drug users (Speilberg et

Research has shown that the majority of adults tested (95%) preferred results to be disclosed by telephone, again highlighting the importance of privacy issues in testing procedures (Speilberg et al., 2000). Positive implications of, rapid testing also include potential for, and increased monitoring and awareness of HIV related risk-behaviour (Speilberg et al., 2000). In MSM, injecting drug users and high risk heterosexuals attending a sexual health clinic (Greensides et al., 2003; Colfax et al., 2002), concerns have been raised about rapid testing in relation to associated costs, privacy issues, accuracy and reliability of results, access to post-test counselling and information, lack of access to testing, and lack of knowledge about testing centres and procedures (Greensides et al., 2003). It has been suggested that concerns regarding the accuracy of the rapid test might limit test acceptance and should be addressed during pre-test information procedures

Nevertheless, despite these concerns, a strong preference has been identified for noninvasive quick testing procedures, in particular, rapid oral testing methods (Chen et al., 2010). Although rapid testing procedures appear to be preferred in these populations, a large proportion of these individuals (almost half) remain unaware of the availability of home collection kits for HIV testing in areas where these are accessible (Greensides et al., 2003; Colfax et al., 2002). Many individuals 'at risk' have reported that they would test more frequently if testing was available for clinic or home use (Chen et al., 2010). In certain populations, such as MSM, those who prefer rapid testing may be significantly more likely to have some formal education, to have discussed testing with a sexual partner, to be aware

Research has investigated the potential for offering rapid testing in commercial and community venues, although a significant number of barriers have been raised. Again, concerns have been raised about the lack of confidentiality and privacy for testing in social venues, and about the potential lack of post-test support for those who test positive (Prost et

Studies of HIV testing have mainly considered *patient* preferences, although recent work has investigated the attitudes of *healthcare* staff towards testing (Arbelaez et al., 2009; Sahoni et al., 2010). For example, it has been shown that hospital staff satisfaction and overall attitudes towards HIV testing program in an emergency department is high, and that healthcare staff attitudes do not represent a barrier to program implementation (Sahoni et al., 2010). Rapid advances in technology have also led to widening of training opportunities for rapid testing across geographically remote healthcare facilities (Knapp et al., 2011). Further, research is emerging which considers the role of various healthcare professionals rapid diagnostic testing for HIV in various regions of the world (e.g. oral health care workers; Patton et al., 2011). Whilst conducting rapid screening in the dental clinic setting has been identified as a viable option (Dietz et al., 2008; Patton et al., 2011), oral healthcare professionals have expressed a lack of confidence that graduating dentists have the skills and willingness to conduct HIV counselling and testing in dental practice; in fact lack of training in prevention counselling has been identified as a primary barrier (Patton et al., 2002). Additional challenges to rapid testing have been identified in a range of medical settings including insufficient staffing, inadequate

privacy or space, associated administration, time limitations and competing priorities.

of rapid testing, and to have had a previous test (Cohall et al., 2010).

al., 2000; Greensides et al., 2003; Colfax et al., 2002; Sy et al., 1998, Chen et al., 2010).

(Merchant et al., 2009).

al., 2007).

*Healthcare populations* 

A large number of studies have been published to date on various aspects of test performance specifically for oral mucosal transudate (OMT) and saliva tests. A number of brief narrative reviews published between 1994-2006 have focused predominantly on the description of oral rapid test technologies, although this early work has not evaluated diagnostic accuracy. Two more recent systematic reviews on diagnostic accuracy have been conducted (Wesolowski, 2006; Pai, 2007). These include a review undertaken by the CDC as part of a post-marketing surveillance of one rapid test (Wesolowski, 2006) and a systematic review focused exclusively on performance of all rapid tests in pregnant women (Pai, 2007). A recent meta-analysis has evaluated OMT, saliva based rapid and point of care tests in at-risk populations worldwide from 1986-2011 (Balram & Pai, 2010). This data provided evidence of good overall performance of oral fluid-based HIV tests in global settings. The authors recommended these oral rapid tests as first line screening alternatives to blood-based rapid test and suggest their enhanced use in global expanded HIV testing initiatives (Balram & Pai, 2010). Furthermore, rapid testing is deemed to be suitable for use in community-based clinical research settings, to assess eligibility both for trial participation and for the provision of on-site voluntary counselling and testing services (Everett et al., 2009).

#### **3.3 Acceptability of HIV rapid tests**

Non-invasive rapid HIV tests have been consistently shown to be a preferred method of testing amongst varied population groups in both youth (Peralta et al., 2001; Pugatch et al., 2001) and adults, including men who have sex with men (MSM) (Sy et al., 1998; Chen et al., 2010) and injecting drug users (Colfax et al., 2002; Greensides et al., 2003; Spielberg et al., 2000). Recent research has also considered the acceptability of testing amongst healthcare professionals.

#### *Youth populations*

Although universal testing of adolescents is currently recommended in the U.S., previous studies have demonstrated that only 41% to 61% of adolescents offered a non-rapid HIV test agree to testing (Mehta et al., 2007; Goodman et al., 1994). Furthermore, only between one and two-thirds of adolescents who are tested return to receive their results and posttest counselling (Goodman et al., 1994; Ilegbodu et al., 1994; Lazebnik et al., 2001; Tsu et al., 2002). A recent study by Mullins et al. (2010) showed that 70% of adolescents preferred rapid to traditional HIV testing, and that rapid testers were more likely to receive their results within the follow-up period. This study suggested that for adolescents noninvasive testing may have a greater impact on their choice of a rapid method than the availability of same day test results. A high preference for rapid oral tests in comparison to invasive blood tests has also been demonstrated elsewhere (Pugatch et al., 2001; Peralta et al., 2001). Studies of rapid testing in specific settings have shown that paediatric emergency departments have been highly rated by adolescents aged 14-21 years, as a preferred location for rapid HIV testing. This supports the need for increased development of prevention and testing programs in this setting (Haines et al., 2011). It has been acknowledged that rapid testing should be followed by HIV prevention opportunities and rapid linkage to care (Peralta et al., 2001).

#### *Adult populations*

A high level of acceptance for rapid testing and a preference for rapid oral tests in comparison to invasive blood tests has been demonstrated in adult 'at risk' populations

A large number of studies have been published to date on various aspects of test performance specifically for oral mucosal transudate (OMT) and saliva tests. A number of brief narrative reviews published between 1994-2006 have focused predominantly on the description of oral rapid test technologies, although this early work has not evaluated diagnostic accuracy. Two more recent systematic reviews on diagnostic accuracy have been conducted (Wesolowski, 2006; Pai, 2007). These include a review undertaken by the CDC as part of a post-marketing surveillance of one rapid test (Wesolowski, 2006) and a systematic review focused exclusively on performance of all rapid tests in pregnant women (Pai, 2007). A recent meta-analysis has evaluated OMT, saliva based rapid and point of care tests in at-risk populations worldwide from 1986-2011 (Balram & Pai, 2010). This data provided evidence of good overall performance of oral fluid-based HIV tests in global settings. The authors recommended these oral rapid tests as first line screening alternatives to blood-based rapid test and suggest their enhanced use in global expanded HIV testing initiatives (Balram & Pai, 2010). Furthermore, rapid testing is deemed to be suitable for use in community-based clinical research settings, to assess eligibility both for trial participation and for the provision of on-site voluntary

Non-invasive rapid HIV tests have been consistently shown to be a preferred method of testing amongst varied population groups in both youth (Peralta et al., 2001; Pugatch et al., 2001) and adults, including men who have sex with men (MSM) (Sy et al., 1998; Chen et al., 2010) and injecting drug users (Colfax et al., 2002; Greensides et al., 2003; Spielberg et al., 2000). Recent research has also considered the acceptability of testing amongst healthcare

Although universal testing of adolescents is currently recommended in the U.S., previous studies have demonstrated that only 41% to 61% of adolescents offered a non-rapid HIV test agree to testing (Mehta et al., 2007; Goodman et al., 1994). Furthermore, only between one and two-thirds of adolescents who are tested return to receive their results and posttest counselling (Goodman et al., 1994; Ilegbodu et al., 1994; Lazebnik et al., 2001; Tsu et al., 2002). A recent study by Mullins et al. (2010) showed that 70% of adolescents preferred rapid to traditional HIV testing, and that rapid testers were more likely to receive their results within the follow-up period. This study suggested that for adolescents noninvasive testing may have a greater impact on their choice of a rapid method than the availability of same day test results. A high preference for rapid oral tests in comparison to invasive blood tests has also been demonstrated elsewhere (Pugatch et al., 2001; Peralta et al., 2001). Studies of rapid testing in specific settings have shown that paediatric emergency departments have been highly rated by adolescents aged 14-21 years, as a preferred location for rapid HIV testing. This supports the need for increased development of prevention and testing programs in this setting (Haines et al., 2011). It has been acknowledged that rapid testing should be followed by HIV prevention

A high level of acceptance for rapid testing and a preference for rapid oral tests in comparison to invasive blood tests has been demonstrated in adult 'at risk' populations

counselling and testing services (Everett et al., 2009).

opportunities and rapid linkage to care (Peralta et al., 2001).

**3.3 Acceptability of HIV rapid tests** 

professionals. *Youth populations* 

*Adult populations* 

including MSM, high-risk heterosexual populations and injecting drug users (Speilberg et al., 2000; Greensides et al., 2003; Colfax et al., 2002; Sy et al., 1998, Chen et al., 2010).

Research has shown that the majority of adults tested (95%) preferred results to be disclosed by telephone, again highlighting the importance of privacy issues in testing procedures (Speilberg et al., 2000). Positive implications of, rapid testing also include potential for, and increased monitoring and awareness of HIV related risk-behaviour (Speilberg et al., 2000). In MSM, injecting drug users and high risk heterosexuals attending a sexual health clinic (Greensides et al., 2003; Colfax et al., 2002), concerns have been raised about rapid testing in relation to associated costs, privacy issues, accuracy and reliability of results, access to post-test counselling and information, lack of access to testing, and lack of knowledge about testing centres and procedures (Greensides et al., 2003). It has been suggested that concerns regarding the accuracy of the rapid test might limit test acceptance and should be addressed during pre-test information procedures (Merchant et al., 2009).

Nevertheless, despite these concerns, a strong preference has been identified for noninvasive quick testing procedures, in particular, rapid oral testing methods (Chen et al., 2010). Although rapid testing procedures appear to be preferred in these populations, a large proportion of these individuals (almost half) remain unaware of the availability of home collection kits for HIV testing in areas where these are accessible (Greensides et al., 2003; Colfax et al., 2002). Many individuals 'at risk' have reported that they would test more frequently if testing was available for clinic or home use (Chen et al., 2010). In certain populations, such as MSM, those who prefer rapid testing may be significantly more likely to have some formal education, to have discussed testing with a sexual partner, to be aware of rapid testing, and to have had a previous test (Cohall et al., 2010).

Research has investigated the potential for offering rapid testing in commercial and community venues, although a significant number of barriers have been raised. Again, concerns have been raised about the lack of confidentiality and privacy for testing in social venues, and about the potential lack of post-test support for those who test positive (Prost et al., 2007).

#### *Healthcare populations*

Studies of HIV testing have mainly considered *patient* preferences, although recent work has investigated the attitudes of *healthcare* staff towards testing (Arbelaez et al., 2009; Sahoni et al., 2010). For example, it has been shown that hospital staff satisfaction and overall attitudes towards HIV testing program in an emergency department is high, and that healthcare staff attitudes do not represent a barrier to program implementation (Sahoni et al., 2010). Rapid advances in technology have also led to widening of training opportunities for rapid testing across geographically remote healthcare facilities (Knapp et al., 2011). Further, research is emerging which considers the role of various healthcare professionals rapid diagnostic testing for HIV in various regions of the world (e.g. oral health care workers; Patton et al., 2011). Whilst conducting rapid screening in the dental clinic setting has been identified as a viable option (Dietz et al., 2008; Patton et al., 2011), oral healthcare professionals have expressed a lack of confidence that graduating dentists have the skills and willingness to conduct HIV counselling and testing in dental practice; in fact lack of training in prevention counselling has been identified as a primary barrier (Patton et al., 2002). Additional challenges to rapid testing have been identified in a range of medical settings including insufficient staffing, inadequate privacy or space, associated administration, time limitations and competing priorities.

Saliva Testing As a Practical Tool for Rapid HIV Screening 637

Arbelaez, C., Wright, E., Losina, E. & et al. (2009). Emergency provider attitudes and barriers

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## **4. Conclusions**

This is a rapidly advancing field and as such this chapter presents an overview of the key issues with selected evidence. In conclusion, it seems that rapid screening tests and/or alternative biological samples (such as oral fluid) are now thought to be effective in HIV prevention strategies by reaching a larger population through improved accessibility and general consent in approaches to screening, immediate referral of HIV positives for medical treatment and partner notification. Oral fluid testing has been implemented in a range of settings. The test appears to perform well in field settings, and can be considered a good alternative to blood samples, suitable for use in epidemiologic surveys aiming to estimate HIV prevalence in general populations and in high risk groups. There are several limitations in that oral fluid assays may be unlikely to detect those in early stages of HIV infection or with reduced viral load, and have shown altered accuracy in pregnancy; however, such limitations also apply to other rapid assays.

Research has suggested that in adults the most important factors in HIV testing are test accuracy, time to results and privacy of results. Studies have also suggested that patients express a preference for oral testing over venepuncture sampling since it is rapid and less invasive, although preferences may vary in different settings. Less invasive methods are preferred also in youth. Indeed, offering less invasive rapid testing to at-risk youth may assist clinicians in increasing the proportion of teens who agree to undergo testing and receive their test result. In general rapid testing is better accepted by patients in both developed and resource-limited settings. Point of care tests specifically assist in making testing accessible in areas with limited laboratory facilities. These tests have the potential for reducing the number of people who do not return to clinics to learn of their test result, and thus reduce the proportion of infected individuals who remain unaware of their diagnosis.

Overall, the majority of studies have demonstrated high sensitivity and specificity of oral fluid-based rapid HIV test in comparison with routinely utilized methods. With recent research showing comparable accuracy for a range of currently approved tests and specimen types, it may be characteristics such as convenience, time to result, shelf life, and cost that will be likely determining factors for selection of a rapid screening test for a specific application (Delaney et al., 2011). This suggests that rapid tests with well documented performance characteristics should be made available in public health and clinical settings.

Specifically, it seems that saliva specimens can be easily collected under difficult field conditions with minimal training and provide a valuable alternative to testing blood for HIV-seroprevalence studies. Salivary testing for HIV may therefore be a convenient and potentially accurate epidemiological tool, although should be used with caution since single test systems may be less appropriate to diagnose HIV infection in an individual without follow-up testing. There is a drive for continual improvement of test performance, such that is has been suggested that all initial positive findings should be repeated by second test method with a second confirmatory specimen found positive prior to informing the patient. This may serve to mitigate the emotional distress and unnecessary treatments associated with false positive HIV testing.

#### **5. References**

Andersson, S., da Silva, Z., Norrgren, H., Dias, F. & Biberfeld, G. (1997). Field evaluation of alternative testing strategies for diagnosis and differentiation of HIV-1 and HIV-2 infections in an HIV-1 and HIV-2-prevalent area, *AIDS,* 11 (15), 1815-1822.

This is a rapidly advancing field and as such this chapter presents an overview of the key issues with selected evidence. In conclusion, it seems that rapid screening tests and/or alternative biological samples (such as oral fluid) are now thought to be effective in HIV prevention strategies by reaching a larger population through improved accessibility and general consent in approaches to screening, immediate referral of HIV positives for medical treatment and partner notification. Oral fluid testing has been implemented in a range of settings. The test appears to perform well in field settings, and can be considered a good alternative to blood samples, suitable for use in epidemiologic surveys aiming to estimate HIV prevalence in general populations and in high risk groups. There are several limitations in that oral fluid assays may be unlikely to detect those in early stages of HIV infection or with reduced viral load, and have shown altered accuracy in pregnancy; however, such

Research has suggested that in adults the most important factors in HIV testing are test accuracy, time to results and privacy of results. Studies have also suggested that patients express a preference for oral testing over venepuncture sampling since it is rapid and less invasive, although preferences may vary in different settings. Less invasive methods are preferred also in youth. Indeed, offering less invasive rapid testing to at-risk youth may assist clinicians in increasing the proportion of teens who agree to undergo testing and receive their test result. In general rapid testing is better accepted by patients in both developed and resource-limited settings. Point of care tests specifically assist in making testing accessible in areas with limited laboratory facilities. These tests have the potential for reducing the number of people who do not return to clinics to learn of their test result, and thus reduce the

Overall, the majority of studies have demonstrated high sensitivity and specificity of oral fluid-based rapid HIV test in comparison with routinely utilized methods. With recent research showing comparable accuracy for a range of currently approved tests and specimen types, it may be characteristics such as convenience, time to result, shelf life, and cost that will be likely determining factors for selection of a rapid screening test for a specific application (Delaney et al., 2011). This suggests that rapid tests with well documented performance

Specifically, it seems that saliva specimens can be easily collected under difficult field conditions with minimal training and provide a valuable alternative to testing blood for HIV-seroprevalence studies. Salivary testing for HIV may therefore be a convenient and potentially accurate epidemiological tool, although should be used with caution since single test systems may be less appropriate to diagnose HIV infection in an individual without follow-up testing. There is a drive for continual improvement of test performance, such that is has been suggested that all initial positive findings should be repeated by second test method with a second confirmatory specimen found positive prior to informing the patient. This may serve to mitigate the emotional distress and unnecessary treatments associated

Andersson, S., da Silva, Z., Norrgren, H., Dias, F. & Biberfeld, G. (1997). Field evaluation of

infections in an HIV-1 and HIV-2-prevalent area, *AIDS,* 11 (15), 1815-1822.

alternative testing strategies for diagnosis and differentiation of HIV-1 and HIV-2

proportion of infected individuals who remain unaware of their diagnosis.

characteristics should be made available in public health and clinical settings.

**4. Conclusions** 

limitations also apply to other rapid assays.

with false positive HIV testing.

**5. References** 


Saliva Testing As a Practical Tool for Rapid HIV Screening 639

McCarthy, B., Wong, J., Munoz, A., & Sonnenberg, F. (1993). Who should be screened for

Makuwa, M., Souquie`re ,S., Niangui, M., Rouquet, P., Apetrei, C. & et al. (2002). Reliability of rapid diagnostic tests for HIV variant infection. *J Virol Methods,* 103, 183–190. Marks, G., Crepaz, N., Senterfitt, J. & Janssen, R. (2005). Meta-analysis of high-risk sexual

Mehta, S., Hall, J., Lyss, S. & et al. (2007). Adult and pediatric emergency department

Merchant, R., Clark, M., Seage, G. 3rd, Mayer, K., Degruttola, V. & Becker, B. (2009).

