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PREVENTING TRANSMISSION OF HIV INFECTION: UNDERSTANDING HOW HIV IS SPREAD: PRINCIPLES OF CONTAGION-SOURCES OF HIV AND TYPES OF CONTACT
A person with HIV infection is almost the sole source of this infection. The only time a person is not directly the source is in the laboratory, when a researcher has taken inadequate precautions and is infected while working with large numbers of the virus. Any person with HIV infection, regardless of symptoms, should be considered capable of transmitting the disease.
Types of Contact-The white blood cells that HIV infects, the CD4 cells, are found in differing numbers in different body fluids. As a result, the numbers of HIV also differ in different body fluids. The numbers of HIV are greatest in semen, breast milk, and blood, including menstrual blood. The numbers of HIV are fewer in women’s genital secretions. HIV is unlikely to be in saliva or tears, though it has been found in these fluids in a minority of people, and then only in very low numbers. HIV has not been found in urine or feces. In order to cause infection, HIV must travel from the body fluids of an infected person into the bloodstream of an uninfected person. The skin that covers the outside of the body is a formidable barrier. If the skin is intact, simple contact between HIV and the skin will not transmit HIV. The mucous membranes that cover most of the insides of the mouth, vagina, and rectum are also a barrier to the virus. But we are less certain whether mucous membranes are as formidable a barrier as skin.
If the skin or a mucous membrane is broken?if it has cuts or sores?the virus can get into the bloodstream. Thus, infected blood, menstrual blood, vaginal fluids, or semen on intact skin is almost invariably safe. But on skin or mucous membranes that have an open sore or a cut, the same fluids can possibly transmit the virus. Injecting large amounts of infected blood into the body?like a transfusion of blood from an infected person?is the most efficient method of transmission.
We can provide absolute assurance that most types of common contact carry no risk of transmitting the virus. These include a variety of experiences often referred to as “casual contact”: shaking hands, hugging, sharing a toilet, sharing eating utensils, closed-mouth kissing, being sneezed on, and so forth. Not only has infection through casual contact not happened, it is biologically unrealistic to suppose it might.
There are three primary types of contact that can result in transmission of HIV:
Sexual contact, that is, contact with infected genital secretions (semen, vaginal fluids, menstrual blood)
Injection of infected blood through transfusions or needle sharing
Pregnancy in an infected mother
Other kinds of contact more rarely result in transmission of HIV.
These are:
Breast-feeding by an infected mother (transmission to baby)
Breast-feeding by an infected baby (transmission to mother)
Organ transplantation using organs from infected donors
Artificial insemination from infected sperm donors
Needlestick injuries in health care professionals caring for infected people
Dental care and possibly surgical procedures done by infected health care workers
Whether oral sex, either cunnilingus (oral sex performed on a woman) or fellatio (oral sex performed on a man), transmits HIV infection is controversial. There are stories about HIV being transmitted through oral sex, but no studies confirm this.
The combined total for these rarer types of contact accounts for less than 0.1 percent, or less than one in a thousand, of the cases of AIDS.
We are sure about what kinds of contact do and do not transmit the virus. Over 160,000 people with AIDS have been studied by the Centers for Disease Control (CDC). The types of contact listed above together account for 95 to 97 percent of all people with AIDS. When researchers went back and looked specifically at the people not accounted for by these types of contact, they found that most were problematic: many people acknowledged risks when questioned by a more experienced interviewer, some people were so seriously ill at the time of reporting that no reliable medical history could be obtained, and some never had HIV infection to begin with. By the time researchers were done, the type of contact responsible for transmission remained ambiguous in less than 1 percent of the people. Given the likelihood that people will lie about such sensitive issues as homosexuality and the use of illegal drugs, 1 percent is an incredibly low figure.
At the same time, it must be acknowledged that other types of contact, though unlikely to transmit HIV, might transmit HIV, at least in theory. HIV has been found in low numbers in saliva and tears. HIV has not been found in feces or urine. Although transmission through these fluids is biologically possible, it doesn’t seem to happen; the CDC, which tracks all cases of AIDS, has no case in which the only type of contact was clearly through saliva, feces, urine, or tears. Perhaps the inoculum size?the numbers of virus?in these fluids is simply too low. In any case, transmission of HIV through these types of contact is extremely inefficient and is not known to happen.