Mortimer, P., Parry, J. (1992). Letter to the Editor: Salivary testing for HIV infection. *BMJ*,

Mullins, T., Braverman, P., Dorn, L, Kollar, L., & Kahn, J. (2010). Adolescent Preferences for

Mutale, W., Michelo, C., Jürgensen, M.& Fylkesnes, K. (2010). Home-based voluntary HIV

Owens, D., Nease, R. & Harris, R. (1996). Cost-effectiveness of HIV screening in acute care

Paltiel, D., Walensky, R., Schackman, B., Seage, G., Mercincavage, L., Weinstein, M., &

Pai, N., Tulsky, J., Cohan, D., Colford, J. & Reingold, A. (2007). Rapid point-of-care HIV

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**26** 

**HAART and Causes of Death in Perinatally** 

Claudia Palladino1, Jose María Bellón2, Francisco J. Climent3,

*1Laboratorio de Inmuno-Biología Molecular, Hospital General Universitario* 

*2Unidad de Investigación, Fundación de Investigación Biomédica Hospital* 

*4Servicio Infecciosas Infantil, Hospital Universitario "La Paz", Madrid,* 

Children represent a population at higher risk of Human Immunodeficiency Virus type 1 (HIV-1) infection and AIDS-related death. Approximately 2.5 million (1.6–3.4) children are infected at present, accounting for 370,000 [230,000–510,000] new infections and 260,000 [150,000–360,000] deaths (Gray et al., 2001). About 90% of children living with HIV-1 are in sub-Saharan Africa. The paediatric HIV-1 epidemic is fuelled by HIV-1 infection in women of childbearing age. In fact, mother-to-child (perinatal) HIV-1 transmission during pregnancy, birth or breastfeeding accounts for the vast majority of HIV-1 cases in children. An estimated 2.4 million infected women give birth annually. This results in the birth of approximately 1,000 HIV-1–infected babies per day, of which 80% occur in resource-limited countries where there are no effective programs for prevention of mother-to-child transmission (MTCT) of HIV-1 . Almost two decades ago, the introduction of antiretroviral chemoprophylaxis to prevent MTCT of HIV-1 was an important milestone in paediatric HIV-1. The use of antiretroviral drugs and elective caesarean section have reduced the incidence of MTCT in industrialised countries to <2% since 1997 (The European Collaborative Study [ECS], 2005; Connor et al., 1994). However, such interventions to prevent MTCT of HIV-1 are still not widely accessible or available in most resource-limited countries where the rate of transmission is estimated at 12–40% (De Cock et al., 2000). Concerning the diagnosis and treatment of HIV-1, significant improvements have been made over the last few years, yet much more needs to be done. The first evidence of the efficacy of antiretroviral therapy (ART) in HIV-1–infected children was published 20 years ago (Pizzo et al., 1988). Since then, the introduction of highly active antiretroviral therapy (HAART) into medical care for HIV-1–infected children and adolescents has increased life expectancy and resulted in AIDS incidence decline in both industrialised countries and resource-limited settings (Judd et al., 2007; Patel et al., 2008; Puthanakit et al., 2007; Reddi et

**1. Introduction** 

**HIV-1-Infected Children** 

Mª Ángeles Muñoz-Fernández1

*"Gregorio Marañón"* 

*"Gregorio Marañón"* 

*Spain* 

María del Palacio Tamarit1, Isabel de José4 and

*3Servicio Infecciosas, Hospital "Ramón y Cajal"* 


## **HAART and Causes of Death in Perinatally HIV-1-Infected Children**

Claudia Palladino1, Jose María Bellón2, Francisco J. Climent3, María del Palacio Tamarit1, Isabel de José4 and Mª Ángeles Muñoz-Fernández1 *1Laboratorio de Inmuno-Biología Molecular, Hospital General Universitario "Gregorio Marañón" 2Unidad de Investigación, Fundación de Investigación Biomédica Hospital "Gregorio Marañón" 3Servicio Infecciosas, Hospital "Ramón y Cajal" 4Servicio Infecciosas Infantil, Hospital Universitario "La Paz", Madrid, Spain* 

## **1. Introduction**

640 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

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Post-marketing Surveillance Team (2006). Post-marketing surveillance of OraQuick

Children represent a population at higher risk of Human Immunodeficiency Virus type 1 (HIV-1) infection and AIDS-related death. Approximately 2.5 million (1.6–3.4) children are infected at present, accounting for 370,000 [230,000–510,000] new infections and 260,000 [150,000–360,000] deaths (Gray et al., 2001). About 90% of children living with HIV-1 are in sub-Saharan Africa. The paediatric HIV-1 epidemic is fuelled by HIV-1 infection in women of childbearing age. In fact, mother-to-child (perinatal) HIV-1 transmission during pregnancy, birth or breastfeeding accounts for the vast majority of HIV-1 cases in children. An estimated 2.4 million infected women give birth annually. This results in the birth of approximately 1,000 HIV-1–infected babies per day, of which 80% occur in resource-limited countries where there are no effective programs for prevention of mother-to-child transmission (MTCT) of HIV-1 . Almost two decades ago, the introduction of antiretroviral chemoprophylaxis to prevent MTCT of HIV-1 was an important milestone in paediatric HIV-1. The use of antiretroviral drugs and elective caesarean section have reduced the incidence of MTCT in industrialised countries to <2% since 1997 (The European Collaborative Study [ECS], 2005; Connor et al., 1994). However, such interventions to prevent MTCT of HIV-1 are still not widely accessible or available in most resource-limited countries where the rate of transmission is estimated at 12–40% (De Cock et al., 2000). Concerning the diagnosis and treatment of HIV-1, significant improvements have been made over the last few years, yet much more needs to be done. The first evidence of the efficacy of antiretroviral therapy (ART) in HIV-1–infected children was published 20 years ago (Pizzo et al., 1988). Since then, the introduction of highly active antiretroviral therapy (HAART) into medical care for HIV-1–infected children and adolescents has increased life expectancy and resulted in AIDS incidence decline in both industrialised countries and resource-limited settings (Judd et al., 2007; Patel et al., 2008; Puthanakit et al., 2007; Reddi et

HAART and Causes of Death in Perinatally HIV-1-Infected Children 643

were enrolled prospectively. Complete ascertainment of all records was carefully sought. Informed consent was obtained from mothers of all patients. The Institutional Ethics Committee approved the study. HIV-1 testing during pregnancy was offered to all women until 1998, when routine testing was introduced for all pregnant women. Patients were actively followed up every 3–6 months (Centers for Disease Control and Prevention [CDC] 1998). At the beginning of the study, the diagnosis of HIV-1 infection was based on the results of a serologic test for HIV-1 antibody, which was performed routinely for children born to seropositive women. When the result of the serologic test was positive, the infection was confirmed by paediatricians and/or through hospital summaries. Later, the diagnosis was done by positive results of HIV-1 PCR DNA and peripheral blood mononuclear cells viral culture assays on two separate samples (Resino et al., 2006a). The clinical classification and definition of AIDS-related events were based on international guidelines (CDC 1994). Children in the A or B clinical category who became older than 13 years were not categorised as having

Deaths were reported by paediatricians. The underlying cause of death (the disease/injury which initiated the morbid event leading to death) was confirmed by reviewing medical histories or autopsy certificates and interviewing paediatricians. Patients were cross-checked with the National Death Index to validate their causes of death classified as: "AIDS-defining" when attributable to a disease in the C clinical category (CDC 1992, 1994); "HIV-related" when attributable to a category A or B disease (CDC 1992, 1994) or to ARV adverse events; "non-HIV-related": all other causes. To report the underlying cause of death, when multiple concurrent causes contributed to death, patients were included as many times as the number of illnesses diagnosed. The study period comprised a pre-HAART era (1982-1996) and a post-HAART era (1997-2009), and was divided into six calendar periods (CP) on the basis of the changing HIV-1 therapy management. CP1 (1982-1989): it was chose as the reference period, when ART was not routinely available; CP2 (1990–1993): the standard of care was zidovudine monotherapy; CP3 (1994–1996): children were receiving dual-nucleoside regimen; CP4 (1997– 1998): when HAART, a combination of three or more drugs, was introduced; CP5 (1999–2004): early-HAART period; CP6 (2005–2009): late-HAART period. Information on sociodemographic characteristics, mother's transmission category, clinical and immunovirological data and the antiretroviral therapy were recorded. Any change in two or more antiretroviral drugs that lasted ≥14 days, excluding dosage changes, in the presence of detectable HIV-1

AIDS and mortality rates were calculated as the number of new AIDS and death cases per hundred person-years (p-y) of follow-up. Individuals were followed from the date of enrolment (i.e., date of HIV-1 diagnosis or first blood test) until the date of development of the event of interest (AIDS or death) or December 31, 2009 (administrative censoring date), whichever occurred first. The risk of progression to AIDS and death over time was estimated by survival analyses using Kaplan-Meier curves and Cox proportional hazards models. Time was calculated from the birth date so that comparisons across different calendar periods were based on individuals who were infected for the same length of time. All models were stratified by hospital and adjusted for potential confounders (gender, mother's transmission category and immunological category). Fisher exact test, χ2 or Mann-Whitney U test were used to derive *P*-values. Poisson regression was used to compare mortality and infection rates between our cohort and the age-similar general population

AIDS by CD4+ cell count criteria when they had <200 cells/ml (CDC 1992).

RNA, was considered to indicate the start of a new regimen.

**2.1.1 Statistical analysis** 

al., 2007). Some studies have also described the immunovirological impact of HAART (Fraaij et al., 2005; Scherpbier et al., 2006; Walker et al., 2004). Nevertheless, in developing countries early diagnosis is a major challenge and ART is often started late. The clinical impact of early treatment has been recognised (Faye et al., 2004; Violari et al., 2007); in fact, in the absence of treatment, 50% of infants die before their second birthday (Newell et al., 2004). Moreover, lack of resources restricts drug supply. Despite the number of children receiving ART increased from about 75,000 in 2005 to 360,000 in 2009, these represent en estimated ART coverage of 28% [21-43%] of all children less than 15 years who need ART in resourcelimited settings (WHO, 2010). On the contrary, in industrialised countries antiretroviral drugs are widely available. In addition, new therapeutic options have been developed for the paediatric population in recent years, such as the protease inhibitor darunavir approved for children aged ≥ 6 years and adolescents (Blanche et al., 2009), or are under evaluation in ongoing clinical trials, including the second generation non-nucleoside reverse transcriptase inhibitor etravirine (ClinicalTrials.gov 2008b, 2009a), the new protease inhibitor tipranavir (Salazar et al., 2008), and the new families of antiretrovirals, such as the CCR5 antagonists and integrase inhibitors (ClinicalTrials.gov 2007, 2008a, 2009b).

## **2. Impact of antiretroviral therapy**

Given that HIV-1 infection has turned into a chronic condition and that exposure to antiretrovirals is likely to be life-long, continuous assessment of the impact of HAART on progression of perinatal HIV-1 infection remains an important public health issue to improve health care strategies. Here, we report the evaluation of HAART effectiveness on the incidence of AIDS and death, and the trends in the underlying causes of death at population level over almost three decades in Madrid (Spain). In Western Europe, Spain continues to be one of the countries with the highest AIDS incidence rate and prevalence. Within Spain, the *Comunidad Autónoma de Madrid* is the area most affected by the infection, with a total of 18,866 AIDS cases up to 2010 (24% of the national cases) (Centro Nacional de Epidemiología [CNE], 2010). The high HIV-1 prevalence had a direct impact on the spread of the infection within the infant population and although the risk of perinatal transmission of HIV-1 has decreased below 2% in recent years, paediatric HIV-1 cases are still being diagnosed (Palladino et al., 2008). In the *Comunidad Autónoma de Madrid*, a total of 237 cumulative AIDS cases due to vertical transmission were reported to the National AIDS Registry from 1981 to 2010 (CNE, 2010). The introduction of HAART in late 1996 and its universal and free availability (Ministerio de sanidad y Consumo, 1998) offered the opportunity to control HIV-1 disease progression in the paediatric population (2005; Resino et al., 2006b). The aim of this study was to describe the mortality and AIDS rates and changes in underlying causes of death in HIV-1–infected paediatric patients. Moreover, risk factors associated with shorter first-line HAART duration among antiretroviral-naïve patients who began HAART after 1996 were examined.

#### **2.1 Study population and methods**

The HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* was established in 1995 as an open cohort of paediatric patients infected by HIV-1 through MTCT, for whom it was assumed that HIV-1 transmission occurred on the date of birth (de Martino et al., 2000). The cohort has included all HIV-1–infected patients identified in a multicenter network of nine referral paediatric hospitals from January 1982 (birth date of the first MTCT–infected child in Madrid). Children infected before 1995 were enrolled retrospectively, while those infected after 1995

al., 2007). Some studies have also described the immunovirological impact of HAART (Fraaij et al., 2005; Scherpbier et al., 2006; Walker et al., 2004). Nevertheless, in developing countries early diagnosis is a major challenge and ART is often started late. The clinical impact of early treatment has been recognised (Faye et al., 2004; Violari et al., 2007); in fact, in the absence of treatment, 50% of infants die before their second birthday (Newell et al., 2004). Moreover, lack of resources restricts drug supply. Despite the number of children receiving ART increased from about 75,000 in 2005 to 360,000 in 2009, these represent en estimated ART coverage of 28% [21-43%] of all children less than 15 years who need ART in resourcelimited settings (WHO, 2010). On the contrary, in industrialised countries antiretroviral drugs are widely available. In addition, new therapeutic options have been developed for the paediatric population in recent years, such as the protease inhibitor darunavir approved for children aged ≥ 6 years and adolescents (Blanche et al., 2009), or are under evaluation in ongoing clinical trials, including the second generation non-nucleoside reverse transcriptase inhibitor etravirine (ClinicalTrials.gov 2008b, 2009a), the new protease inhibitor tipranavir (Salazar et al., 2008), and the new families of antiretrovirals, such as the CCR5 antagonists

Given that HIV-1 infection has turned into a chronic condition and that exposure to antiretrovirals is likely to be life-long, continuous assessment of the impact of HAART on progression of perinatal HIV-1 infection remains an important public health issue to improve health care strategies. Here, we report the evaluation of HAART effectiveness on the incidence of AIDS and death, and the trends in the underlying causes of death at population level over almost three decades in Madrid (Spain). In Western Europe, Spain continues to be one of the countries with the highest AIDS incidence rate and prevalence. Within Spain, the *Comunidad Autónoma de Madrid* is the area most affected by the infection, with a total of 18,866 AIDS cases up to 2010 (24% of the national cases) (Centro Nacional de Epidemiología [CNE], 2010). The high HIV-1 prevalence had a direct impact on the spread of the infection within the infant population and although the risk of perinatal transmission of HIV-1 has decreased below 2% in recent years, paediatric HIV-1 cases are still being diagnosed (Palladino et al., 2008). In the *Comunidad Autónoma de Madrid*, a total of 237 cumulative AIDS cases due to vertical transmission were reported to the National AIDS Registry from 1981 to 2010 (CNE, 2010). The introduction of HAART in late 1996 and its universal and free availability (Ministerio de sanidad y Consumo, 1998) offered the opportunity to control HIV-1 disease progression in the paediatric population (2005; Resino et al., 2006b). The aim of this study was to describe the mortality and AIDS rates and changes in underlying causes of death in HIV-1–infected paediatric patients. Moreover, risk factors associated with shorter first-line HAART duration

among antiretroviral-naïve patients who began HAART after 1996 were examined.

The HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* was established in 1995 as an open cohort of paediatric patients infected by HIV-1 through MTCT, for whom it was assumed that HIV-1 transmission occurred on the date of birth (de Martino et al., 2000). The cohort has included all HIV-1–infected patients identified in a multicenter network of nine referral paediatric hospitals from January 1982 (birth date of the first MTCT–infected child in Madrid). Children infected before 1995 were enrolled retrospectively, while those infected after 1995

and integrase inhibitors (ClinicalTrials.gov 2007, 2008a, 2009b).

**2. Impact of antiretroviral therapy** 

**2.1 Study population and methods** 

were enrolled prospectively. Complete ascertainment of all records was carefully sought. Informed consent was obtained from mothers of all patients. The Institutional Ethics Committee approved the study. HIV-1 testing during pregnancy was offered to all women until 1998, when routine testing was introduced for all pregnant women. Patients were actively followed up every 3–6 months (Centers for Disease Control and Prevention [CDC] 1998). At the beginning of the study, the diagnosis of HIV-1 infection was based on the results of a serologic test for HIV-1 antibody, which was performed routinely for children born to seropositive women. When the result of the serologic test was positive, the infection was confirmed by paediatricians and/or through hospital summaries. Later, the diagnosis was done by positive results of HIV-1 PCR DNA and peripheral blood mononuclear cells viral culture assays on two separate samples (Resino et al., 2006a). The clinical classification and definition of AIDS-related events were based on international guidelines (CDC 1994). Children in the A or B clinical category who became older than 13 years were not categorised as having AIDS by CD4+ cell count criteria when they had <200 cells/ml (CDC 1992).

Deaths were reported by paediatricians. The underlying cause of death (the disease/injury which initiated the morbid event leading to death) was confirmed by reviewing medical histories or autopsy certificates and interviewing paediatricians. Patients were cross-checked with the National Death Index to validate their causes of death classified as: "AIDS-defining" when attributable to a disease in the C clinical category (CDC 1992, 1994); "HIV-related" when attributable to a category A or B disease (CDC 1992, 1994) or to ARV adverse events; "non-HIV-related": all other causes. To report the underlying cause of death, when multiple concurrent causes contributed to death, patients were included as many times as the number of illnesses diagnosed. The study period comprised a pre-HAART era (1982-1996) and a post-HAART era (1997-2009), and was divided into six calendar periods (CP) on the basis of the changing HIV-1 therapy management. CP1 (1982-1989): it was chose as the reference period, when ART was not routinely available; CP2 (1990–1993): the standard of care was zidovudine monotherapy; CP3 (1994–1996): children were receiving dual-nucleoside regimen; CP4 (1997– 1998): when HAART, a combination of three or more drugs, was introduced; CP5 (1999–2004): early-HAART period; CP6 (2005–2009): late-HAART period. Information on sociodemographic characteristics, mother's transmission category, clinical and immunovirological data and the antiretroviral therapy were recorded. Any change in two or more antiretroviral drugs that lasted ≥14 days, excluding dosage changes, in the presence of detectable HIV-1 RNA, was considered to indicate the start of a new regimen.

#### **2.1.1 Statistical analysis**

AIDS and mortality rates were calculated as the number of new AIDS and death cases per hundred person-years (p-y) of follow-up. Individuals were followed from the date of enrolment (i.e., date of HIV-1 diagnosis or first blood test) until the date of development of the event of interest (AIDS or death) or December 31, 2009 (administrative censoring date), whichever occurred first. The risk of progression to AIDS and death over time was estimated by survival analyses using Kaplan-Meier curves and Cox proportional hazards models. Time was calculated from the birth date so that comparisons across different calendar periods were based on individuals who were infected for the same length of time. All models were stratified by hospital and adjusted for potential confounders (gender, mother's transmission category and immunological category). Fisher exact test, χ2 or Mann-Whitney U test were used to derive *P*-values. Poisson regression was used to compare mortality and infection rates between our cohort and the age-similar general population

HAART and Causes of Death in Perinatally HIV-1-Infected Children 645

*CP2 (90-93)*

4.0 (1.8 – 6.6)

1980-1989 168 144 115 85 79 47 1990-1993 – 136 115 93 90 85 1994-1996 – – 87 73 68 63 1997-1998 – – – 31 29 27 1999-2004 – – – – 49 44 2005-2009 – – – – – 13

Sex ratio, n. of girls 1.00 1.19 1.23 1.27 1.32 1.41

264 (94.3)

Central America 0 (0) 3 (1.1) 4 (1.3) 8 (2.8) 10 (3.2) 9 (3.2) South America 3 (1.8) 4 (1.4) 6 (1.9) 6 (2.1) 8 (2.5) 8 (2.9) North Africa 0 (0) 0 (0) 1 (0.3) 1 (0.4) 1 (0.3) 2 (0.7) Sub-Sahara Africa 0 (0) 3 (1.1) 5 (1.6) 8 (2.8) 19 (6.0) 20 (7.2) Other 2 (1.2) 2 (0.7) 2 (0.6) 3 (1.1) 5 (1.6) 4 (1.4) Unknown/Unavailable 7 (4.2) 4 (1.4) 1 (0.3) - 1 (0.3) 1 (0.4)

> 189 (67.5)

Clinical category C, n. (%) 69 (41.3) 106 (38.3) 137 (44.1) 102 (37.4) 124 (40.8) 102 (37.5)

Death, n. (%) 21 (12.5) 49 (17.5) 63 (19.9) 12 (4.3) 10 (3.2) 4 (1.4) Table 1. Demographic and clinical characteristics of the HIV-1–infected patients enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* at the end of each calendar period (CP). IQR: interquartile range; clinical classification was based on the 1994 revised

Heterosexual 29 (17.3) 56 (20.0) 69 (21.8) 69 (24.5) 78 (24.8) 74 (26.5) IDU / Heterosexual 13 (7.7) 23 (8.2) 29 (9.1) 24 (8.5) 23 (7.3) 19 (6.8) Transfusion 3 (1.8) 3 (1.1) 7 (2.2) 6 (2.1) 6 (1.9) 6 (2.2) Unknown/Unavailable 4 (2.4) 9 (3.2) 16 (5.0) 15 (5.3) 23 (7.3) 26 (9.3)

N. of HIV-1–infected patients 168 280 317 282 315 279

*(80-89)* 

(1.0 – 4.4)

(92.9)

(70.8)

**Characteristics** *CP1* 

Age, years (median, IQR) 2.6

Date of birth, n. of patients

Geographic origin, n. (%)

Spain <sup>156</sup>

Maternal transmission, n. (%)

Injecting drug use <sup>119</sup>

CDC guidelines. IDU: injecting drug use.

**Period**

*CP4 (97-98)*

6.7 (3.8 – 9.6)

> 256 (90.8)

> 168 (59.6)

*CP5 (99-04)* 

11.1 (7.8 – 14.0)

> 271 (86.0)

> 185 (58.7)

*CP6 (05-09)* 

14.8 (11.6–17.5)

> 235 (84.0)

> 154 (55.2)

*CP3 (94-96)*

5.0 (2.6 – 8.0)

> 298 (94.0)

> 196 (61.8)

living in the *Comunidad Autónoma de Madrid*. The median duration of initial HAART regimen was determined by Kaplan-Meier analysis. Univariate proportional hazards regressions were used to identify factors associated with a shorter initial regimen. The variables examined included demographics, socio-economic characteristics, baseline laboratory values (CD4+ cell count, HIV-1 RNA, haemoglobin), clinical status and adherence to initial HAART regimen. Then, multivariate regression analysis was performed including all factors for which the results of univariate analysis were statistically signicant (*P*<0.05, 2-sided). Analyses were performed with SPSS 16 and Epidat 3.1.

## **3. Results**

Overall, 484 children who acquired HIV-1 from their mothers between 1982 and 2009 were enrolled and followed for 5298.2 person-years (11.6 years; interquartile range (IQR): 5.2-16.7). HIV-1 infection occurred mainly in 1992 [IQR: 1988-1995]; 270 (56%) patients were girls and 299 (62%) had a mother who acquired the virus through injection drug use. Table 1 provides the characteristics of the children at the end of each calendar period (CP). The cohort had the highest number of enrolled children between 1994 and 1996; in the last period (2005-2009) there were 279 children included, of whom 13 were born in this period. The sex ratio remained stable over time (CP1: 1.0; CP6: 1.4), while the median age (CP1: 2.6 [1.0-4.4]; CP6: 14.8 [11.6-17.5]; *P*<0.001) and the proportion of immigrants (CP1: 3.1; CP6: 15.5; *P*<0.0001) increased. An increase of the median CD4+ cell percentage at the end of each calendar period was observed (CP2: 22.5 [11.9-32.1]; CP4: 26.5 [18.2-33.7]; CP6: 33.4 [28.0-39.7]) and a concomitant decrease of HIV-1 RNA since 1997 (median log10 copies/ml CP4: 4.31 [3.80-4.91]; CP6: 2.60 [1.70-3.55]). The proportion of children with <400 copies/ml was 9% (13/151) in CP3, 20% (39/196) in CP4, 60% (150/248) in CP5, and 80% (160/199) in CP6. Two adolescents died in CP2 achieving undetectable HIV-1 RNA at death. The CD8+ cell percentage remained stable (CP2: 42.0 [29.0-52.0]; CP4: 43.7 [35.6-52.5]; CP6: 38.9 [31.7-45.7]). The changes over time in antiretroviral therapy management are described in Fig. 1. Monotherapy was used in the early 1990s and dual-nucleoside therapy in mid-1990s. An increasing proportion of children receiving HAART from 1997 onward was observed; by 2005, up to 80% of the children were on HAART.

#### **3.1 Time to AIDS or death**

Information on 471 children, of whom 285 (61%) developed an AIDS-defining disease, was available for the progression to AIDS analyses. The AIDS incidence rate increased over time until 1989 (32.6 per 100 p-y), it arose again during the first half of the 1990s (13.2 in 1991; 18.8 in 1995) and waned off thereafter (3.2 in 1999; 0.0 in 2009) (Fig. 2). The cumulative incidence curves showed a reduction in the proportion of patients developing AIDS after 1997 compared to the period 1982-1989 (Fig. 3A). Multivariate Cox analysis showed a more pronounced decline in the last period (CP6) (AHR: 0.07; 95%CI: 0.04-0.16) than in the CP5 (AHR: 0.23; 95%CI: 0.15-0.37) (Table 2). A total of 159/484 (33%) deaths occurred. The death incidence rate was 7.4 per 100 p-y at risk in 1986, it peaked in 1995 (10.1 per 100 p-y) and declined thereafter (0.7 in 1999; 0.0 in 2009) (Fig. 2). The incidence of death decreased since 1997 compared to the period 1982-1989 (Fig. 3B, Table 2). Multivariate analysis showed more marked improvements in survival in the CP6 (AHR: 0.16; 95%CI: 0.05-0.50) than in the CP5 (AHR: 0.25; 95%CI: 0.11-0.56).


living in the *Comunidad Autónoma de Madrid*. The median duration of initial HAART regimen was determined by Kaplan-Meier analysis. Univariate proportional hazards regressions were used to identify factors associated with a shorter initial regimen. The variables examined included demographics, socio-economic characteristics, baseline laboratory values (CD4+ cell count, HIV-1 RNA, haemoglobin), clinical status and adherence to initial HAART regimen. Then, multivariate regression analysis was performed including all factors for which the results of univariate analysis were statistically signicant (*P*<0.05, 2-sided).

Overall, 484 children who acquired HIV-1 from their mothers between 1982 and 2009 were enrolled and followed for 5298.2 person-years (11.6 years; interquartile range (IQR): 5.2-16.7). HIV-1 infection occurred mainly in 1992 [IQR: 1988-1995]; 270 (56%) patients were girls and 299 (62%) had a mother who acquired the virus through injection drug use. Table 1 provides the characteristics of the children at the end of each calendar period (CP). The cohort had the highest number of enrolled children between 1994 and 1996; in the last period (2005-2009) there were 279 children included, of whom 13 were born in this period. The sex ratio remained stable over time (CP1: 1.0; CP6: 1.4), while the median age (CP1: 2.6 [1.0-4.4]; CP6: 14.8 [11.6-17.5]; *P*<0.001) and the proportion of immigrants (CP1: 3.1; CP6: 15.5; *P*<0.0001) increased. An increase of the median CD4+ cell percentage at the end of each calendar period was observed (CP2: 22.5 [11.9-32.1]; CP4: 26.5 [18.2-33.7]; CP6: 33.4 [28.0-39.7]) and a concomitant decrease of HIV-1 RNA since 1997 (median log10 copies/ml CP4: 4.31 [3.80-4.91]; CP6: 2.60 [1.70-3.55]). The proportion of children with <400 copies/ml was 9% (13/151) in CP3, 20% (39/196) in CP4, 60% (150/248) in CP5, and 80% (160/199) in CP6. Two adolescents died in CP2 achieving undetectable HIV-1 RNA at death. The CD8+ cell percentage remained stable (CP2: 42.0 [29.0-52.0]; CP4: 43.7 [35.6-52.5]; CP6: 38.9 [31.7-45.7]). The changes over time in antiretroviral therapy management are described in Fig. 1. Monotherapy was used in the early 1990s and dual-nucleoside therapy in mid-1990s. An increasing proportion of children receiving HAART from 1997 onward was observed; by 2005, up to 80% of the

Information on 471 children, of whom 285 (61%) developed an AIDS-defining disease, was available for the progression to AIDS analyses. The AIDS incidence rate increased over time until 1989 (32.6 per 100 p-y), it arose again during the first half of the 1990s (13.2 in 1991; 18.8 in 1995) and waned off thereafter (3.2 in 1999; 0.0 in 2009) (Fig. 2). The cumulative incidence curves showed a reduction in the proportion of patients developing AIDS after 1997 compared to the period 1982-1989 (Fig. 3A). Multivariate Cox analysis showed a more pronounced decline in the last period (CP6) (AHR: 0.07; 95%CI: 0.04-0.16) than in the CP5 (AHR: 0.23; 95%CI: 0.15-0.37) (Table 2). A total of 159/484 (33%) deaths occurred. The death incidence rate was 7.4 per 100 p-y at risk in 1986, it peaked in 1995 (10.1 per 100 p-y) and declined thereafter (0.7 in 1999; 0.0 in 2009) (Fig. 2). The incidence of death decreased since 1997 compared to the period 1982-1989 (Fig. 3B, Table 2). Multivariate analysis showed more marked improvements in survival in the CP6 (AHR: 0.16; 95%CI: 0.05-0.50) than in the CP5

Analyses were performed with SPSS 16 and Epidat 3.1.

**3. Results** 

children were on HAART.

**3.1 Time to AIDS or death** 

(AHR: 0.25; 95%CI: 0.11-0.56).


Table 1. Demographic and clinical characteristics of the HIV-1–infected patients enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* at the end of each calendar period (CP). IQR: interquartile range; clinical classification was based on the 1994 revised CDC guidelines. IDU: injecting drug use.

HAART and Causes of Death in Perinatally HIV-1-Infected Children 647

muerte **AIDS Death**

83 85 87 89 91 93 95 97 99 01 03 05 07 09

Follow-up (year)

0,0 0,0 0,0 0,0 7,4 3,6 1,9 8,3 5,2 6,2 8,3 5,9 8,4 10,1 7,3 2,7 1,9 0,7 0,4 0,7 0,4 1,1 0,4 0,4 0,4 0,4 0,5 0,0

**Years p-y N. Rate p-y N. Rate** 

0,0 0,0 0,0 4,6 12,4 8,9 22,6 32,6 8,7 13,2 10,9 12,7 12,2 18,8 17,1 11,5 6,3 3,2 6,5 2,6 6,5 2,6 2,6 1,3 3,5 1,5 0,0 0,0

Fig. 2. Annual AIDS and mortality incidence rates per 100 person-years (p-y) in the HIV

Paediatric Cohort of the *Comunidad Autónoma de Madrid*.

TASA muerte TASA SIDA

Death rate AIDS rate

0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0

Incidence rate per 100

persons-year

(year)Fig. 1. Use of antiretroviral therapy among HIV-1 vertically infected children enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid.* NT: not treated; MT: monotherapy; combined/dual-nucleoside therapy; HAART: highly active antiretroviral therapy.


Table 2. Effect of calendar period on the risk of AIDS and death. Note: Adjusted hazard ratios were derived from a standard Cox proportional hazard model that included calendar period (external time-dependent covariate), gender, mother's transmission category, immunological category and it is stratified by hospital.

HAART C T MT NT

NT MT CT HAART

Follow-up (year)

**(95% CI)**

1.00 0.49 (0.33 - 0.69) 0.64 (0.44 - 0.91) 0.39 (0.25 - 0.63) 0.23 (0.15 - 0.37) 0.07 (0.04 - 0.16)

**(95% CI)**

1.00 1.33 (0.77 - 2.28) 1.71 (1.00 – 2.94) 0.54 (0.25 - 1.14) 0.25 (0.11 - 0.56) 0.16 (0.05 - 0.50)

Fig. 1. Use of antiretroviral therapy among HIV-1 vertically infected children enrolled in the

HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid.* NT: not treated; MT: monotherapy; combined/dual-nucleoside therapy; HAART: highly active antiretroviral

**Calendar period N. N. of cases Adjusted HR** 

**Calendar period N. N. of cases Adjusted HR** 

Table 2. Effect of calendar period on the risk of AIDS and death. Note: Adjusted hazard ratios were derived from a standard Cox proportional hazard model that included calendar period (external time-dependent covariate), gender, mother's transmission category,

**AIDS** 

**Death** 

immunological category and it is stratified by hospital.

90 92 94 96 98 00 02 04 06 08

HIV-1 infected children receiving ART

therapy.

0%

20%

40%

60%

80%

100%


Fig. 2. Annual AIDS and mortality incidence rates per 100 person-years (p-y) in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*.

HAART and Causes of Death in Perinatally HIV-1-Infected Children 649

100

80

60

Survival (%)

20

40 CP1 (82-89)

CP2 (90-93) CP3 (94-96) CP4 (97-98) CP5 (99-04) CP6 (05-09)

0

(A) (B)

Fig. 3. Kaplan-Meier curves for HIV-1–infected children enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* without AIDS (A) and for survival (B) in

0 2468

Follow-up (years)

0 24 68 Follow-up (years)

CP1 (82-89) CP2 (90-93) CP3 (94-96) CP4 (97-98) CP5 (99-04) CP6 (05-09)

different calendar periods.

100

80

60

40

AIDS-free children (%)

20

0

In the population aged 0-19 years of the *Comunidad Autónoma de Madrid*, the mortality decreased from 4.2 deaths per 10,000 inhabitants in 1996 to 3.5 in 2007. In spite of the mortality decline in our cohort, it still was 10.4-fold (95%CI: 5.8-18.8; *P*<0.001) higher than in age-similar general population after 1999. Since 1999, the HIV-1–infected infants had a higher mortality rate than children/adolescents (IRR: 6.9; 95%CI: 2.3-20.3; *P*<0.001), as in the general population (IRR: 18.9; 95%CI: 17.9-19.9; *P*<0.001). A lower decrease of mortality among HIV-1–infected infants (IRR: 2.6; 95%CI: 0.9-7.4; *P*=0.069) between pre-HAART and post-HAART era than among older patients (IRR: 12.5; 95%CI: 7.6-20.4; *P*<0.001) was observed. On the contrary, mortality decreased equally in infants (IRR: 1.8; 95%CI: 1.8-1.9; *P*<0.001) and children/adolescents (IRR: 1.5; 95%CI: 1.5-1.6; *P*<0.001) in the general population.

#### **3.2 Causes of death**

Overall, 169 causes of death were documented for 151/159 (95%) patients (Table3). The 81% (137/169) were AIDS-defining, 12% (20/169) HIV-related and 7% (12/169) non-HIV-related. Multiple causes of death were reported in 16/151 (11%) patients, 3.2 (0.6–6.3) years old at death, of which 7 were infants: 13/129 (10%) died in pre-HAART era and 3/22 (14%) in post-HAART era. Concomitant pathologies were diagnosed in 101/151 (67%) patients (Table 4). The majority (83%) of the subjects died in the post-HAART era had a low/medium socio-economic status. From 1999 to 2007, the risk of death from infections was 115.9 times (95% CI: 42.0–265.8; *P*<0.001) higher in our cohort than in the *Comunidad Autónoma de Madrid*. It was not possible to evaluate the risk of death from other causes than infections due to the low number of events.

AIDS-defining causes were 82% (118/144) in pre-HAART and 76% (19/25) in post-HAART era. The most frequent contributing events were opportunistic infections (58%, 79/137) (Table 4), wasting syndrome (19%, 26/137) and lymphoid interstitial pneumonia (12%, 16/137). The largest components of opportunistic infections were bacterial (20%, 28/137), fungal (mainly *Pneumocystis jiroveci*; 15%, 20/137), and mycobacterial infections (mainly *Mycobacterium tuberculosis*; 10%, 14/137). These three etiologic pathogens were associated with the only cases of death occurred in 2005-2007. No statistically significant changes over time were observed in the proportions of the causes of death. HIV-related causes were 11% (16/144) in pre-HAART and 16% (4/25) in post-HAART era. Overall, the leading causes of death were infections (75%, 15/20), mainly bacterial (65%, 13/20), and bleeding (15%, 3/20). The causes of death reported in post-HAART era were: bacterial infection, pulmonary bleeding caused by thrombocytopenia, pulmonary arterial hypertension and lactic acidosis (1 case each). Non-HIV-related causes were 7% (10/144) in pre-HAART and 8% (2/25) in post-HAART era. Infections were the main cause of death (75%, 9/12), mainly viral infections (67%, 8/12), followed by cancer (17%, 2/12) and hepatic pathology (8%, 1/12). The only causes of death reported in post-HAART era were cancer and hepatic failure (1 case each).

#### **3.3 Duration of HAART regimen**

Of 484 patients included in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, 105 (22%) were naïve to antiretrovirals when HAART began as of January 1997. It was possible to analyse the duration of the first HAART regimen in 82 of them. Half of the patients were girls (42; 51%) and had a median age at HAART initiation of 3.6 years (0.6- 7.3).

In the population aged 0-19 years of the *Comunidad Autónoma de Madrid*, the mortality decreased from 4.2 deaths per 10,000 inhabitants in 1996 to 3.5 in 2007. In spite of the mortality decline in our cohort, it still was 10.4-fold (95%CI: 5.8-18.8; *P*<0.001) higher than in age-similar general population after 1999. Since 1999, the HIV-1–infected infants had a higher mortality rate than children/adolescents (IRR: 6.9; 95%CI: 2.3-20.3; *P*<0.001), as in the general population (IRR: 18.9; 95%CI: 17.9-19.9; *P*<0.001). A lower decrease of mortality among HIV-1–infected infants (IRR: 2.6; 95%CI: 0.9-7.4; *P*=0.069) between pre-HAART and post-HAART era than among older patients (IRR: 12.5; 95%CI: 7.6-20.4; *P*<0.001) was observed. On the contrary, mortality decreased equally in infants (IRR: 1.8; 95%CI: 1.8-1.9; *P*<0.001) and

Overall, 169 causes of death were documented for 151/159 (95%) patients (Table3). The 81% (137/169) were AIDS-defining, 12% (20/169) HIV-related and 7% (12/169) non-HIV-related. Multiple causes of death were reported in 16/151 (11%) patients, 3.2 (0.6–6.3) years old at death, of which 7 were infants: 13/129 (10%) died in pre-HAART era and 3/22 (14%) in post-HAART era. Concomitant pathologies were diagnosed in 101/151 (67%) patients (Table 4). The majority (83%) of the subjects died in the post-HAART era had a low/medium socio-economic status. From 1999 to 2007, the risk of death from infections was 115.9 times (95% CI: 42.0–265.8; *P*<0.001) higher in our cohort than in the *Comunidad Autónoma de Madrid*. It was not possible to evaluate the risk of death from other causes than

AIDS-defining causes were 82% (118/144) in pre-HAART and 76% (19/25) in post-HAART era. The most frequent contributing events were opportunistic infections (58%, 79/137) (Table 4), wasting syndrome (19%, 26/137) and lymphoid interstitial pneumonia (12%, 16/137). The largest components of opportunistic infections were bacterial (20%, 28/137), fungal (mainly *Pneumocystis jiroveci*; 15%, 20/137), and mycobacterial infections (mainly *Mycobacterium tuberculosis*; 10%, 14/137). These three etiologic pathogens were associated with the only cases of death occurred in 2005-2007. No statistically significant changes over time were observed in the proportions of the causes of death. HIV-related causes were 11% (16/144) in pre-HAART and 16% (4/25) in post-HAART era. Overall, the leading causes of death were infections (75%, 15/20), mainly bacterial (65%, 13/20), and bleeding (15%, 3/20). The causes of death reported in post-HAART era were: bacterial infection, pulmonary bleeding caused by thrombocytopenia, pulmonary arterial hypertension and lactic acidosis (1 case each). Non-HIV-related causes were 7% (10/144) in pre-HAART and 8% (2/25) in post-HAART era. Infections were the main cause of death (75%, 9/12), mainly viral infections (67%, 8/12), followed by cancer (17%, 2/12) and hepatic pathology (8%, 1/12). The only causes of death reported in post-HAART era were cancer and hepatic failure (1

Of 484 patients included in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, 105 (22%) were naïve to antiretrovirals when HAART began as of January 1997. It was possible to analyse the duration of the first HAART regimen in 82 of them. Half of the patients were girls (42; 51%) and had a median age at HAART initiation of 3.6 years (0.6-

children/adolescents (IRR: 1.5; 95%CI: 1.5-1.6; *P*<0.001) in the general population.

**3.2 Causes of death** 

case each).

7.3).

**3.3 Duration of HAART regimen** 

infections due to the low number of events.

Fig. 3. Kaplan-Meier curves for HIV-1–infected children enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* without AIDS (A) and for survival (B) in different calendar periods.


Table 3. All causes of death for HIV-1–infected children enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* stratified by pre-HAART era and post-HAART era. Pulmonary cause of death includes lymphoid interstitial pneumonia cases and 1 case of pulmonary hypertension. AGE: acute gastroenteritis; HL: Hodgkin's lymphoma; NHL: non-Hodgkin's lymphoma; PML: progressive multifocal leukoencephalopathy (JC virus). Percentage may not total 100 because of rounding.

HAART and Causes of Death in Perinatally HIV-1-Infected Children 651

**Opportunistic infection N=67/129 (51.9%) N=12/22 (54.5%)** 

Recurrent bacterial infection 22 (32.8) 6 (50.0) *Pneumocystis jiroveci* 13 (19.4) 3 (25.0) Cryptosporidiosis 9 (13.4) 0

mycobacteria 6 (9.0) 2 (16.7) *Mycobacterium tuberculosis* 5 (7.5) 1 (8.3) Candidasis 4 (6.0) 0 Cytomegalovirus 6 (9.0) 0 Toxoplasmosis 1 (1.5) 0 JC virus 1 (1.5) 0

**Comorbidity\* N= 87/129 (64.9%) N=14/22 (60.9%)** 

Table 4. Prevalence of opportunistic infections and comorbidity in the deceased patients of the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, stratified by pre-HAART and post-HAART era. HSV: Herpes simplex virus. \*Note: Patients can be counted more than

The majority originated from Spain (58; 71%) and 19 (23%) were adopted or lived in institutions. The socio-economic status was medium-high for 28 (56%) out of 50 patients and low for 22 (44%). At baseline, the median CD4+ cell count was 707 (19%) cells/ml (212-1,443) and HIV-1 RNA was 100,000 (5.0 log10) copies/ml. The median duration of the first HAART regimen was 40.5 months (20.9-80.2). Fifty (61%) subjects were still on the same regimen at the end of the follow-up (Fig. 4, circle chart), being the median HAART duration in this group of 64.5 months (28.6-95.1). The rest of the study group (32/82; 39%) switched to a second regimen after 25.9 months (12.4-39.2) of first regimen. The median first-line HAART duration was significantly different between the two groups (*P*<0.0001). Among the 32 patients who experienced first-line HAART discontinuation, up to 6 switches to successive regimens were observed and had a median duration of 25.9 months (20.7-29.2) (Fig. 4, bar chart). The cumulative incidence curves for time to initial HAART regimen discontinuation showed a longer median HAART duration for the 65/82 (79%) children who started the

Wasting 52 (38.8) 11 (47.8) Encephalopathy 50 (37.3) 7 (30.4) Hepatic 17 (12.7) 2 (8.7) Miocardiophaty 20 (14.9) 2 (8.7) Hematologic alterations 15 (11.2) 3 (13.0) Candidiasis 10 (7.5) -- Hypertension 3 (2.2) -- Nephropathology 3 (2.2) -- Giardiasis 1 (0.7) -- HSV 1 (0.7) --

**1996)** 

**Post-HAART (1997- 2009)** 

**Pre-HAART (1982-**

Nontuberculous

once.

**Cause of death** N=144 (85.2%) N=25 (14.8%) Cancer 6 (4.2) 3 (12.0) NHL 5 (3.5) 2 (8.0) HL 1 (0.7) -- Others -- 1 (4.0) Infections 90 (62.5) 13 (52.0) Bacterial infections 34 (23.6) 7 (28.0) Pneumonia 20 (13.9) 3 (12.0) Sepsis 14 (9.7) 3 (12.0) Meningitis -- 1 (4.0) Fungal infections 17 (11.8) 3 (12.0) Pneumonia 13 (9.0) 3 (12.0) Esophageal 4 (2.8) -- Mycobacterial infections 13 (9.0) 3 (12.0) Nontuberculous 8 (5.6) 2 (8.0) Tuberculosis 5 (3.5) 1 (4.0)

Viral infections 15 (10.4) --

Parasitic infections 11 (7.6) --

Other causes 48 (33.3) 9 (36.0) Wasting 22 (15.3) 4 (16.0) Pulmonary 15 (10.4) 2 (8.0) Encephalopathy 9 (6.3) -- Hepatic -- 1 (4.0) Bleeding 2 (1.4) 1 (4.0) Lactic acidosis -- 1 (4.0)

Table 3. All causes of death for HIV-1–infected children enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid* stratified by pre-HAART era and post-HAART era. Pulmonary cause of death includes lymphoid interstitial pneumonia cases and 1 case of pulmonary hypertension. AGE: acute gastroenteritis; HL: Hodgkin's lymphoma; NHL: non-Hodgkin's lymphoma; PML: progressive multifocal leukoencephalopathy (JC virus).

Pneumonia 5 (3.5) Sepsis 6 (4.2) AGE 3 (2.1) PML 1 (0.7)

Cryptosporidiasis 9 (6.3) Toxoplasmosis 1 (0.7) Leishmaniasis 1 (0.7)

Percentage may not total 100 because of rounding.

**1996)** 

**Post-HAART (1997-2009)** 

**Pre-HAART (1982-**


Table 4. Prevalence of opportunistic infections and comorbidity in the deceased patients of the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, stratified by pre-HAART and post-HAART era. HSV: Herpes simplex virus. \*Note: Patients can be counted more than once.

The majority originated from Spain (58; 71%) and 19 (23%) were adopted or lived in institutions. The socio-economic status was medium-high for 28 (56%) out of 50 patients and low for 22 (44%). At baseline, the median CD4+ cell count was 707 (19%) cells/ml (212-1,443) and HIV-1 RNA was 100,000 (5.0 log10) copies/ml. The median duration of the first HAART regimen was 40.5 months (20.9-80.2). Fifty (61%) subjects were still on the same regimen at the end of the follow-up (Fig. 4, circle chart), being the median HAART duration in this group of 64.5 months (28.6-95.1). The rest of the study group (32/82; 39%) switched to a second regimen after 25.9 months (12.4-39.2) of first regimen. The median first-line HAART duration was significantly different between the two groups (*P*<0.0001). Among the 32 patients who experienced first-line HAART discontinuation, up to 6 switches to successive regimens were observed and had a median duration of 25.9 months (20.7-29.2) (Fig. 4, bar chart). The cumulative incidence curves for time to initial HAART regimen discontinuation showed a longer median HAART duration for the 65/82 (79%) children who started the

HAART and Causes of Death in Perinatally HIV-1-Infected Children 653

**First HAART regimen discontinuation** 

Table 5. Effect of age at HAART initiation and adherence on the risk of first HAART regimen discontinuation. Note: Adjusted hazard ratios were derived from a standard Cox

Fig. 6. Relative proportion of initial HAART regimen types among the 82 antiretroviralnaïve patients who started HAART since 1997 (circle chart); months of HAART regimen duration in patients who did not suspended the first HAART regimen (dark coloured bars) and who suspended the first regimen (light coloured bars). NRTI: nucleoside reversetranscriptase inhibitor; NNRTI: non-nucleoside reverse-transcriptase inhibitor; PI: protease

The results of this multicenter study on 484 patients infected by HIV-1 through perinatal transmission from the region of Madrid, show that the immunovirological response observed after the introduction of HAART has improved steadily since 1997. Also, an increase in clinical outcome with calendar period was observed. The marked reduction in progression to AIDS and death (by 93% and 84%, respectively) in recent years compared to 1982-1989 suggests a relationship between clinical outcome and HAART, which became widely available from 1997 onward. However, in the latter period, a low but stable mortality rate was recorded, in

accordance with those recently reported by others (Brady et al., 2010; Judd et al., 2007).

40 12

31 21 **cases (%)**

14 (35.0) 8 (66.7)

8 (25.8) 14 (66.7) **Adjusted HR (95% CI)**

1.00 4.56 (1.76 – 11.86)

1.00 5.02 (2.02 – 12.47)

**N. N. of** 

Age at HAART initiation > 6 months ≤ 6 months

> Good/perfect Poor/intermediate

proportional hazard model.

inhibitor.

**4. Discussion** 

Adherence to first HAART regimen

therapy after 6 months of age compared with the 17 (21%) infants who started at or before 6 months (*P*=0.033) (Fig 5A). In addition, this analysis showed a longer median HAART duration for the 31 (60%) out of 52 subjects with good/perfect adherence compared with the 21 (40%) subjects with poor/intermediate adherence (*P*<0.0001) (Fig. 5B). Initial HAART regimen discontinuation remained associated to younger ages (AHR: 4.56; 95%CI: 1.76– 11.86; *P*=0.002) and poor adherence (AHR: 5.02; 95%CI: 2.02–12.47; *P*=0.001) in the multivariate analysis performed for 52 patients (Table 5). The most frequently prescribed first-line regimen was based on protease inhibitors, while one-quarter of the patients received therapy based on non-nucleoside reverse-transcriptase inhibitors (Fig. 6). Two nucleosides backbone therapy remains the cornerstone for all patients but one who had 3 nucleosides. For patients who discontinued the first-regimen, there was a difference, approaching statistical significance, between the duration of the PI-based therapy (30.0 months [13.1-40.5]) and the NNRTI-based therapy (15.2 [5.5-23.2]; *P*=0.054).

Fig. 4. Relative proportion of patients according to the number of HAART regimens among the 82 antiretroviral-naïve patients who start HAART since 1997 (circle chart); months of HAART regimen duration among the 32 patients with regimen switch (bat chart).

Fig. 5. Kaplan-Meier curves for time to discontinuation of first HAART regimen according to the age of HAART initiation (A) and to adherence to first HAART regimen (B).

therapy after 6 months of age compared with the 17 (21%) infants who started at or before 6 months (*P*=0.033) (Fig 5A). In addition, this analysis showed a longer median HAART duration for the 31 (60%) out of 52 subjects with good/perfect adherence compared with the 21 (40%) subjects with poor/intermediate adherence (*P*<0.0001) (Fig. 5B). Initial HAART regimen discontinuation remained associated to younger ages (AHR: 4.56; 95%CI: 1.76– 11.86; *P*=0.002) and poor adherence (AHR: 5.02; 95%CI: 2.02–12.47; *P*=0.001) in the multivariate analysis performed for 52 patients (Table 5). The most frequently prescribed first-line regimen was based on protease inhibitors, while one-quarter of the patients received therapy based on non-nucleoside reverse-transcriptase inhibitors (Fig. 6). Two nucleosides backbone therapy remains the cornerstone for all patients but one who had 3 nucleosides. For patients who discontinued the first-regimen, there was a difference, approaching statistical significance, between the duration of the PI-based therapy (30.0

Fig. 4. Relative proportion of patients according to the number of HAART regimens among the 82 antiretroviral-naïve patients who start HAART since 1997 (circle chart); months of HAART regimen duration among the 32 patients with regimen switch (bat chart).

(A) (B) Fig. 5. Kaplan-Meier curves for time to discontinuation of first HAART regimen according

to the age of HAART initiation (A) and to adherence to first HAART regimen (B).

Good/perfect Poor/intermediate

>6 months old ≤ 6 months old

months [13.1-40.5]) and the NNRTI-based therapy (15.2 [5.5-23.2]; *P*=0.054).


Table 5. Effect of age at HAART initiation and adherence on the risk of first HAART regimen discontinuation. Note: Adjusted hazard ratios were derived from a standard Cox proportional hazard model.

Fig. 6. Relative proportion of initial HAART regimen types among the 82 antiretroviralnaïve patients who started HAART since 1997 (circle chart); months of HAART regimen duration in patients who did not suspended the first HAART regimen (dark coloured bars) and who suspended the first regimen (light coloured bars). NRTI: nucleoside reversetranscriptase inhibitor; NNRTI: non-nucleoside reverse-transcriptase inhibitor; PI: protease inhibitor.

## **4. Discussion**

The results of this multicenter study on 484 patients infected by HIV-1 through perinatal transmission from the region of Madrid, show that the immunovirological response observed after the introduction of HAART has improved steadily since 1997. Also, an increase in clinical outcome with calendar period was observed. The marked reduction in progression to AIDS and death (by 93% and 84%, respectively) in recent years compared to 1982-1989 suggests a relationship between clinical outcome and HAART, which became widely available from 1997 onward. However, in the latter period, a low but stable mortality rate was recorded, in accordance with those recently reported by others (Brady et al., 2010; Judd et al., 2007).

HAART and Causes of Death in Perinatally HIV-1-Infected Children 655

In terms of specific causes of death, AIDS–defining events were the most represented, with proportions higher than that recently observed in adults (Martinez et al., 2007; Palella et al., 2006). This finding might be directly linked to a late HIV-1 diagnosis at the beginning of the epidemic and to the persistence of opportunistic infections, that were the leading AIDS– defining causes of death (Brady et al., 2010; Selik & Lindegren 2003), although less represented since HAART advent (Currier et al., 1998; Kaplan et al., 2001). As in previous studies, bacterial infections were the largest component of opportunistic infections (Gona et al., 2006; Langston et al., 2001). Although specific information for their aetiology was mainly unavailable, we supposed that pneumococcus (*Streptococcus pneumoniae*) might has been the prominent microbial on the basis of recent reports (Cotton et al., 2008; Gortmaker et al., 2001; Kapogiannis et al., 2008). In addition, the pneumococcal conjugate vaccine available since 2000 (Black et al., 2000) and recommended for all HIV-infected children, has a lower efficacy in these patients than in HIV-uninfected children (Bliss et al., 2008). Some bacterial infections occurred with normal CD4+ cell percentage (≥25%), consistently with previous report (Gona et al., 2006), maybe because the HIV-1 infection does not allow the correct development of primary immune function leading to the production of polyclonal, nonspecific immunoglobulin increasing the risk of infections with encapsulated bacteria (Brady et al., 2010; Cotton et al., 2008; Gortmaker et al., 2001; Kapogiannis et al., 2008). The population-based analysis yielded consistent results with studies of HIV–infected patients (Kapogiannis et al., 2008; Martinez et al., 2007), highlighting a higher incidence of infections in our cohort than in the general population of similar age from the same region. Along with host immune factors (Janoff et al., 1992), antimicrobial resistance (Cotton et al., 2008; Jaspan et al., 2008), comorbidity and co-infections might have contributed to the high risk of death from opportunistic infections. The introduction of both *Pneumocystis* pneumonia prophylaxis (CDC 1995; Simonds et al., 1995) and HAART in our cohort has been accompanied by substantial reductions in mortality caused by *Pneumocystis* pneumonia (Gona et al., 2006; Kaplan et al., 2000), which have continued to occur in post-HAART era only in infants born to women with late HIV-1 diagnosis or unmonitored pregnancy, causing failure to implement *Pneumocystis* pneumonia prophylaxis (Gibb et al., 2003; Simpson et al., 2000). The cases of *M. avium* complex infection in our cohort have decreased over time (Gona et al., 2006). The cases reported in CP2 were diagnosed in children 6-11 years old, probably as a complication of advanced immunologic deterioration and the difficulty to realize a complete adherence to HAART and *M. avium* complex chemoprophylaxis. On the other hand, our data have shown an increase in the median age at death over time that might reflect improved management and prolongation in the time to development of a first bacteremia (Kapogiannis et al., 2008). More prolonged survival might allow chronic underlying comorbid conditions to become more clinically relevant in the next future. The proportion of HIV–related causes of deaths (12%) increased over time even if not statistically significant. Interestingly, the case of lactic acidosis was related to HAART regimen (stavudine + didanosine + efavirenz) that caused mitochondrial toxicity, whose rate is known to be increased by stavudine + didanosine co-administration (Blanco et al., 2003; Cote et al., 2002). Among non-HIV–related causes of death, the 7% of all the underlying causes, the fulminant hepatic failure occurred in 2008 was HCV-associated. We did not observe the increase of conditions, including diabetes mellitus, cancer, cardiovascular, liver and renal diseases that have become frequent in HIV-1–infected adults (Crum et al., 2006;

Remarkably, mortality continued to be more than ten-fold higher in our cohort than in agesimilar general population after 1996 and mainly affected patients of low/medium socioeconomic status (Palladino et al., 2008). In addition, HIV-1–infected infants were still at higher risk for death compared with older paediatric patients, being this pattern mirrored in the general paediatric population and maybe attributable to the immature of the immune system (Gortmaker et al., 2001). Finally, the mortality trend had a strikingly lower decrease among infants than among children aged ≥ 1 year in our cohort, where it decreased equally in both groups in the general population. These findings highlight the HIV-1-infected infants as a major target for healthcare policy. We observed very high AIDS and mortality incidence rates during the first years of follow-up. These data on mortality are consistent with historical European series (ECS, (1994). and with data on HIV-1 progression in children living in setting where they do not receive medical care (Brahmbhatt et al., 2006; Marinda et al., 2007). In fact, zidovudine monotherapy administration to paediatric patients started only in 1988 (Pizzo et al., 1988) and in our cohort the majority of the children were still untreated in this year. Moreover, the high HIV-1 prevalence among the female population fuelled by the so called "epidemic of heroin" had a direct impact on the spread of the infection in infants.

Our study shows that monotherapy exerted some benefit in the management of symptomatic children (Butler et al., 1991; McKinney et al., 1991; Resino et al., 2006b). Nevertheless, it had a time-limited effect due to ongoing viral replication that inevitably leads to the emergence of resistant HIV-1 quasispecies, which was also promoted by the lack of drug dosage adjustments for children at that time. The dual-nucleoside therapy proved to be more effective than monotherapy (Englund et al., 1997; Resino et al., 2006b). However, in our setting its effect on mortality or AIDS prevention between 1994- 1996 was similar to that exerted by monotherapy. This finding might be partially attributable to the regimen switch to dual-drug therapy (mainly zidovudine plus didanosine) after several years of zidovudine treatment in many children, when zidovudine was not more completely active. Thus, even with perfect adherence, dual-drug therapy was only partially suppressive being administered as functional monotherapy and due to crossresistance within the nucleoside analogue class. In addition, during this period more than 40% of the children were still untreated and more than 35% were on monotherapy. Previous studies reported the effectiveness of HAART on the risk of death in the setting of large paediatric cohorts, but these had limited follow-up and lacked assessment of the progression to AIDS (de Martino et al., 2000; Gortmaker et al., 2001). In 2000, the Italian Register for HIV Infection in Children (de Martino et al., 2000) observed a reduction in the mortality rate of 71% in individuals undergoing triple-combination therapy compared with untreated patients, while Gortmaker and colleagues found a 67% reduction comparing HAART with other therapy (Gortmaker et al., 2001). Important reductions of 76% have also been reported recently by a 10-year follow-up survey (Patel et al., 2008). Our analyses found a stronger reduction (84%), but it is not directly comparable with previous published data due to the longer follow-up and to the difference in the performed analyses. In fact, we dealt with the trend of the risk of death in different calendar periods considered as an external time-dependent covariate. The high prevalence of comorbidities, along with multiple causes of death, resulted in increasing complexity of the management of patients with HIV/AIDS.

Remarkably, mortality continued to be more than ten-fold higher in our cohort than in agesimilar general population after 1996 and mainly affected patients of low/medium socioeconomic status (Palladino et al., 2008). In addition, HIV-1–infected infants were still at higher risk for death compared with older paediatric patients, being this pattern mirrored in the general paediatric population and maybe attributable to the immature of the immune system (Gortmaker et al., 2001). Finally, the mortality trend had a strikingly lower decrease among infants than among children aged ≥ 1 year in our cohort, where it decreased equally in both groups in the general population. These findings highlight the HIV-1-infected infants as a major target for healthcare policy. We observed very high AIDS and mortality incidence rates during the first years of follow-up. These data on mortality are consistent with historical European series (ECS, (1994). and with data on HIV-1 progression in children living in setting where they do not receive medical care (Brahmbhatt et al., 2006; Marinda et al., 2007). In fact, zidovudine monotherapy administration to paediatric patients started only in 1988 (Pizzo et al., 1988) and in our cohort the majority of the children were still untreated in this year. Moreover, the high HIV-1 prevalence among the female population fuelled by the so called "epidemic of heroin" had a direct impact on the spread of the infection in

Our study shows that monotherapy exerted some benefit in the management of symptomatic children (Butler et al., 1991; McKinney et al., 1991; Resino et al., 2006b). Nevertheless, it had a time-limited effect due to ongoing viral replication that inevitably leads to the emergence of resistant HIV-1 quasispecies, which was also promoted by the lack of drug dosage adjustments for children at that time. The dual-nucleoside therapy proved to be more effective than monotherapy (Englund et al., 1997; Resino et al., 2006b). However, in our setting its effect on mortality or AIDS prevention between 1994- 1996 was similar to that exerted by monotherapy. This finding might be partially attributable to the regimen switch to dual-drug therapy (mainly zidovudine plus didanosine) after several years of zidovudine treatment in many children, when zidovudine was not more completely active. Thus, even with perfect adherence, dual-drug therapy was only partially suppressive being administered as functional monotherapy and due to crossresistance within the nucleoside analogue class. In addition, during this period more than 40% of the children were still untreated and more than 35% were on monotherapy. Previous studies reported the effectiveness of HAART on the risk of death in the setting of large paediatric cohorts, but these had limited follow-up and lacked assessment of the progression to AIDS (de Martino et al., 2000; Gortmaker et al., 2001). In 2000, the Italian Register for HIV Infection in Children (de Martino et al., 2000) observed a reduction in the mortality rate of 71% in individuals undergoing triple-combination therapy compared with untreated patients, while Gortmaker and colleagues found a 67% reduction comparing HAART with other therapy (Gortmaker et al., 2001). Important reductions of 76% have also been reported recently by a 10-year follow-up survey (Patel et al., 2008). Our analyses found a stronger reduction (84%), but it is not directly comparable with previous published data due to the longer follow-up and to the difference in the performed analyses. In fact, we dealt with the trend of the risk of death in different calendar periods considered as an external time-dependent covariate. The high prevalence of comorbidities, along with multiple causes of death, resulted in increasing complexity of

infants.

the management of patients with HIV/AIDS.

In terms of specific causes of death, AIDS–defining events were the most represented, with proportions higher than that recently observed in adults (Martinez et al., 2007; Palella et al., 2006). This finding might be directly linked to a late HIV-1 diagnosis at the beginning of the epidemic and to the persistence of opportunistic infections, that were the leading AIDS– defining causes of death (Brady et al., 2010; Selik & Lindegren 2003), although less represented since HAART advent (Currier et al., 1998; Kaplan et al., 2001). As in previous studies, bacterial infections were the largest component of opportunistic infections (Gona et al., 2006; Langston et al., 2001). Although specific information for their aetiology was mainly unavailable, we supposed that pneumococcus (*Streptococcus pneumoniae*) might has been the prominent microbial on the basis of recent reports (Cotton et al., 2008; Gortmaker et al., 2001; Kapogiannis et al., 2008). In addition, the pneumococcal conjugate vaccine available since 2000 (Black et al., 2000) and recommended for all HIV-infected children, has a lower efficacy in these patients than in HIV-uninfected children (Bliss et al., 2008). Some bacterial infections occurred with normal CD4+ cell percentage (≥25%), consistently with previous report (Gona et al., 2006), maybe because the HIV-1 infection does not allow the correct development of primary immune function leading to the production of polyclonal, nonspecific immunoglobulin increasing the risk of infections with encapsulated bacteria (Brady et al., 2010; Cotton et al., 2008; Gortmaker et al., 2001; Kapogiannis et al., 2008). The population-based analysis yielded consistent results with studies of HIV–infected patients (Kapogiannis et al., 2008; Martinez et al., 2007), highlighting a higher incidence of infections in our cohort than in the general population of similar age from the same region. Along with host immune factors (Janoff et al., 1992), antimicrobial resistance (Cotton et al., 2008; Jaspan et al., 2008), comorbidity and co-infections might have contributed to the high risk of death from opportunistic infections. The introduction of both *Pneumocystis* pneumonia prophylaxis (CDC 1995; Simonds et al., 1995) and HAART in our cohort has been accompanied by substantial reductions in mortality caused by *Pneumocystis* pneumonia (Gona et al., 2006; Kaplan et al., 2000), which have continued to occur in post-HAART era only in infants born to women with late HIV-1 diagnosis or unmonitored pregnancy, causing failure to implement *Pneumocystis* pneumonia prophylaxis (Gibb et al., 2003; Simpson et al., 2000). The cases of *M. avium* complex infection in our cohort have decreased over time (Gona et al., 2006). The cases reported in CP2 were diagnosed in children 6-11 years old, probably as a complication of advanced immunologic deterioration and the difficulty to realize a complete adherence to HAART and *M. avium* complex chemoprophylaxis. On the other hand, our data have shown an increase in the median age at death over time that might reflect improved management and prolongation in the time to development of a first bacteremia (Kapogiannis et al., 2008). More prolonged survival might allow chronic underlying comorbid conditions to become more clinically relevant in the next future. The proportion of HIV–related causes of deaths (12%) increased over time even if not statistically significant. Interestingly, the case of lactic acidosis was related to HAART regimen (stavudine + didanosine + efavirenz) that caused mitochondrial toxicity, whose rate is known to be increased by stavudine + didanosine co-administration (Blanco et al., 2003; Cote et al., 2002). Among non-HIV–related causes of death, the 7% of all the underlying causes, the fulminant hepatic failure occurred in 2008 was HCV-associated. We did not observe the increase of conditions, including diabetes mellitus, cancer, cardiovascular, liver and renal diseases that have become frequent in HIV-1–infected adults (Crum et al., 2006;

HAART and Causes of Death in Perinatally HIV-1-Infected Children 657

Network for Treatment of AIDS (PENTA), Fundación Caja Navarra, Fondo de Investigación Sanitaria (FIS INTRASALUD PI09/02029). The Spanish MICINN through the Juan de la

Black, S., Shinefield, H., Fireman, B., Lewis, E., Ray, P., Hansen, J. R., Elvin, L., Ensor, K. M.,

Blanche, S., Bologna, R., Cahn, P., Rugina, S., Flynn, P., Fortuny, C., Vis, P., Sekar, V., van

Blanco, F., Garcia-Benayas, T., Jose de la Cruz, J., Gonzalez-Lahoz, J., & Soriano, V. (2003).

Bliss, S. J., O'Brien, K. L., Janoff, E. N., Cotton, M. F., Musoke, P., Coovadia, H., & Levine, O.

Brady, M. T., Oleske, J. M., Williams, P. L., Elgie, C., Mofenson, L. M., Dankner, W. M., &

53, No. 1, (Jan 2010), pp. 86-94, 1944-7884 (Electronic) 1525-4135 (Linking) Brahmbhatt, H., Kigozi, G., Wabwire-Mangen, F., Serwadda, D., Lutalo, T., Nalugoda, F.,

Butler, K. M., Husson, R. N., Balis, F. M., Brouwers, P., Eddy, J., el-Amin, D., Gress, J.,

Centers for Disease Control and Prevention. (Dec 1992). Revised classification system for

 <http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00018871.htm> Centers for Disease Control and Prevention. (Sep 1994). Revised classification system for

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4135 (Print) 1525-4135 (Linking)

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Hackell, J., Siber, G., Malinoski, F., Madore, D., Chang, I., Kohberger, R., Watson, W., Austrian, R., & Edwards, K. (2000). Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. *Pediatr Infect Dis J*, Vol. 19, No. 3,

Baelen, B., Dierynck, I., & Spinosa-Guzman, S. (2009). Pharmacokinetics, safety and efficacy of darunavir/ritonavir in treatment-experienced children and adolescents. *AIDS*, Vol. 23, No. 15, (Sep 2009), pp. 2005-13, 1473-5571 (Electronic) 0269-9370

First-line therapy and mitochondrial damage: different nucleosides, different findings. *HIV Clin Trials*, Vol. 4, No. 1, (Jan-Feb 2003), pp. 11-19, 1528-4336 (Print)

S. (2008). The evidence for using conjugate vaccines to protect HIV-infected children against pneumococcal disease. *Lancet Infect Dis*, Vol. 8, No. 1, (Jan 2008),

Van Dyke, R. B. (2010). Declines in mortality rates and changes in causes of death in HIV-1-infected children during the HAART era. *J Acquir Immune Defic Syndr*, Vol.

Sewankambo, N., Kiduggavu, M., Wawer, M., & Gray, R. (2006). Mortality in HIVinfected and uninfected children of HIV-infected and uninfected mothers in rural Uganda. *J Acquir Immune Defic Syndr*, Vol. 41, No. 4, (Apr 2006), pp. 504-508, 1525-

Hawkins, M., Jarosinski, P., Moss, H., & et al. (1991). Dideoxyinosine in children with symptomatic human immunodeficiency virus infection. *N Engl J Med*, Vol.

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human immunodeficiency virus infection in children less than 13 years of age. *Morbidity and Mortality Weekly Report CDC Surveill Summ,* Vol. 43, No. RR-12, pp. 1-

Cierva program (JCI-2009–05650) (to C.P.).

**7. References** 

(Linking)

1528-4336 (Linking)

Lewden et al., 2008; Novoa et al., 2008; Palella et al., 2006; Sackoff et al., 2006; Smit et al., 2006). The lack of increase of non-HIV–related causes of death might be due to the long duration pathogenesis of these diseases as well as to their rarity, which might have limited power to identify such evolution.

The duration of initial HAART regimens for antiretroviral-naïve children has not been reported. On the contrary, several studies have assessed this public health issue in HIV-1– infected adults (Chen et al., 2003; Miller et al., 1999; Palella Jr et al., 2002; Phillips et al., 2001). The median duration of the first regimen observed in our study population was more than 3 years, the double of the duration described by Cheng and colleagues (2003) in a group of 405 antiretroviral-naïve adults and longer than that observed by Palella et al. (2002) who enrolled patients with previous antiretroviral experience. Notably, our study had a longer follow-up which could in part explain this difference. Among the therapy-naïve paediatric patients enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, poor adherence has been identified as primary risk factor for initial HAART regimens discontinuation and short duration. This result is in agreement with the association between adherence and response to antiretroviral therapy reported for paediatric patients, being incomplete adherence the primary cause of treatment failure (Chiappini et al., 2006; Gray et al., 2001; Hainaut et al., 2003; Resino et al., 2003). In addiction, the age at HAART initiation was found to be another independent risk factor for first HAART regimen discontinuation. The impact of HAART on the morbidity and mortality in Spanish HIV-1 vertically infected children has been discussed elsewhere (Resino et al., 2006b; Sanchez et al., 2003). However, an assessment of underlying causes of mortality and a population effectiveness analysis have never been performed in the context of an observational paediatric cohort in Spain. A number of limitations of this study should be noted. First, temporal changes in the spectrum of causes of deaths were not statistically significant; whether this result has been due to the limited number of deaths occurred after 1996 should be cautiously taken into account. Second, a survivor bias due to the partially retrospective enrolment might have caused mortality underestimation in infants at the beginning of the epidemic. Nevertheless our cohort remains more than representative of the HIV-1 epidemic in one of the Spanish regions most affected by the disease over almost three decades.

### **5. Conclusion**

Despite the population effectiveness of HAART in reducing HIV-1-associated mortality, new challenges could arise for national surveillance systems as prolonged survival and long-term antiretroviral exposure might contribute to additional and different causes of death in perinatally infected patients in the future.

## **6. Acknowledgments**

The authors thank patients for their participation and the HIV HGM BioBank belonging to the Spanish AIDS Research Network (RED RIS) and Red Nacional de BioBancos, and The cohort of the Spanish Paediatric HIV Research Network CoRISpe cohort node 1.

This study was partially supported by grants from Red Temática de Investigación Cooperativa Sanitaria ISCIII (RETIC RD06/0006/0035), Fundación para la Investigación y Prevención del SIDA en España (FIPSE 240800/09 and 380910/10), Paediatric European Network for Treatment of AIDS (PENTA), Fundación Caja Navarra, Fondo de Investigación Sanitaria (FIS INTRASALUD PI09/02029). The Spanish MICINN through the Juan de la Cierva program (JCI-2009–05650) (to C.P.).

## **7. References**

656 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

Lewden et al., 2008; Novoa et al., 2008; Palella et al., 2006; Sackoff et al., 2006; Smit et al., 2006). The lack of increase of non-HIV–related causes of death might be due to the long duration pathogenesis of these diseases as well as to their rarity, which might have limited

The duration of initial HAART regimens for antiretroviral-naïve children has not been reported. On the contrary, several studies have assessed this public health issue in HIV-1– infected adults (Chen et al., 2003; Miller et al., 1999; Palella Jr et al., 2002; Phillips et al., 2001). The median duration of the first regimen observed in our study population was more than 3 years, the double of the duration described by Cheng and colleagues (2003) in a group of 405 antiretroviral-naïve adults and longer than that observed by Palella et al. (2002) who enrolled patients with previous antiretroviral experience. Notably, our study had a longer follow-up which could in part explain this difference. Among the therapy-naïve paediatric patients enrolled in the HIV Paediatric Cohort of the *Comunidad Autónoma de Madrid*, poor adherence has been identified as primary risk factor for initial HAART regimens discontinuation and short duration. This result is in agreement with the association between adherence and response to antiretroviral therapy reported for paediatric patients, being incomplete adherence the primary cause of treatment failure (Chiappini et al., 2006; Gray et al., 2001; Hainaut et al., 2003; Resino et al., 2003). In addiction, the age at HAART initiation was found to be another independent risk factor for first HAART regimen discontinuation. The impact of HAART on the morbidity and mortality in Spanish HIV-1 vertically infected children has been discussed elsewhere (Resino et al., 2006b; Sanchez et al., 2003). However, an assessment of underlying causes of mortality and a population effectiveness analysis have never been performed in the context of an observational paediatric cohort in Spain. A number of limitations of this study should be noted. First, temporal changes in the spectrum of causes of deaths were not statistically significant; whether this result has been due to the limited number of deaths occurred after 1996 should be cautiously taken into account. Second, a survivor bias due to the partially retrospective enrolment might have caused mortality underestimation in infants at the beginning of the epidemic. Nevertheless our cohort remains more than representative of the HIV-1 epidemic in one of the Spanish regions most affected by the disease over almost three

Despite the population effectiveness of HAART in reducing HIV-1-associated mortality, new challenges could arise for national surveillance systems as prolonged survival and long-term antiretroviral exposure might contribute to additional and different causes of

The authors thank patients for their participation and the HIV HGM BioBank belonging to the Spanish AIDS Research Network (RED RIS) and Red Nacional de BioBancos, and The

This study was partially supported by grants from Red Temática de Investigación Cooperativa Sanitaria ISCIII (RETIC RD06/0006/0035), Fundación para la Investigación y Prevención del SIDA en España (FIPSE 240800/09 and 380910/10), Paediatric European

cohort of the Spanish Paediatric HIV Research Network CoRISpe cohort node 1.

power to identify such evolution.

decades.

**5. Conclusion** 

**6. Acknowledgments** 

death in perinatally infected patients in the future.


<http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00018871.htm>

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**27** 

*Poland* 

**Cannabinoids – Influence on the Immune** 

*Department of Biomedical and Environmental Analyses, Faculty of Pharmacy,* 

*Cannabis sativa* (Fig. 1.) has been valued for its medicinal as well as its psychotropic properties dating back to ancient times. In nineteenth century W.B. O'Shaughnessy used marijuana for pain relief and Jean-Jacques Moreau de Tours – French psychiatrist, said, that cannabis is very helpful in therapy of psychiatric disorders (Booth, 2004). Main constituents of *Cannabis sativa*  were discovered in 1960's and named after the plant – cannabinoids. The identification of the chemical structure of *cannabis* components and the possibility of obtaining its pure constituents were related to a significant increase in scientific interest in this plant. This interest was renewed in the 1990's with the description of cannabinoid receptors and the identification of

The most notable of the cannabinoids are: tetrahydrocannabinol (THC) – the most psychoactive substance found in the cannabis plant and cannabidiol – constituent which has displayed sedative effects. Both constituents can be found in the brown resin secreted by the hair which covers female plants (Truta et al., 2002). Cannabinoids bind to the cannabinoid receptors (CB receptors), change metabolism of the cells, moderate neurotransmission and hormones extraction, what affect main functions of the human body (Demuth et al., 2006,

The cannabinoid receptor family currently includes two types: CB1, characterized mostly in neuronal cells and brain, and CB2, characterized in immune cells (lymphocytes and macrophages) and tissues (spleen and tonsils) (Demuth et al., 2006). Both receptors are proteins and consist of seven transmembrane−spanning domains (Fig. 2.)(Joy et al., 1999). The CB1 molecule is larger than CB2. However, both receptor molecules are alike in four of the seven regions embedded in the cell membrane (known as the transmembrane regions). The intracellular loops of the two receptor subtypes are quite different, which might affect the cellular response to the ligand (Szulakowska&Milnerowicz, 2007). Human body also produces substances that activate CB receptors, they are known as endocannabinoids. The studies have revealed a broad role of endocannabinoids and cannabinoid receptors in a variety of physiological processes as neuromodulation, pain and appetite sensation, motor

an endogenous cannabinoid system in the brain (Zuardi, 2006).

**1. Introduction** 

ElSohly et al., 2005).

learning (Saito et al., 2010).

**System and Their Potencial Use in** 

Alicja Szulakowska and Halina Milnerowicz

*Silesian Piasts University of Medicine in Wroclaw* 

**Supplementary Therapy of HIV/AIDS** 


## **Cannabinoids – Influence on the Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS**

Alicja Szulakowska and Halina Milnerowicz

*Department of Biomedical and Environmental Analyses, Faculty of Pharmacy, Silesian Piasts University of Medicine in Wroclaw Poland* 

## **1. Introduction**

664 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

The European Collaborative Study. Mother-to-child transmission of HIV infection in the era

The European Collaborative Study (1994). Natural history of vertically acquired human

Violari, A., Cotton, M., Gibb, D., Babiker, A., Steyn, J., Jean-Phillip, P., J., M., & Team., o. b. o.

Walker, A. S., Doerholt, K., Sharland, M., & Gibb, D. M. (2004). Response to highly active

WHO/UNAIDS/UNICEF. (Sep 2010). Towards Universal Access: Scaling up Priority

458-465, 1537-6591 (Electronic) 1058-4838 (Linking)

<http://www.ias2007.org/pag/Abstracts.aspx?AID=5557>

<http://www.who.int/hiv/pub/2010progressreport/en/>

815-819, 0031-4005 (Print) 0031-4005 (Linking)

0269-9370 (Linking)

of highly active antiretroviral therapy. *Clin Infect Dis*, Vol. 40, No. 3, (Feb 2005), pp.

immunodeficiency virus-1 infection. *Pediatrics*, Vol. 94, No. 6 Pt 1, (Dec 1994), pp.

t. C. S. (2007). Antiretroviral therapy initiated before 12 weeks of age reduces early mortality in young HIV-infected infants: evidence from the Children with HIV Early Antiretroviral Therapy (CHER) Study. Fourth Internationa AIDS Society Conference, Sydney, Australia, July 22–25, 2007, 17.02.2011, Available from;

antiretroviral therapy varies with age: the UK and Ireland Collaborative HIV Paediatric Study. *AIDS*, Vol. 18, No. 14, (Sep 2004), pp. 1915-1924, 0269-9370 (Print)

HIV/AIDS Interventions in the Health Sector: Progress Report 2010. Geneva, Switzerland: World Health Organization, pp. 1-146, 20.01.2011, Available from:

*Cannabis sativa* (Fig. 1.) has been valued for its medicinal as well as its psychotropic properties dating back to ancient times. In nineteenth century W.B. O'Shaughnessy used marijuana for pain relief and Jean-Jacques Moreau de Tours – French psychiatrist, said, that cannabis is very helpful in therapy of psychiatric disorders (Booth, 2004). Main constituents of *Cannabis sativa*  were discovered in 1960's and named after the plant – cannabinoids. The identification of the chemical structure of *cannabis* components and the possibility of obtaining its pure constituents were related to a significant increase in scientific interest in this plant. This interest was renewed in the 1990's with the description of cannabinoid receptors and the identification of an endogenous cannabinoid system in the brain (Zuardi, 2006).

The most notable of the cannabinoids are: tetrahydrocannabinol (THC) – the most psychoactive substance found in the cannabis plant and cannabidiol – constituent which has displayed sedative effects. Both constituents can be found in the brown resin secreted by the hair which covers female plants (Truta et al., 2002). Cannabinoids bind to the cannabinoid receptors (CB receptors), change metabolism of the cells, moderate neurotransmission and hormones extraction, what affect main functions of the human body (Demuth et al., 2006, ElSohly et al., 2005).

The cannabinoid receptor family currently includes two types: CB1, characterized mostly in neuronal cells and brain, and CB2, characterized in immune cells (lymphocytes and macrophages) and tissues (spleen and tonsils) (Demuth et al., 2006). Both receptors are proteins and consist of seven transmembrane−spanning domains (Fig. 2.)(Joy et al., 1999). The CB1 molecule is larger than CB2. However, both receptor molecules are alike in four of the seven regions embedded in the cell membrane (known as the transmembrane regions). The intracellular loops of the two receptor subtypes are quite different, which might affect the cellular response to the ligand (Szulakowska&Milnerowicz, 2007). Human body also produces substances that activate CB receptors, they are known as endocannabinoids. The studies have revealed a broad role of endocannabinoids and cannabinoid receptors in a variety of physiological processes as neuromodulation, pain and appetite sensation, motor learning (Saito et al., 2010).

Cannabinoids – Influence on the

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 667

marijuana smokers, with a mean CD4/CD8 ratio of 1.95 as opposed to 1.27 in controls (Nong et al., 2002; Massi et al., 2006). Finally, Klein and Co. proved that cannabinoids affect cytotoxic T lymphocytes (CTL) – after incubation with THC, the cytolytic activity of CTL was depressed by about 60% (Klein et al., 1991). It also appeared that cannabinoids can disrupt proliferation and cytolytic activity in natural killer cells (NK), which plays very

Functions of macrophages are also impaired by cannabinoids through either a receptor- or non-receptor-mediated mechanism. Studies with pulmonary alveolar macrophages showed that cannabinoids significantly lowered the level of tumor necrosis factor α ( TNFα) in the bronchoalveolar lavage (Klein et al., 1991). Scientists proved that cannabinoids influenced the ability of macrophages to process antigens necessary for the activation of CD4+ T lymphocytes (McCoy et al., 1999), reduced chemotaxis (Sacerdote et al., 2000) and affect the production of arachidonic acid metabolites in macrophage cultures (Berdyshev et al., 2000).

Cannabinoids can modulate the action of cytokines mostly by affecting immune cells, for example macrophages or Th cells, their immunomodulatory properties are complex, what

Scientists proved that cannabinoids can modulate immune response also by affecting hormones release. For example administration of THC, may increase level of adrenocorticotropic hormone and corticosterone, what is causing downstream release of immunoregulatory molecules as cortizol and sex hormones and inhibition of immune

The influence of cannabinoids on NO production is still unclear (Massi et al., 2006).

response (Massi et al., 2006; Tanasescu&Constantinescu, 2010; Baker et al., 2007).

important role in host defences against tumors and microbes (Massi et al., 2006).

Fig. 2. Cannabinoid receptors CB1 and CB2 (Joy et al., 1999).

**2.2 Cytokines and hormones** 

was shown in the Table 1.

Fig. 1. *Cannabis sativa* (Kohler, 1887).

## **2. Cannabinoids and the immune system**

The study of marijuana cannabinoid biology has led to many important discoveries in immunology; not only existence of a new physiological system - the endocannabinoid system, but also its role in the regulation of the immune system. Studies examining the effect of cannabinoids on immunity have shown that many cellular and cytokine mechanisms are suppressed by these agents (Klein&Cabral, 2006).

## **2.1 Cellular effects**

Scientists have already suggested in 1970s that cannabinoids can change the number and function of T cells. Various functions from cytotoxic T cell killing to antibody production by B cells have been examined. Nong and Co. have studied the T-cell rosetting capacity of lymphocytes in CD4 and CD8 subsets – it was impaired in peripheral blood cells from marijuana users. Scientists examined also the effects on the number of lymphocytes in CD4 and CD8 subsets. The percentage of CD4 T cells was increased in peripheral blood cells from

The study of marijuana cannabinoid biology has led to many important discoveries in immunology; not only existence of a new physiological system - the endocannabinoid system, but also its role in the regulation of the immune system. Studies examining the effect of cannabinoids on immunity have shown that many cellular and cytokine

Scientists have already suggested in 1970s that cannabinoids can change the number and function of T cells. Various functions from cytotoxic T cell killing to antibody production by B cells have been examined. Nong and Co. have studied the T-cell rosetting capacity of lymphocytes in CD4 and CD8 subsets – it was impaired in peripheral blood cells from marijuana users. Scientists examined also the effects on the number of lymphocytes in CD4 and CD8 subsets. The percentage of CD4 T cells was increased in peripheral blood cells from

Fig. 1. *Cannabis sativa* (Kohler, 1887).

**2.1 Cellular effects** 

**2. Cannabinoids and the immune system** 

mechanisms are suppressed by these agents (Klein&Cabral, 2006).

marijuana smokers, with a mean CD4/CD8 ratio of 1.95 as opposed to 1.27 in controls (Nong et al., 2002; Massi et al., 2006). Finally, Klein and Co. proved that cannabinoids affect cytotoxic T lymphocytes (CTL) – after incubation with THC, the cytolytic activity of CTL was depressed by about 60% (Klein et al., 1991). It also appeared that cannabinoids can disrupt proliferation and cytolytic activity in natural killer cells (NK), which plays very important role in host defences against tumors and microbes (Massi et al., 2006).

Fig. 2. Cannabinoid receptors CB1 and CB2 (Joy et al., 1999).

Functions of macrophages are also impaired by cannabinoids through either a receptor- or non-receptor-mediated mechanism. Studies with pulmonary alveolar macrophages showed that cannabinoids significantly lowered the level of tumor necrosis factor α ( TNFα) in the bronchoalveolar lavage (Klein et al., 1991). Scientists proved that cannabinoids influenced the ability of macrophages to process antigens necessary for the activation of CD4+ T lymphocytes (McCoy et al., 1999), reduced chemotaxis (Sacerdote et al., 2000) and affect the production of arachidonic acid metabolites in macrophage cultures (Berdyshev et al., 2000). The influence of cannabinoids on NO production is still unclear (Massi et al., 2006).

## **2.2 Cytokines and hormones**

Cannabinoids can modulate the action of cytokines mostly by affecting immune cells, for example macrophages or Th cells, their immunomodulatory properties are complex, what was shown in the Table 1.

Scientists proved that cannabinoids can modulate immune response also by affecting hormones release. For example administration of THC, may increase level of adrenocorticotropic hormone and corticosterone, what is causing downstream release of immunoregulatory molecules as cortizol and sex hormones and inhibition of immune response (Massi et al., 2006; Tanasescu&Constantinescu, 2010; Baker et al., 2007).

Cannabinoids – Influence on the

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 669

Fig. 3. Immune regulation by cannabinoids. Exogenously administered cannabinoids (a, b) or endocannabinoids (c) may inhibit the action of the immune response in either the

periphery (a, b) or the central nervous system (CNS; c) via either a direct (a, c) or indirect (b)

Cannabinoids can modulate immune reactions in the periphery but also in the brain, influence T cell subset balance and cytokine expression. Generally, they alter many

functions of the immune response, what was shown in the Fig. 3. (Baker et al., 2007).

**3. Immunological consequences of cannabinoids use by HIV/AIDS patients**  Anti-inflammatory potential action of cannabinoids tends to be evident from the studies discussed in the previous paragraph. Cannabinoids do induce apoptosis in immune cells and alleviate inflammatory responses (Rieder et al., 2010). Even though the progressive failure of the immune system is a cause of AIDS disease, no conclusive data have been obtained as to potential risk associated with HIV infection and the use of cannabinoids. In 2003 Abrams and co. examined short-term effects of cannabinoids in patients with HIV-1

action on leukocytes (from Baker et al., 2007).


Table 1. Cannabinoid influence on cytokines profile

**Cannabinoid infulence General result References** 

1992, 1996)

1992, 1996)

2010)

1993)

2000)

2010)

al., 2005)

Massi et al., 2006; Klein et al., 2000; Sacerdote et al., 2005)

IFNγ Decreased level Anti-inflammatory action (Zheng et al.,

TNFα Decreased level Anti-inflammatory action (Zheng et al.,

Il-1 Decreased level Anti-inflammatory action (Kozela et al.,

Il-2 Decreased level Anti-inflammatory action (Zhu et al.,

Il-4 Increased level Action unclear (Klein et al.,

Il-6 Decreased level Anti-inflammatory action (Kozela et al.,

Il-10 Decreased level Action unclear (Sacerdote et

Anti-inflammatory action (THC)/ Anti-inflammatory action

Decreased level (THC)/increased level (CBD)

Table 1. Cannabinoid influence on cytokines profile

**Name of the cytokine** 

Il-12

Fig. 3. Immune regulation by cannabinoids. Exogenously administered cannabinoids (a, b) or endocannabinoids (c) may inhibit the action of the immune response in either the periphery (a, b) or the central nervous system (CNS; c) via either a direct (a, c) or indirect (b) action on leukocytes (from Baker et al., 2007).

Cannabinoids can modulate immune reactions in the periphery but also in the brain, influence T cell subset balance and cytokine expression. Generally, they alter many functions of the immune response, what was shown in the Fig. 3. (Baker et al., 2007).

## **3. Immunological consequences of cannabinoids use by HIV/AIDS patients**

Anti-inflammatory potential action of cannabinoids tends to be evident from the studies discussed in the previous paragraph. Cannabinoids do induce apoptosis in immune cells and alleviate inflammatory responses (Rieder et al., 2010). Even though the progressive failure of the immune system is a cause of AIDS disease, no conclusive data have been obtained as to potential risk associated with HIV infection and the use of cannabinoids. In 2003 Abrams and co. examined short-term effects of cannabinoids in patients with HIV-1

Cannabinoids – Influence on the

information about alternative therapy (Peltzer et al., 2008).

Much better [%]

Lack of appetite 111 79 18 2 0 1 Pain in muscle 65 63 31 6 0 0 Nausea 62 56 37 3 2 2 Anxiety 98 64 49 3 2 2 Nerve pain 53 51 40 9 0 0 Depression 94 56 30 9 4 1 Tingling 46 37 48 9 7 0 Numbness 42 36 36 24 5 0 Weight loss 62 45 24 31 0 0 Headaches 46 35 30 33 2 0 Tremor 24 37 29 21 13 0 Constipation 24 21 29 46 4 0 Tiredness 60 17 33 33 15 2 Diarrhea 48 13 23 56 6 2 Vision dimness 22 9 27 55 9 0 Weakness 48 10 21 54 15 0 Memory loss 38 13 5 34 34 13 Slurred speech 9 11 0 78 11 0

Table 2. Effect of marijuana on Complaint of Symptoms in 143 HIV Patients (from

Little better [%]

No change [%]

Little worse [%]

Much worse [%]

complaints

Symptom Number of

Woolridge et al., 2005).

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 671

those) reported recreational use only of marijuana and 44.3% admitted mixed use of marijuana for therapeutic and recreational purposes (Fogarty et al., 2007). In 2007/2008 in South Africa only 3.7% of 618 admitted that was using marijuana in the past six month, mostly for stress relief (85.7%) and to a lesser extent for recreational purposes (relaxation) (23.5%) and pain relief (17.6%) (Peltzer et al., 2008). These results from different places in the world show that substantial proportion of people living with HIV/AIDS use marijuana for therapeutic purposes, despite considerable legal barriers, suggesting that cannabis represents another option in their health management (Fogarty et al., 2007). The small percentage of South Africans with HIV/AIDS using marijuana for therapeutic purposes may be caused by poverty (marijuana is more expensive than other alternative, supplementary methods like micronutrients, religious healing) and limited access to

infection. Scientists measured HIV RNA level and CD4+ and CD8+ cell subsets, during 21 days of oral and smoked marijuana administration among 67 patients with HIV-1 infection. At days 0 and 21, HIV RNA was undetectable in 50% to 55% of patients in each group, the mean changes were decreases in both cannabinoid groups: marijuana group and dronabinol group. The unadjusted mean increases in CD4+ cell counts were greater for patients receiving cannabinoids than for patients receiving placebo. CD8+ cell counts were on average 20% greater for patients receiving marijuana than for patients receiving placebo and marginally greater (average 10%) for patients receiving dronabinol than for those receiving placebo. Authors concluded that smoked and oral cannabinoids did not seem to be unsafe in patients with HIV infection with respect to HIV RNA levels, CD4+ and CD8+ cell counts (Abrams et al., 2003).

Kosel and co. decided to examine effects of cannabinoids on the pharmacokinetics of indinavir and nelfinavir – protease inhibitors used as a component of highly active antiretroviral therapy to treat HIV infection and AIDS. Patients on stable regimens containing indinavir or nelfinavir were randomized to one of three treatments: 3.95% THC marijuana cigarettes, dronabinol 2.5 mg capsules or placebo capsules administered three times daily. The treatment lasted 14 days. Authors concluded that their results after marijuana treatment (statistically significant decrease in maximum concentration of nelfinavir - C(max)) by -17.4% (P=0.46) and the magnitude of changes in indinavir concentration - C(max) by -14.1% (P=0.039)), are likely to have no short-term clinical consequence. The use of cannabinoids is unlikely to impact antiretroviral efficacy (Kosel et al., 2002).

## **4. Therapeutic use of marijuana for people living with HIV/AIDS**

Over 40 million people are affected by HIV/AIDS in the world. There is still no cure available for this disease, although remarkable improvements in the quality and life expectancy have been achieved. Most of the patients are on long-term treatment with combinations of antiretroviral therapies and cope with the side effects of these therapies (nausea, vomiting, pain, reduced appetite, weight loss, headaches, diarrhea, constipation, anxiety and depression) (Woolridge et al., 2005). Recently, therapeutic use of marijuana has emerged as an important issue for people living with HIV/AIDS. Fogarty et al. reported that people with HIV/AIDS who use marijuana indicate improved moods, sensory experiences, creativity, increased socialising, elation and changes in appetite (Fogarty et al., 2007; Woolridge et al., 2005). In 2005 Woolridge et al. surveyed 143 HIV positive people who reported using marijuana to manage side effects of long-term anti-retroviral treatment. Results were shown in the table below (Table 2.) (Woolridge et al., 2005).

The ability of cannabinoid to treat pain, nausea, appetite loss, muscle spasm and a wide variety of other symptoms causes that more and more HIV/AIDS patients reach for marijuana as an alternative remedy. The actual numbers of HIV/AIDS patients that use marijuana to treat HIV related symptoms is a difficult number to quantify, but some researchers report that this number is quite significant (Cannon, 2010).

In 1998/1999, in Canada approximately 15% of 977 responders were using marijuana for medical purposes (Braitstein et al., 2001). In California in 2001 – 33.3% of the 442 responders reported the use of marijuana (Cannon, 2010). Regarding this data, in 2007 scientists examined people living with HIV/AIDS in Australia. The results show that among 408 participants, 59.8% reported some use of marijuana in the past six months. 244 (55.7% of

infection. Scientists measured HIV RNA level and CD4+ and CD8+ cell subsets, during 21 days of oral and smoked marijuana administration among 67 patients with HIV-1 infection. At days 0 and 21, HIV RNA was undetectable in 50% to 55% of patients in each group, the mean changes were decreases in both cannabinoid groups: marijuana group and dronabinol group. The unadjusted mean increases in CD4+ cell counts were greater for patients receiving cannabinoids than for patients receiving placebo. CD8+ cell counts were on average 20% greater for patients receiving marijuana than for patients receiving placebo and marginally greater (average 10%) for patients receiving dronabinol than for those receiving placebo. Authors concluded that smoked and oral cannabinoids did not seem to be unsafe in patients with HIV infection with respect to HIV RNA levels, CD4+ and CD8+ cell counts

Kosel and co. decided to examine effects of cannabinoids on the pharmacokinetics of indinavir and nelfinavir – protease inhibitors used as a component of highly active antiretroviral therapy to treat HIV infection and AIDS. Patients on stable regimens containing indinavir or nelfinavir were randomized to one of three treatments: 3.95% THC marijuana cigarettes, dronabinol 2.5 mg capsules or placebo capsules administered three times daily. The treatment lasted 14 days. Authors concluded that their results after marijuana treatment (statistically significant decrease in maximum concentration of nelfinavir - C(max)) by -17.4% (P=0.46) and the magnitude of changes in indinavir concentration - C(max) by -14.1% (P=0.039)), are likely to have no short-term clinical consequence. The use of cannabinoids is unlikely to impact antiretroviral efficacy (Kosel et

Over 40 million people are affected by HIV/AIDS in the world. There is still no cure available for this disease, although remarkable improvements in the quality and life expectancy have been achieved. Most of the patients are on long-term treatment with combinations of antiretroviral therapies and cope with the side effects of these therapies (nausea, vomiting, pain, reduced appetite, weight loss, headaches, diarrhea, constipation, anxiety and depression) (Woolridge et al., 2005). Recently, therapeutic use of marijuana has emerged as an important issue for people living with HIV/AIDS. Fogarty et al. reported that people with HIV/AIDS who use marijuana indicate improved moods, sensory experiences, creativity, increased socialising, elation and changes in appetite (Fogarty et al., 2007; Woolridge et al., 2005). In 2005 Woolridge et al. surveyed 143 HIV positive people who reported using marijuana to manage side effects of long-term anti-retroviral treatment.

The ability of cannabinoid to treat pain, nausea, appetite loss, muscle spasm and a wide variety of other symptoms causes that more and more HIV/AIDS patients reach for marijuana as an alternative remedy. The actual numbers of HIV/AIDS patients that use marijuana to treat HIV related symptoms is a difficult number to quantify, but some

In 1998/1999, in Canada approximately 15% of 977 responders were using marijuana for medical purposes (Braitstein et al., 2001). In California in 2001 – 33.3% of the 442 responders reported the use of marijuana (Cannon, 2010). Regarding this data, in 2007 scientists examined people living with HIV/AIDS in Australia. The results show that among 408 participants, 59.8% reported some use of marijuana in the past six months. 244 (55.7% of

**4. Therapeutic use of marijuana for people living with HIV/AIDS** 

Results were shown in the table below (Table 2.) (Woolridge et al., 2005).

researchers report that this number is quite significant (Cannon, 2010).

(Abrams et al., 2003).

al., 2002).

those) reported recreational use only of marijuana and 44.3% admitted mixed use of marijuana for therapeutic and recreational purposes (Fogarty et al., 2007). In 2007/2008 in South Africa only 3.7% of 618 admitted that was using marijuana in the past six month, mostly for stress relief (85.7%) and to a lesser extent for recreational purposes (relaxation) (23.5%) and pain relief (17.6%) (Peltzer et al., 2008). These results from different places in the world show that substantial proportion of people living with HIV/AIDS use marijuana for therapeutic purposes, despite considerable legal barriers, suggesting that cannabis represents another option in their health management (Fogarty et al., 2007). The small percentage of South Africans with HIV/AIDS using marijuana for therapeutic purposes may be caused by poverty (marijuana is more expensive than other alternative, supplementary methods like micronutrients, religious healing) and limited access to information about alternative therapy (Peltzer et al., 2008).


Table 2. Effect of marijuana on Complaint of Symptoms in 143 HIV Patients (from Woolridge et al., 2005).

Cannabinoids – Influence on the

**5. Antiemetic action** 

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 673

Fig. 4. DDS pain severity scores for participants in the cannabis (CNB) and placebo (PCB) arms before study treatment (W/I), during each of the 2 treatment weeks (1, 2) and during

 Low food intake – low appetite is common among HIV/AIDS patients and is mostly caused by anti-retroviral drugs (their side effects such as nausea, changes in the sense of taste, or tingling around the mouth also decrease appetite). Moreover, opportunistic

 Poor nutrient absorption – opportunistic infections of the gastrointestinal tract can interfere with the absorption of nutrients. Moreover, HIV may directly affect the intestinal lining and reduce nutrient absorption; diarrhea may affect nutrient absorption

 Altered metabolism – HIV/AIDS affects food processing and protein building. It is probably caused by the increased activity of the immune system. People need more

Scientists suppose that emesis (the side effect of anti-retroviral therapy) is caused by the stimulation of receptors in the central nervous system or the gastrointestinal tract. This stimulation appears to be caused by the drug used in treatment itself or a metabolite of the drug. The high concentration of cannabinoid receptors in the nucleus of the solitary tract, suggest that exogenous cannabinoids bind to receptors and prevent them from binding with drugs and metabolites (Szulakowska&Milnerowicz, 2007). Recent findings suggest that the mechanism of anti-emetic action of cannabinoids is more complex – CB1 agonist suppresses vomiting, which is reversed by CB1 antagonism, and CB1 inverse agonism promotes vomiting. Parker et al. proved that cannabinoid agonists –THC suppress nausea. It occurred

calories just to maintain their body weight (Cannon, 2010; The Body, 2011).

infections in the mouth, throat or stomach may also reduce food intake.

indirectly – it flushes the system of needed nutrients and calories.

the Washout (W/O) between treatment weeks (from Ellis et al., 2009).

#### **4.1 Pain management**

Neuropathic pain and muscular pain is reported by people living with HIV/AIDS. Patients describe pain as "aching", "burning" and "painful numbness" of legs and hands mostly (Cannon, 2010). Despite management with opioids and other pain modifying therapies, neuropathic pain continues to reduce the quality of life among 30% or more of HIV-infected individuals. Scientists suppose that pain perception is modulated by cannabinoid receptors in the central and peripheral nervous system (Ellis et al., 2009) via endocannabinoids, an endogenous system of retrograde neuromodulatory messengers that work in tandem with endogenous opioids (McCarberg, 2007).

Cannabinoids have been shown to inhibit the experience of pain in both – animal and human studies. It was demonstrated in 2007 in a study conducted by Abrams et al. He decided to determine the effect of smoked cannabis on the neuropathic pain of HIVassociated sensory neuropathy and an experimental pain model. Scientists asked fifty patients to smoke either cannabis or identical placebo cigarettes with the cannabinoids extracted three times daily for 5 days. Reduction in pain intensity was measured. It occurred that smoked cannabis reduced daily pain by 34% with placebo. Greater than 30% reduction of pain was reported by 52% in the cannabis group and by 24% in the placebo group. The first cannabis cigarette reduced chronic pain by a median of 72% vs 15% with placebo (Abrams et al., 2007). Similar trial was conducted by American scientists in 2009. Ellis et al. examined 127 HIV-associated distal sensory predominant polyneuropathy and measured change in pain intensity by the Descriptor Differential Scale (DDS) from a pretreatment baseline to the end of each treatment week. Treatments were placebo and delta-9 tetrahydrocannabinol, smoked four times daily for 5 consecutive days during each of 2 treatment weeks, separated by a 2-week washout. Among all the patients, pain relief was greater with cannabis than placebo and the proportions of subjects achieving at least 30% pain relief with cannabis vs placebo were 0.46 and 0.18. Results were shown in Fig. 4. (Ellis et al., 2009). This study's findings are equivalent to those achieved by Abrams et al. in 2007 and consistent with other recent research supporting the short-term efficacy of cannabis for neuropathic pain (Ellis et al., 2009; Abrams et al., 2007).

Results of other studies show that cannabis can treat not only the neuropathic pain but also muscular and chronic pain. Woolridge study demonstrated that 94% of participants reported positive results for muscular pain management using marijuana (Cannon, 2010; Woolridge et al., 2005). Finally, as it was mentioned in the previous paragraph, 30% reduction in chronic pain was reported by 52% of the smoked cannabis group (Cannon, 2010; Abrams et al., 2007).

Scientists suppose that analgetic properties of cannabinoids are effect of additional receptor and non-receptor mechanisms of their activity. Synergy between opioids and cannabinoids may produce opioid-sparing effects, as well as extend the duration of analgesia and reduce opioid tolerance and dependence, what is very important in long-term palliative treatment (McCarberg, 2007; Karst&Wippermann, 2009).

#### **4.2 Management of wasting syndrome**

Wasting is big problem for people living with HIV/AIDS and is linked to disease progression and death. It is defined as the involuntary loss of more than 10% of normal body weight in addition to at least 30 days of diarrhea, fever and generalized weakness. It is caused by several factors:

Fig. 4. DDS pain severity scores for participants in the cannabis (CNB) and placebo (PCB) arms before study treatment (W/I), during each of the 2 treatment weeks (1, 2) and during the Washout (W/O) between treatment weeks (from Ellis et al., 2009).


## **5. Antiemetic action**

672 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

Neuropathic pain and muscular pain is reported by people living with HIV/AIDS. Patients describe pain as "aching", "burning" and "painful numbness" of legs and hands mostly (Cannon, 2010). Despite management with opioids and other pain modifying therapies, neuropathic pain continues to reduce the quality of life among 30% or more of HIV-infected individuals. Scientists suppose that pain perception is modulated by cannabinoid receptors in the central and peripheral nervous system (Ellis et al., 2009) via endocannabinoids, an endogenous system of retrograde neuromodulatory messengers that work in tandem with

Cannabinoids have been shown to inhibit the experience of pain in both – animal and human studies. It was demonstrated in 2007 in a study conducted by Abrams et al. He decided to determine the effect of smoked cannabis on the neuropathic pain of HIVassociated sensory neuropathy and an experimental pain model. Scientists asked fifty patients to smoke either cannabis or identical placebo cigarettes with the cannabinoids extracted three times daily for 5 days. Reduction in pain intensity was measured. It occurred that smoked cannabis reduced daily pain by 34% with placebo. Greater than 30% reduction of pain was reported by 52% in the cannabis group and by 24% in the placebo group. The first cannabis cigarette reduced chronic pain by a median of 72% vs 15% with placebo (Abrams et al., 2007). Similar trial was conducted by American scientists in 2009. Ellis et al. examined 127 HIV-associated distal sensory predominant polyneuropathy and measured change in pain intensity by the Descriptor Differential Scale (DDS) from a pretreatment baseline to the end of each treatment week. Treatments were placebo and delta-9 tetrahydrocannabinol, smoked four times daily for 5 consecutive days during each of 2 treatment weeks, separated by a 2-week washout. Among all the patients, pain relief was greater with cannabis than placebo and the proportions of subjects achieving at least 30% pain relief with cannabis vs placebo were 0.46 and 0.18. Results were shown in Fig. 4. (Ellis et al., 2009). This study's findings are equivalent to those achieved by Abrams et al. in 2007 and consistent with other recent research supporting the short-term efficacy of cannabis for

Results of other studies show that cannabis can treat not only the neuropathic pain but also muscular and chronic pain. Woolridge study demonstrated that 94% of participants reported positive results for muscular pain management using marijuana (Cannon, 2010; Woolridge et al., 2005). Finally, as it was mentioned in the previous paragraph, 30% reduction in chronic pain was reported by 52% of the smoked cannabis group (Cannon,

Scientists suppose that analgetic properties of cannabinoids are effect of additional receptor and non-receptor mechanisms of their activity. Synergy between opioids and cannabinoids may produce opioid-sparing effects, as well as extend the duration of analgesia and reduce opioid tolerance and dependence, what is very important in long-term palliative treatment

Wasting is big problem for people living with HIV/AIDS and is linked to disease progression and death. It is defined as the involuntary loss of more than 10% of normal body weight in addition to at least 30 days of diarrhea, fever and generalized weakness. It is caused by

**4.1 Pain management** 

endogenous opioids (McCarberg, 2007).

neuropathic pain (Ellis et al., 2009; Abrams et al., 2007).

(McCarberg, 2007; Karst&Wippermann, 2009).

**4.2 Management of wasting syndrome** 

2010; Abrams et al., 2007).

several factors:

Scientists suppose that emesis (the side effect of anti-retroviral therapy) is caused by the stimulation of receptors in the central nervous system or the gastrointestinal tract. This stimulation appears to be caused by the drug used in treatment itself or a metabolite of the drug. The high concentration of cannabinoid receptors in the nucleus of the solitary tract, suggest that exogenous cannabinoids bind to receptors and prevent them from binding with drugs and metabolites (Szulakowska&Milnerowicz, 2007). Recent findings suggest that the mechanism of anti-emetic action of cannabinoids is more complex – CB1 agonist suppresses vomiting, which is reversed by CB1 antagonism, and CB1 inverse agonism promotes vomiting. Parker et al. proved that cannabinoid agonists –THC suppress nausea. It occurred

Cannabinoids – Influence on the

2007).

**6.1 Mood control** 

Fogarty et al., 2007).

countries (Cannon, 2010).

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 675

by four days of placebo washout. Results were shown in the Fig. 5. In comparison to placebo, marijuana and dronabinol increased daily caloric intake and body weight. It is probably caused by the increased number of eating occasions – marijuana and dronabinol increased the number of eating occasions but didn't alter the number of calories intake. Moreover, marijuana and dronabinol produced significant shifts in the distribution of macronutrient administration by enhancing the proportion of calories derived from fat. The final effect of increased caloric intake and macronutrients administration was weight gain – 1.2 kg after 4 days of dronabinol and 1.1 kg after 4 days of marijuana (Haney et al.,

Scientists consider that prevalence of psychiatric disorders (mostly depression) is really high among the people living with HIV/AIDS. In 2001 in the USA nearly half of the population screened positive for a psychiatric disorder (36% major depression, 26.5% dysthymia, 15.8% generalized anxiety disorder, 10.5% panic attack)(Bing et al., 2001). Psychiatric disorders may be triggered by side effects of medications or the effects of HIV on the brain. Research show that depression can limit the energy needed to keep focused on staying health and

Clinical data suggests that cannabinoids can strongly modulate mood of the people living with HIV/AIDS. Marijuana and dronabinol can help to overcome psychiatric disorders like anxiety, depression and sleeping disorders. In 2004 Prentiss et al. reported that 60.3% of 133 people living with HIV/AIDS and coping with psychological disorders recently used marijuana to alleviate the symptoms. Only few of them (9.1%) reported smoking marijuana/using dronabinol ineffective (Prentiss et al., 2004). Moreover, Haney et al. showed also that cannabinoids from marijuana or dronabinol can improve mood without producing disruptions in psychomotor functioning and add benefit of improving rating of sleep (Haney et al., 2007). In general, people living with HIV/AIDS reported that using marijuana cause reduction in stress, relief from anxiety and improve sleep (Cannon, 2010;

Scientists suppose that anti-depressive properties of THC and CBD are probably effect of involvement of these cannabinoids in the modulation of serotonergic signaling by their capacity to increase the availability of circulating tryptophan (precursor necessary for the biosynthesis of the 5-HT). The compensation of tryptophan degradation might be an important mechanism, by which THC and CBD may improve mood disturbances – mainly

Scientists from all over the world have explored the use of medical marijuana. Many of them have clearly reported that cannabinoids have therapeutic benefits (Cannon, 2010). According to this information, many countries, including Canada, Australia, The Netherlands and Switzerland, have legalized marijuana for medical purposes. The process of legislation of medical marijuana began in the United States in 2005. Today medical marijuana is legal at least in thirteen states (Active State Medical Marijuana Programs, 2011). Table 4. shows a summary of the main features of medical marijuana programs in different

may accelerate HIV's progression to AIDS (The Body, 2002).

cause by alteration of serotonergic activity) (Jenny et al., 2010).

**7. Medical marijuana use – Legal issues** 

that cannabidiol (CBD) can also be used in the supplementary therapy of HIV/AIDS. The antiemetic effects of CBD may be mediated by indirect activation of somatodendritic 5-HT (1A) receptors in the dorsal raphe nucleus; activation of these autoreceptors reduces the release of 5-HT in terminal forebrain regions and inhibit nausea and emesis (Parker et al., 2010).

In 2001 Tramer et al. decided to search systematically for randomised controlled comparisons of the antiemetic efficacy of cannabinoids with any antiemetic or placebo (control) in chemotherapy, radiotherapy, surgery or HIV/AIDS. Scientist analyzed data from 30 randomised controlled trials published between 1975 and 1997 (1366 patients). Across all the trials, cannabinoids were more effective than active comparators and placebo. Results were shown in the Table 3. (Tramer et al., 2001).


Table 3. Control of nausea and vomiting and patients' preference for treatment in trials of cannabinoids against active antiemetic or control treatment (Tramer et al., 2001).

## **6. Appetite stimulation**

Cannabinoids can also stimulate appetite and food intake. This property is connected with the presence of functional cannabinoid type 1 receptors in the digestive system, especially the liver. Hepatocytes express CB1 receptors, the activation of which increase the expression of lipogenic genes and *de novo* fatty acid synthesis, which contributes to the development of diet-induced obesity. Cannabinoids can also stimulate AMP-activated protein kinase in the hypothalamus, whereas they inhibit it in the liver and adipose tissues (Osei-Hyiaman, 2007). Moreover, scientists proved that CBs can activate fatty acid synthase (FAS), whereas the inhibition of FAS is a result of profound anorexia. These finding thus suggest that the same molecular pathway is involved in both central appetitive and the peripheral anabolic effects of cannabinoids (Szulakowska&Milnerowicz, 2007; Osei-Hyiaman et al., 2005).

In 2007 Haney et al. decided to check tolerability and efficacy of smoked marijuana and oral dronabinol in HIV-positive marijuana smokers. This placebo-controlled withinsubjects study evaluated marijuana and dronabinol across a range of eating topography and mood. Scientists administered 4 times daily for 4 days each dronabinol and marijuana, but only one drug was active per day. Administration of drugs was separated by four days of placebo washout. Results were shown in the Fig. 5. In comparison to placebo, marijuana and dronabinol increased daily caloric intake and body weight. It is probably caused by the increased number of eating occasions – marijuana and dronabinol increased the number of eating occasions but didn't alter the number of calories intake. Moreover, marijuana and dronabinol produced significant shifts in the distribution of macronutrient administration by enhancing the proportion of calories derived from fat. The final effect of increased caloric intake and macronutrients administration was weight gain – 1.2 kg after 4 days of dronabinol and 1.1 kg after 4 days of marijuana (Haney et al., 2007).

## **6.1 Mood control**

674 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

that cannabidiol (CBD) can also be used in the supplementary therapy of HIV/AIDS. The antiemetic effects of CBD may be mediated by indirect activation of somatodendritic 5-HT (1A) receptors in the dorsal raphe nucleus; activation of these autoreceptors reduces the release of 5-HT in terminal forebrain regions and inhibit nausea and emesis (Parker et al.,

In 2001 Tramer et al. decided to search systematically for randomised controlled comparisons of the antiemetic efficacy of cannabinoids with any antiemetic or placebo (control) in chemotherapy, radiotherapy, surgery or HIV/AIDS. Scientist analyzed data from 30 randomised controlled trials published between 1975 and 1997 (1366 patients). Across all the trials, cannabinoids were more effective than active comparators and placebo.

Complete control of nausea *vs* placebo 70 (81/116) 57 (66/115) Complete control of vomiting *vs* placebo 66 (76/116) 36 (41/115)

comparator 59 (122/207) 43 (93/215)

comparator 57 (111/194) 45 (90/201)

Cannabinoids *vs* placebo 76 (153/202) 13 (27/202) Cannabinoids *vs* active comparator 61 (371/604) 26 (156/608) Table 3. Control of nausea and vomiting and patients' preference for treatment in trials of

cannabinoids against active antiemetic or control treatment (Tramer et al., 2001).

(Szulakowska&Milnerowicz, 2007; Osei-Hyiaman et al., 2005).

Cannabinoids can also stimulate appetite and food intake. This property is connected with the presence of functional cannabinoid type 1 receptors in the digestive system, especially the liver. Hepatocytes express CB1 receptors, the activation of which increase the expression of lipogenic genes and *de novo* fatty acid synthesis, which contributes to the development of diet-induced obesity. Cannabinoids can also stimulate AMP-activated protein kinase in the hypothalamus, whereas they inhibit it in the liver and adipose tissues (Osei-Hyiaman, 2007). Moreover, scientists proved that CBs can activate fatty acid synthase (FAS), whereas the inhibition of FAS is a result of profound anorexia. These finding thus suggest that the same molecular pathway is involved in both central appetitive and the peripheral anabolic effects of cannabinoids

In 2007 Haney et al. decided to check tolerability and efficacy of smoked marijuana and oral dronabinol in HIV-positive marijuana smokers. This placebo-controlled withinsubjects study evaluated marijuana and dronabinol across a range of eating topography and mood. Scientists administered 4 times daily for 4 days each dronabinol and marijuana, but only one drug was active per day. Administration of drugs was separated

Cannabinoids % (number of patients)

Control % (number of patients)

Results were shown in the Table 3. (Tramer et al., 2001).

**Control of nausea and vomiting** 

**Patients' rating** 

**6. Appetite stimulation** 

Complete control of nausea *vs* active

Complete control of vomiting *vs* active

2010).

Scientists consider that prevalence of psychiatric disorders (mostly depression) is really high among the people living with HIV/AIDS. In 2001 in the USA nearly half of the population screened positive for a psychiatric disorder (36% major depression, 26.5% dysthymia, 15.8% generalized anxiety disorder, 10.5% panic attack)(Bing et al., 2001). Psychiatric disorders may be triggered by side effects of medications or the effects of HIV on the brain. Research show that depression can limit the energy needed to keep focused on staying health and may accelerate HIV's progression to AIDS (The Body, 2002).

Clinical data suggests that cannabinoids can strongly modulate mood of the people living with HIV/AIDS. Marijuana and dronabinol can help to overcome psychiatric disorders like anxiety, depression and sleeping disorders. In 2004 Prentiss et al. reported that 60.3% of 133 people living with HIV/AIDS and coping with psychological disorders recently used marijuana to alleviate the symptoms. Only few of them (9.1%) reported smoking marijuana/using dronabinol ineffective (Prentiss et al., 2004). Moreover, Haney et al. showed also that cannabinoids from marijuana or dronabinol can improve mood without producing disruptions in psychomotor functioning and add benefit of improving rating of sleep (Haney et al., 2007). In general, people living with HIV/AIDS reported that using marijuana cause reduction in stress, relief from anxiety and improve sleep (Cannon, 2010; Fogarty et al., 2007).

Scientists suppose that anti-depressive properties of THC and CBD are probably effect of involvement of these cannabinoids in the modulation of serotonergic signaling by their capacity to increase the availability of circulating tryptophan (precursor necessary for the biosynthesis of the 5-HT). The compensation of tryptophan degradation might be an important mechanism, by which THC and CBD may improve mood disturbances – mainly cause by alteration of serotonergic activity) (Jenny et al., 2010).

## **7. Medical marijuana use – Legal issues**

Scientists from all over the world have explored the use of medical marijuana. Many of them have clearly reported that cannabinoids have therapeutic benefits (Cannon, 2010). According to this information, many countries, including Canada, Australia, The Netherlands and Switzerland, have legalized marijuana for medical purposes. The process of legislation of medical marijuana began in the United States in 2005. Today medical marijuana is legal at least in thirteen states (Active State Medical Marijuana Programs, 2011). Table 4. shows a summary of the main features of medical marijuana programs in different countries (Cannon, 2010).

Cannabinoids – Influence on the

**United States of** 

**America** 

Immune System and Their Potencial Use in Supplementary Therapy of HIV/AIDS 677

HIV/AIDS Cancer Arthritis Anorexia Chronic pain Spasticity Glaucoma Migraine

HIV/AIDS Cancer

Multiple Sclerosis Spinal cord injury/disease Severe arthritis Epilepsy

Part of a palliative care treatment program

Multiple Sclerosis

HIV/AIDS Cancer

Tourette's Syndrome Chronic pain Spasticity

Table 4. A summary of the main features of the medical marijuana programs in different

There is constant debate whether cannabis should be considered therapeutic for HIV/AIDS patients. According to the literature, management of HIV-associated symptoms is one of the most common applications ascribed to medical marijuana (Prentiss et al., 2004). More and more studies have characterized the extent of cannabis use for medical benefit to address HIVrelated symptoms like nausea (Parker et al., 2010), lack of appetite (Tramer et al., 2001), emesis (Parker et al., 2010), pain (McCarberg, 2007), depression (Bing et al., 2001), anxiety Haney et al., 2007) and weight loss (Fogarty et al., 2007). However, it has to be mentioned, that use of cannabinoids can have side effects. Several scientists have warned about the negative effects of marijuana use on the cardiovascular, respiratory and nervous system (Cannon, 2010; Corless et al., 2009), and psychological dysfunction including loss of memory (Seamon et al., 2007) and pointed out the necessity for further investigation of the effects of cannabinoids. Moreover, recent legislative efforts to support legalization of medical marijuana suggest the need for more precise understanding of the typical patterns and determinants of marijuana use, and

**conditions Access** 

Patients must receive a prescription from a

Patients must become licensed by the Medical Marijuana Resource Centre to access marijuana

Patients must voluntarily apply through the

Department of Public Health to join the program and be issued with an identification car

physician

**Country Legal issues Eligible health** 

Legal for medical purposes in 13

states

purposes

for personal use

**Canada** Legal for medical

**The Netherlands** Illegal – exception

countries (Cannon, 2010).

**8. Conclusion** 

Fig. 5. Mean total daily caloric intake and total number of eating occasions as a function of marijuana (MJ) and dronabinol (Dronab) dose (Haney et al., 2007).


Table 4. A summary of the main features of the medical marijuana programs in different countries (Cannon, 2010).

## **8. Conclusion**

676 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

Fig. 5. Mean total daily caloric intake and total number of eating occasions as a function of

marijuana (MJ) and dronabinol (Dronab) dose (Haney et al., 2007).

There is constant debate whether cannabis should be considered therapeutic for HIV/AIDS patients. According to the literature, management of HIV-associated symptoms is one of the most common applications ascribed to medical marijuana (Prentiss et al., 2004). More and more studies have characterized the extent of cannabis use for medical benefit to address HIVrelated symptoms like nausea (Parker et al., 2010), lack of appetite (Tramer et al., 2001), emesis (Parker et al., 2010), pain (McCarberg, 2007), depression (Bing et al., 2001), anxiety Haney et al., 2007) and weight loss (Fogarty et al., 2007). However, it has to be mentioned, that use of cannabinoids can have side effects. Several scientists have warned about the negative effects of marijuana use on the cardiovascular, respiratory and nervous system (Cannon, 2010; Corless et al., 2009), and psychological dysfunction including loss of memory (Seamon et al., 2007) and pointed out the necessity for further investigation of the effects of cannabinoids. Moreover, recent legislative efforts to support legalization of medical marijuana suggest the need for more precise understanding of the typical patterns and determinants of marijuana use, and

Cannabinoids – Influence on the

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**28** 

*Botswana* 

**Small Livestock, Food Security, Nutrition** 

*1Department of Animal Science and Production, Botswana College of Agriculture* 

Livestock contribute to people's livelihoods in many ways, and their contributions tend to be particularly important for poorer people. These include source of cash income, liquid asset, inputs to crop production (draught power and manure), diversification of risk/ buffer to crop production, cultural value (livestock may be sacrificed at the time of a certain festival) and source of food (Conroy, 2005). Sale of livestock and their products can be a valuable source of income. For example, animals, especially small livestock (i.e., goats, sheep, poultry and rabbits) can be sold to meet immediate family needs such as food,

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Africa is the hardest hit continent in the world in terms of HIV epidemic (Topouzis, 1999; FAO, 2005). The HIV and AIDS pandemic in sub-Saharan Africa is widely recognised as development disaster threatening poverty reduction, economic growth and not merely a health issue (Mohiddin & Johnson, 2006). HIV and AIDS affects households' nutrition by decreasing food consumption and impairing nutrient absorption (Hanze et al., 2005). According to FAO (2005), people that live with HIV and AIDS (PLWHA) have special nutritional needs to assist them to remain active and productive workers and to ward off the opportunistic infections that accompany the disease and in prolonging their lives. The PLWHA need good nutrition to stay

**1. Introduction** 

clothing, medical expenses, school fees etc.

faced with negative income shocks.

**Security and HIV/AIDS Mitigation** 

John Cassius Moreki1 and Richard Dikeme2

*2Botswana Network of People Living with HIV and AIDS,* 


## **Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation**

John Cassius Moreki1 and Richard Dikeme2 *1Department of Animal Science and Production, Botswana College of Agriculture 2Botswana Network of People Living with HIV and AIDS, Botswana* 

## **1. Introduction**

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alpha maturation and secretion but not its transcrip-tion in mouse macrophages, *Int* 

tetrahydrocannabinol (THC) decreases the number of high and intermediate affinity IL-2 receptors of the IL-2 dependentcell line NKB61A2, *Int J Immunopharm,*  Livestock contribute to people's livelihoods in many ways, and their contributions tend to be particularly important for poorer people. These include source of cash income, liquid asset, inputs to crop production (draught power and manure), diversification of risk/ buffer to crop production, cultural value (livestock may be sacrificed at the time of a certain festival) and source of food (Conroy, 2005). Sale of livestock and their products can be a valuable source of income. For example, animals, especially small livestock (i.e., goats, sheep, poultry and rabbits) can be sold to meet immediate family needs such as food, clothing, medical expenses, school fees etc.

Livestock play an important role in supporting the social and economic safety nets of households and communities. They are central to people's livelihoods, food security and nutrition; they act as a "bank" to be called upon in times of stress or need (either sold, traded, or slaughtered). Also, livestock are central in many of the major events of life, i.e. birth ceremonies, weddings and funerals. However, it appears that little is known about how traditional community institutions, particularly around livestock production (e.g. women's poultry groups, grazing support and dairy cooperatives) are holding up under the stress induced by HIV and AIDS and related chronic illnesses (FAO, 2003). The study of Mutenje et al. (2008) in the Muzarabani and Bindura districts of Mashonaland Central Province in Zimbabwe found that livestock, particularly poultry and smallstock (sheep and goats), play a significant role in smoothing income fluctuations due to HIV and AIDS. The workers reported that about 90% of HIV and AIDS-afflicted households, headed mainly by women or children, used poultry and goats as consumption-smoothing strategies when faced with negative income shocks.

Africa is the hardest hit continent in the world in terms of HIV epidemic (Topouzis, 1999; FAO, 2005). The HIV and AIDS pandemic in sub-Saharan Africa is widely recognised as development disaster threatening poverty reduction, economic growth and not merely a health issue (Mohiddin & Johnson, 2006). HIV and AIDS affects households' nutrition by decreasing food consumption and impairing nutrient absorption (Hanze et al., 2005). According to FAO (2005), people that live with HIV and AIDS (PLWHA) have special nutritional needs to assist them to remain active and productive workers and to ward off the opportunistic infections that accompany the disease and in prolonging their lives. The PLWHA need good nutrition to stay

Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation 683

work, to work for long periods or follow strict work schedules; hence the need to rear smallstock such as a poultry which are easy to keep as they require few inputs. According to Winrock International (1992), livestock contribute directly to the sustainability of the farming systems by providing manure, which is the principal soil amendment and fertilizer available to large numbers of African farmers. A recent study of Simainga et al. (2010) in Zambia reported that the majority of the respondents in Mongu and Kalabo districts used manure from village chickens to fertilize gardens in order to produce vegetables for the households.

According to Sitholimela (2000) in South Africa, the advantages of goats over cattle include: they are easily handled by women and children, e.g., they can be easily milked, dewormed and vaccinated; they require less feed; produce significant quantities of meat and milk for households' consumption; have a short generation interval and produce more progenies. In addition, they are easy to sell to meet immediate households' needs and can be bartered for household commodities such as grain and seeds. To the majority of rural communities in the developing countries, livestock is regarded as "a walking bank" or "a bank in the hoof"

Small livestock, especially village poultry can provide the start of the owner climbing the "livestock ladder", leading to other livestock species such as goats and cattle (Dolberg, 2003). Botswana Network of People Living with HIV/AIDS (BONEPWA) (2010) reported that from October 2005 to October 2010, the beneficiaries of a chicken project supported by Swedish International Development Corporation Agency (SIDA) purchased 250 goats from the proceeds of chickens. Figure 2 shows chickens that were sold to buy goats while the purchased goats are shown in Figures 3 and 4. In a recent field day held in Bobonong in

Figure 1 shows vegetables that were fertilized with chicken manure in Botswana.

because they provide readily available petty cash in times of need.

Fig. 1. Tomato plants fertilized with manure

**3. The first rung on the livestock ladder** 

as healthy as possible. However, good nutrition cannot cure AIDS or prevent HIV infection, but it can delay the progression from HIV to full-blown AIDS and related diseases, and improve the quality of life of PLWHA. Slater & Wiggins (2005) argued that households may sell off large livestock, such as cattle, and use smaller stock units, such as goats and chickens, that can be reared closer to the homestead, and that can be sold off in small quantities to release cash for purchase of medicines for the sick or basic needs where regular sources of income are lost. Small livestock, especially village chickens (also referred to as family chickens) are the most significant livestock species in terms of levels of ownership, supply of protein, and the potential for earning cash income. It has been demonstrated in Botswana, Lesotho and Zambia that livestock, especially village poultry can play an important role in mitigating the impacts of HIV and AIDS on household and community food security and nutrition, as well as, economic empowerment of the vulnerable groups.

As women are the main carers of sick people, chickens can play an important role in providing them with additional resources to perform the important task of caring for people living with HIV and AIDS (Alders et al., 2007a, 2007b). In Mozambique, Alders et al. (2009) reported that village chickens play an important role in households where there is lack of able-bodied workers, such as those affected by HIV and AIDS or those family members living with disabilities. In households headed by widows, children or grandparents, chickens represent the easiest species to raise for sale and home consumption, providing high quality protein and micronutrients, which play an important role in the nutrition of HIV and AIDS patients. Furthermore, village poultry production also provides women and children with experience in small-scale business management and improved knowledge about human nutrition (Alders et al., 2009).

Among the small livestock species reared by individuals and communities in the rural villages, village poultry predominates; hence the emphasis of this chapter is on village poultry. Livestock, especially poultry species, have shown to provide an effective first step in alleviating abject rural poverty (Mack et al., 2004). According to Rural Self-Help Development Association (RSDA) (2011), throughout Africa village poultry are a valuable asset to local populations as they contribute to food security, poverty alleviation and promote gender equality, especially in the disadvantaged groups (HIV and AIDS infected and affected people, women, poor farmers etc.) and less favoured areas of rural Africa where the majority of the poor people reside. The study of Moreki et al. (2010a) in Chobe district of Botswana reported the main reasons for rearing village chickens to be family consumption (75%), source of income (75%), prestige (36%), traditional healing ceremonies (6.82%) and barter (6.82%). These findings clearly show that village poultry have a bearing in the lives of rural populace. Pica-Ciamarra & Otte (2009) in India concluded that backyard poultry farming remains important for rural households, as it ensures a steady flow of high quality food and, through cash income, reduces vulnerability.

#### **2. Advantages of small livestock over larger stock**

Unlike larger stock such as cattle, small livestock require less space; they are less capital intensive and are easy to manage as they can be reared within or near homesteads. This makes it much easier for women who are mainly carers of sick people and children to look after both the sick and small livestock simultaneously; hence cutting on labour costs. The rearing of small livestock near or within homesteads ensures regular supply of food to the families in terms of eggs, meat and milk. Lengkeek et al. (2008) argued that PLHWA are less able to perform heavy

as healthy as possible. However, good nutrition cannot cure AIDS or prevent HIV infection, but it can delay the progression from HIV to full-blown AIDS and related diseases, and improve the quality of life of PLWHA. Slater & Wiggins (2005) argued that households may sell off large livestock, such as cattle, and use smaller stock units, such as goats and chickens, that can be reared closer to the homestead, and that can be sold off in small quantities to release cash for purchase of medicines for the sick or basic needs where regular sources of income are lost. Small livestock, especially village chickens (also referred to as family chickens) are the most significant livestock species in terms of levels of ownership, supply of protein, and the potential for earning cash income. It has been demonstrated in Botswana, Lesotho and Zambia that livestock, especially village poultry can play an important role in mitigating the impacts of HIV and AIDS on household and community food security and nutrition, as well as, economic

As women are the main carers of sick people, chickens can play an important role in providing them with additional resources to perform the important task of caring for people living with HIV and AIDS (Alders et al., 2007a, 2007b). In Mozambique, Alders et al. (2009) reported that village chickens play an important role in households where there is lack of able-bodied workers, such as those affected by HIV and AIDS or those family members living with disabilities. In households headed by widows, children or grandparents, chickens represent the easiest species to raise for sale and home consumption, providing high quality protein and micronutrients, which play an important role in the nutrition of HIV and AIDS patients. Furthermore, village poultry production also provides women and children with experience in small-scale business management and improved knowledge

Among the small livestock species reared by individuals and communities in the rural villages, village poultry predominates; hence the emphasis of this chapter is on village poultry. Livestock, especially poultry species, have shown to provide an effective first step in alleviating abject rural poverty (Mack et al., 2004). According to Rural Self-Help Development Association (RSDA) (2011), throughout Africa village poultry are a valuable asset to local populations as they contribute to food security, poverty alleviation and promote gender equality, especially in the disadvantaged groups (HIV and AIDS infected and affected people, women, poor farmers etc.) and less favoured areas of rural Africa where the majority of the poor people reside. The study of Moreki et al. (2010a) in Chobe district of Botswana reported the main reasons for rearing village chickens to be family consumption (75%), source of income (75%), prestige (36%), traditional healing ceremonies (6.82%) and barter (6.82%). These findings clearly show that village poultry have a bearing in the lives of rural populace. Pica-Ciamarra & Otte (2009) in India concluded that backyard poultry farming remains important for rural households, as it ensures a steady flow of high

Unlike larger stock such as cattle, small livestock require less space; they are less capital intensive and are easy to manage as they can be reared within or near homesteads. This makes it much easier for women who are mainly carers of sick people and children to look after both the sick and small livestock simultaneously; hence cutting on labour costs. The rearing of small livestock near or within homesteads ensures regular supply of food to the families in terms of eggs, meat and milk. Lengkeek et al. (2008) argued that PLHWA are less able to perform heavy

empowerment of the vulnerable groups.

about human nutrition (Alders et al., 2009).

quality food and, through cash income, reduces vulnerability.

**2. Advantages of small livestock over larger stock** 

work, to work for long periods or follow strict work schedules; hence the need to rear smallstock such as a poultry which are easy to keep as they require few inputs. According to Winrock International (1992), livestock contribute directly to the sustainability of the farming systems by providing manure, which is the principal soil amendment and fertilizer available to large numbers of African farmers. A recent study of Simainga et al. (2010) in Zambia reported that the majority of the respondents in Mongu and Kalabo districts used manure from village chickens to fertilize gardens in order to produce vegetables for the households. Figure 1 shows vegetables that were fertilized with chicken manure in Botswana.

According to Sitholimela (2000) in South Africa, the advantages of goats over cattle include: they are easily handled by women and children, e.g., they can be easily milked, dewormed and vaccinated; they require less feed; produce significant quantities of meat and milk for households' consumption; have a short generation interval and produce more progenies. In addition, they are easy to sell to meet immediate households' needs and can be bartered for household commodities such as grain and seeds. To the majority of rural communities in the developing countries, livestock is regarded as "a walking bank" or "a bank in the hoof" because they provide readily available petty cash in times of need.

Fig. 1. Tomato plants fertilized with manure

#### **3. The first rung on the livestock ladder**

Small livestock, especially village poultry can provide the start of the owner climbing the "livestock ladder", leading to other livestock species such as goats and cattle (Dolberg, 2003). Botswana Network of People Living with HIV/AIDS (BONEPWA) (2010) reported that from October 2005 to October 2010, the beneficiaries of a chicken project supported by Swedish International Development Corporation Agency (SIDA) purchased 250 goats from the proceeds of chickens. Figure 2 shows chickens that were sold to buy goats while the purchased goats are shown in Figures 3 and 4. In a recent field day held in Bobonong in

Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation 685

Fig. 3. Some of the goats bought with money from chicken sales

Botswana, one beneficiary of SIDA supported project reported having bought a cow from the chicken proceeds. This clearly indicates that the rearing of small livestock enables rural families to start owning larger livestock such as cattle, which are considered status symbols in most African countries. BONEPWA (2010) concluded that the rearing of small livestock provides their owners the opportunity to climb the societal ladder by owning larger stock.

Fig. 2. Part of the chickens that were sold to buy goats

Botswana, one beneficiary of SIDA supported project reported having bought a cow from the chicken proceeds. This clearly indicates that the rearing of small livestock enables rural families to start owning larger livestock such as cattle, which are considered status symbols in most African countries. BONEPWA (2010) concluded that the rearing of small livestock provides their owners the opportunity to climb the societal ladder by owning larger stock.

Fig. 2. Part of the chickens that were sold to buy goats

Fig. 3. Some of the goats bought with money from chicken sales

Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation 687

Good nutrition is crucial for PLWHA who need more calories and protein than uninfected individuals. Malnourished HIV-infected people progress more quickly to AIDS and nutrition is critically important to people on retro-viral therapy. The ways of improving the nutrition component of mitigation strategies include promoting block farming, school gardening, community kitchens for orphans and vulnerable children, home-based care nutrition support and nutrition campaigns and training (Economic Commission for Africa, 2006). The rearing of village poultry in Botswana, Lesotho and Zambia has also demonstrated played by village chickens a crucial role in nutrition and food security among PLWHA. RSDA (2011) in Lesotho reported that some people consider village chickens as an option to mitigate HIV and AIDS after realizing that chickens can be the easiest way of obtaining daily nutritional requirements. Moreki et al. (2011) in their study in Botswana reported that all the respondents (46) acknowledged the contribution of chickens in human nutrition. In that study, the respondents said chickens provided relish and hence were the main supplier of good quality protein to the households. Furthermore, the sale of chickens contributed to improved habitable shelter. The proceeds from the sale of chickens contributed to the purchase of building materials for construction of houses. Figure 6 shows

the house that was painted following sale of chickens in Nata in Botswana.

livestock products, including eggs and chicken meat.

Eggs, in particular, offer a great nutritional bargain: they contain approximately 315 kilojoules and are one of the best quality food sources known. Eggs supply an array of vitamins such as A and B12, and they are one of the best food sources of vitamin K, a boneboosting nutrient. In addition, eggs provide choline, a B vitamin that plays a role in brain development (Alders et al., 2003). Also, eggs are an ideal carrier for enriching human diets with important dietary minerals such as selenium and iodine. Jacques (2006) stated that selenium is involved in the proper functioning of the immune system or inhibiting the progression from HIV to AIDS. The disease is reported to be less prevalent in countries with high selenium soil content than those with low selenium content. Selenium is involved in the conversion of thyroxine (T4) to triodothyronine (T3), indicating its importance in the functioning of the thyroid gland. Seafoods are a rich source of selenium, as are some

Fig. 5. A woman milking a goat in Bobonong, Botswana

Fig. 4. Goats being appreciated by development workers in Botswana

## **4. Nutrition and household income generation**

The roles played by small livestock in household nutrition and income generation are briefly discussed in the sections below.

## **4.1 Nutrition**

Livestock products such as meat, egg and milk products supply proteins, vitamins and minerals and extra energy, and help to strengthen muscles and the immune system. People with weak health (immune system) are more vulnerable to infections, including diseases transmitted by animals or through contaminated food and water. Even people with access to anti-retrovirals need a balanced diet to fully benefit from such treatment (FAO, 2005).

As shown in Figure 5, goats provide milk which is a balanced diet. Milk is a rich source of nutritionally available minerals (Allen & Miller, 1981) and it contains more of calcium and phosphorus than cow and human milk (Jenness, 1978). From human nutrition's view point, milk and milk products are a source of selenium which plays an important role in the immune system. Goat milk increases the resistance of the body against AIDS. Selenium helps to protect the organism against oxidation stress, participates in the synthesis and metabolism of thyroid hormones, proteosynthesis, it is important for reproduction and its anti-carcinogenic effect plays an important role as well (Schrauzer, 2000). Melse-Boonstra et al. (2007) reported that observational studies on selenium and HIV and AIDS consistently show a positive association between selenium status and delayed disease progression or increased mortality. The study of Barrionuevo et al. (2003) showed that goat-milk has an important and beneficial effect on the bioavailability of copper, zinc and selenium. Belewu and Adewole (2009) concluded that goat milk is affordable, available and nutritious; hence a wide variation of knowledge on the nutrition and hypollergic characteristics of goat milk could promote the direct use of the milk in the nutrition of orphans and vulnerable children.

Fig. 4. Goats being appreciated by development workers in Botswana

The roles played by small livestock in household nutrition and income generation are briefly

Livestock products such as meat, egg and milk products supply proteins, vitamins and minerals and extra energy, and help to strengthen muscles and the immune system. People with weak health (immune system) are more vulnerable to infections, including diseases transmitted by animals or through contaminated food and water. Even people with access to anti-retrovirals need a balanced diet to fully benefit from such treatment (FAO, 2005). As shown in Figure 5, goats provide milk which is a balanced diet. Milk is a rich source of nutritionally available minerals (Allen & Miller, 1981) and it contains more of calcium and phosphorus than cow and human milk (Jenness, 1978). From human nutrition's view point, milk and milk products are a source of selenium which plays an important role in the immune system. Goat milk increases the resistance of the body against AIDS. Selenium helps to protect the organism against oxidation stress, participates in the synthesis and metabolism of thyroid hormones, proteosynthesis, it is important for reproduction and its anti-carcinogenic effect plays an important role as well (Schrauzer, 2000). Melse-Boonstra et al. (2007) reported that observational studies on selenium and HIV and AIDS consistently show a positive association between selenium status and delayed disease progression or increased mortality. The study of Barrionuevo et al. (2003) showed that goat-milk has an important and beneficial effect on the bioavailability of copper, zinc and selenium. Belewu and Adewole (2009) concluded that goat milk is affordable, available and nutritious; hence a wide variation of knowledge on the nutrition and hypollergic characteristics of goat milk could promote the direct use of the milk in the nutrition of orphans and vulnerable children.

**4. Nutrition and household income generation** 

discussed in the sections below.

**4.1 Nutrition** 

Fig. 5. A woman milking a goat in Bobonong, Botswana

Good nutrition is crucial for PLWHA who need more calories and protein than uninfected individuals. Malnourished HIV-infected people progress more quickly to AIDS and nutrition is critically important to people on retro-viral therapy. The ways of improving the nutrition component of mitigation strategies include promoting block farming, school gardening, community kitchens for orphans and vulnerable children, home-based care nutrition support and nutrition campaigns and training (Economic Commission for Africa, 2006). The rearing of village poultry in Botswana, Lesotho and Zambia has also demonstrated played by village chickens a crucial role in nutrition and food security among PLWHA. RSDA (2011) in Lesotho reported that some people consider village chickens as an option to mitigate HIV and AIDS after realizing that chickens can be the easiest way of obtaining daily nutritional requirements. Moreki et al. (2011) in their study in Botswana reported that all the respondents (46) acknowledged the contribution of chickens in human nutrition. In that study, the respondents said chickens provided relish and hence were the main supplier of good quality protein to the households. Furthermore, the sale of chickens contributed to improved habitable shelter. The proceeds from the sale of chickens contributed to the purchase of building materials for construction of houses. Figure 6 shows the house that was painted following sale of chickens in Nata in Botswana.

Eggs, in particular, offer a great nutritional bargain: they contain approximately 315 kilojoules and are one of the best quality food sources known. Eggs supply an array of vitamins such as A and B12, and they are one of the best food sources of vitamin K, a boneboosting nutrient. In addition, eggs provide choline, a B vitamin that plays a role in brain development (Alders et al., 2003). Also, eggs are an ideal carrier for enriching human diets with important dietary minerals such as selenium and iodine. Jacques (2006) stated that selenium is involved in the proper functioning of the immune system or inhibiting the progression from HIV to AIDS. The disease is reported to be less prevalent in countries with high selenium soil content than those with low selenium content. Selenium is involved in the conversion of thyroxine (T4) to triodothyronine (T3), indicating its importance in the functioning of the thyroid gland. Seafoods are a rich source of selenium, as are some livestock products, including eggs and chicken meat.

Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation 689

Some of the mitigation strategies mentioned previously attempted to provide some ideas for those working with livestock and communities to mitigate the impact of HIV/AIDS on livestock production and household food security. In addition to these potential interventions, it is important to consider the nutritional needs of the affected individuals and households, review existing support institutions (whether it be extended family, community-based organisations, etc.) and assess, with the community, and particularly those affected, the best way forward to ensure livestock production within, or for, those households. Labour and financial constraints of households must be considered before

Small livestock can provide income generation for family activities such as education, nutrition, health and clothing. Copland and Alders (2009) stated that village poultry have constantly commanded a price premium over commercial birds and there is a wide market demand for village poultry products. In Zambia, Simainga et al. (2011) reported that income from sale of chickens and eggs was used for groceries, school fees and uniforms, transport to hospitals or medical facilities, medication and talk time (air

Generally, small livestock are owned by women. In Botswana, Mrema & Rannobe (1996) reported that women own more goats than their male counterparts who have more resources and can afford to own cattle. Furthermore, village poultry are owned and managed by women and children and are often essential elements of female-headed households (Alders et al., 2003; Guéye, 2004; Bagnol, 2005). The study of Moreki et al. (2010b) showed that 83.2% of women owned chickens compared to 16.8% for men. A recent study (Moreki et al., 2010c) also showed that 73.5% of women own goats. The authors argued that, chickens are generally regarded as livestock that women raise mainly because they are perceived to be of less commercial value than other livestock such as cattle. In the opinion of Moreki et al. (2010b), in Botswana men tend to be responsible for cattle and larger animals and women for smaller animals such as sheep, goats and poultry. These results led Moreki et al. (2010c) to conclude that sheep and goats rearing plays an important role in food security, in addressing issues of gender imbalances, as well as, in poverty eradication in furtherance of the Millennium Development Goals

Small livestock and products are sold on a one-on-one basis, which is referred to as direct marketing. Usually, small livestock are sold when there is immediate need for cash. Unlike in commercial livestock, no cold chain is required as stock is sold live and products raw. Recently, Simainga et al. (2011) in Zambia reported that women, especially mothers are involved in chicken sales than men, indicating that women owned chickens and decided on their sales, as well as, how money was used. However, it is likely that women consulted

strategies are discussed or plans developed.

**5. Ownership of small livestock** 

**4.2 Income generation** 

(United Nations, 2010).

their spouses on how the money was used.

**6. Marketing** 

time).

Fig. 6. House painted using money from chicken sales in Botswana

Some of the mitigation strategies mentioned previously attempted to provide some ideas for those working with livestock and communities to mitigate the impact of HIV/AIDS on livestock production and household food security. In addition to these potential interventions, it is important to consider the nutritional needs of the affected individuals and households, review existing support institutions (whether it be extended family, community-based organisations, etc.) and assess, with the community, and particularly those affected, the best way forward to ensure livestock production within, or for, those households. Labour and financial constraints of households must be considered before strategies are discussed or plans developed.

#### **4.2 Income generation**

688 HIV and AIDS – Updates on Biology, Immunology, Epidemiology and Treatment Strategies

Fig. 6. House painted using money from chicken sales in Botswana

Small livestock can provide income generation for family activities such as education, nutrition, health and clothing. Copland and Alders (2009) stated that village poultry have constantly commanded a price premium over commercial birds and there is a wide market demand for village poultry products. In Zambia, Simainga et al. (2011) reported that income from sale of chickens and eggs was used for groceries, school fees and uniforms, transport to hospitals or medical facilities, medication and talk time (air time).

## **5. Ownership of small livestock**

Generally, small livestock are owned by women. In Botswana, Mrema & Rannobe (1996) reported that women own more goats than their male counterparts who have more resources and can afford to own cattle. Furthermore, village poultry are owned and managed by women and children and are often essential elements of female-headed households (Alders et al., 2003; Guéye, 2004; Bagnol, 2005). The study of Moreki et al. (2010b) showed that 83.2% of women owned chickens compared to 16.8% for men. A recent study (Moreki et al., 2010c) also showed that 73.5% of women own goats. The authors argued that, chickens are generally regarded as livestock that women raise mainly because they are perceived to be of less commercial value than other livestock such as cattle. In the opinion of Moreki et al. (2010b), in Botswana men tend to be responsible for cattle and larger animals and women for smaller animals such as sheep, goats and poultry. These results led Moreki et al. (2010c) to conclude that sheep and goats rearing plays an important role in food security, in addressing issues of gender imbalances, as well as, in poverty eradication in furtherance of the Millennium Development Goals (United Nations, 2010).

## **6. Marketing**

Small livestock and products are sold on a one-on-one basis, which is referred to as direct marketing. Usually, small livestock are sold when there is immediate need for cash. Unlike in commercial livestock, no cold chain is required as stock is sold live and products raw. Recently, Simainga et al. (2011) in Zambia reported that women, especially mothers are involved in chicken sales than men, indicating that women owned chickens and decided on their sales, as well as, how money was used. However, it is likely that women consulted their spouses on how the money was used.

Small Livestock, Food Security, Nutrition Security and HIV/AIDS Mitigation 691

Alders, R.; Bagnol, B.; Harun, M. & Young, M. (2007b). Village poultry, food security and

Alders, R.; Bagnol, B.; Chicamisse, M.; Serafim, J. & Langa, J. (2009) The role of village

Allen, J.C. & Miller, W.J. (1981). Transfer of selenium from blood to milk goats and non-

Anon (2006). HIV/AIDS and small livestock development. Retrieved from

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Belewu, M.A. & Adewole, A.M. (2009). Goat milk: A feasible dietary Based approach to

Botswana Network of People Living with HIV and AIDS (2010). Annual Technical Report –

Conroy, C. (2005). Participatory Livestock Research: A Guide. ITDG Publishing. The

Copland, J.W. & Alders, R.G. (2009). The comparative advantages of village poultry or

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October 2009 to September 2010: Village chicken component. Gaborone, Botswana.

smallholder poultry in rural development. In, Alders R.G., Spradbrow P.B. and Young M.P. (eds) 2009. Village chickens, poverty alleviation and the sustainable control of Newcastle disease. Proceedings of an international conference held in Dar es Salaam, Tanzania, 5-7 October 2005. ACIAR Proceedings No. 131. 207-209. Dolberg, F. (2003). Review of household poultry production as a tool in poverty reduction

with focus on Bangladesh and India. FAO Pro-Poor Livestock Policy Initiative Working Paper No. 6. Food and Agriculture Organizations of the United Nations.

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http://aciar.gov.au/files/node/11133/PR131%20part%201.pdf

in rats. Journal of Physiology and Biochemistry 59: 111-118.

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interference of copper with selenium metabolism. Journal of Dairy Science 64: 814-

## **7. HIV and AIDS and small livestock production**

Smallstock play a vital role in many rural livelihoods, providing food, income and security. The products of smallstock are rich in protein, minerals and vitamins. They are sources of income and manure for use as compost or fuel, and a store of wealth and insurance. Small livestock may enable women to have more economic independence if they control the income earned from the sale of livestock and their products. Tending to the ongoing everyday requirement of smallstock can normally be integrated into the time and labour constraints facing many HIV/AIDS affected households (Anon, 2006).

According to BONEPWA (2010), the majority of support group members infected and affected by HIV and AIDS in Botswana has attested that through ownership and sale of small livestock (i.e., chickens, guinea fowl and goats), they were able to reduce the number of patients that default from taking anti-retroviral drugs, as they are able to sell chickens to buy medication and food, and also pay for transport to the hospitals for treatment. The effects of HIV and AIDS scourge at household level has reduced since beneficiaries are now able to feed their households resulting in reduced dependency on government hand-outs, family members and relatives. Some of the patients who were bedridden due to AIDS have recovered and are caring for their livestock. This has led to one support group member to say "*we are finding ourselves to be useful members of the community since we are back into our productive lives after spending a long time in sick beds*". This indicates that small livestock production plays a pivotal role in food and nutrition security, as well as, restoring selfesteem among the affected community members.

## **8. Conclusion**

This review has demonstrated that small livestock have an important role to play in poverty alleviation, improving food and nutrition security, as well as, in economic empowerment of PLWHA and other vulnerable groups. Successful HIV and AIDS mitigation strategies involving goats and chickens in Botswana, Lesotho and Zambia indicate that small livestock play a vital role in the fight against the HIV and AIDS scourge, mainly through provision of nutrition and income generation. Therefore, support from government and nongovernmental organizations is crucial if the benefits are to be extended to the rest of the rural communities, the majority of whom are poverty-stricken

#### **9. Acknowledgements**

The authors wish to acknowledge assistance they received from BONEPWA+, RSDA and Golden Valley Agricultural Research Trust in Botswana, Lesotho and Zambia, respectively

#### **10. References**

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Smallstock play a vital role in many rural livelihoods, providing food, income and security. The products of smallstock are rich in protein, minerals and vitamins. They are sources of income and manure for use as compost or fuel, and a store of wealth and insurance. Small livestock may enable women to have more economic independence if they control the income earned from the sale of livestock and their products. Tending to the ongoing everyday requirement of smallstock can normally be integrated into the time and labour

According to BONEPWA (2010), the majority of support group members infected and affected by HIV and AIDS in Botswana has attested that through ownership and sale of small livestock (i.e., chickens, guinea fowl and goats), they were able to reduce the number of patients that default from taking anti-retroviral drugs, as they are able to sell chickens to buy medication and food, and also pay for transport to the hospitals for treatment. The effects of HIV and AIDS scourge at household level has reduced since beneficiaries are now able to feed their households resulting in reduced dependency on government hand-outs, family members and relatives. Some of the patients who were bedridden due to AIDS have recovered and are caring for their livestock. This has led to one support group member to say "*we are finding ourselves to be useful members of the community since we are back into our productive lives after spending a long time in sick beds*". This indicates that small livestock production plays a pivotal role in food and nutrition security, as well as, restoring self-

This review has demonstrated that small livestock have an important role to play in poverty alleviation, improving food and nutrition security, as well as, in economic empowerment of PLWHA and other vulnerable groups. Successful HIV and AIDS mitigation strategies involving goats and chickens in Botswana, Lesotho and Zambia indicate that small livestock play a vital role in the fight against the HIV and AIDS scourge, mainly through provision of nutrition and income generation. Therefore, support from government and nongovernmental organizations is crucial if the benefits are to be extended to the rest of the

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**8. Conclusion** 

**9. Acknowledgements** 

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## *Edited by Nancy Dumais*

The continuing AIDS pandemic reminds us that despite the unrelenting quest for knowledge since the early 1980s, we have much to learn about HIV and AIDS. This terrible syndrome represents one of the greatest challenges for science and medicine. The purpose of this book is to aid clinicians, provide a source of inspiration for researchers, and serve as a guide for graduate students in their continued search for a cure of HIV. The first part of this book, "From the laboratory to the clinic," and the second part, "From the clinic to the patients," represent the unique but intertwined mission of this work: to provide basic and clinical knowledge on HIV/AIDS.

Photo by shutterstock / Ivan Cholakov

HIV and AIDS - Updates on Biology, Immunology, Epidemiology and Treatment Strategies

HIV and AIDS

Updates on Biology, Immunology,

Epidemiology and Treatment Strategies

*Edited by Nancy Dumais*