One type of contact that people worry about is mouth contact. HIV is found in low numbers in saliva, so deep kissing, mouth-to-mouth resuscitation, biting, being spat upon, and the like might potentially transmit the virus. It is noteworthy that HIV is actually found in saliva in only about 1 or 2 percent of people with HIV infection. Moreover, even in these people, the numbers of the virus are so low that researchers believe that transmission through saliva is biologically improbable and perhaps impossible. Nevertheless, we periodically hear of a case where saliva is a suggested type of contact. As a result, contact through saliva remains a theoretical concern that cannot be excluded.
Another type of contact people worry about is indirect: becoming infected by a virus on a surface outside the body. To repeat, no one (except the rare laboratory worker using high concentrations of the virus) has ever become infected by the virus living on a surface outside the body. The reason is that HIV cannot survive outside its host cells, and outside the body, cells die quickly. When host cells die, HIV dies with them. Although HIV can survive outside the body on a surface for up to fifteen days, the numbers of viruses on a surface fall rapidly to levels well below those necessary for infection.
A third possibility that people worry about, probably because the news media have paid a lot of attention to it, is that insects, particularly mosquitoes, could conceivably transmit the virus. The argument is that insects transmit other microbes in the blood, such as malaria. But even in Africa, where mosquito-borne diseases like malaria are common, scientists have not been able to find a clear case in which HIV has been transmitted by a mosquito. AIDS in Africa is a disease found almost exclusively in babies and sexually active adults, especially those in cities. Mosquitoes, however, do not select out babies and sexually active adults in cities to bite; mosquitoes are everywhere and bite everyone.
Epidemiologic studies have been done specifically to study the possibility that HIV is spread by mosquitoes. These studies found that the areas in the United States with large populations of mosquitoes have no more cases of HIV infection than other areas; nor do they have more cases of HIV infection whose source of infection is unknown. Further studies in the laboratory show that mosquitoes cannot transmit HIV mechanically. The conclusion by most authorities in this field is that mosquitoes are not a source of HIV infection.
*24/191/2*

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PREVENTING TRANSMISSION OF HIV INFECTION: UNDERSTANDING HOW HIV IS SPREAD: PRINCIPLES OF CONTAGION
Preventing transmission begins with understanding the principles that govern how infections are transmitted. These principles are called the principles of contagion.
The terms infectious diseases and contagious diseases refer to different things. Infectious diseases are caused by microbes; microbes are viruses, bacteria, fungi, and parasites. Contagious diseases can be spread from person to person. Some diseases, like toxic shock syndrome or
Legionnaires’ disease, are infectious but not contagious. HIV infection, however, is both infectious (it is caused by a microbe) and contagious (with specific kinds of contact, it can be spread from one person to another). This article will begin by comparing HIV infection to another infectious and contagious disease most people know well from firsthand experience: influenza.
The microbe that causes influenza is a virus found in the nose, throat, and lungs of the person who is infected. Influenza is spread when secretions from the nose, throat, or lungs of the infected person are passed to another person. When an infected person coughs or sneezes on another person, or touches another person, these secretions and the virus they carry are transmitted.
People can be either susceptible or not susceptible to an influenza virus. If they have been infected with that particular virus or a closely related one before, or if they have been vaccinated against the virus, they already have antibodies against it, so they are not susceptible and will not get influenza. If they do not have these antibodies, they are susceptible and will get influenza.
Whether susceptible or not, the person will not become infected if the type of contact is wrong. Specific viruses can live only on specific tissues within the body. An influenza virus on the skin of your hand will not give you influenza; the same virus on the membranes of your nose, throat, or lungs will. If the virus is on your hand and you bring your hand to your mouth, however, you may get influenza.
Given susceptibility and the right type of contact, some viruses are more likely than others to be spread from person to person, that is, some viruses are transmitted with greater efficiency than others. Some viruses are difficult to spread; for others, like the influenza virus, even very brief contact with a person who is infected is likely to result in transmission. Highly efficient transmission accounts for the annual epidemics of influenza.
The efficiency with which a virus is transmitted also depends on the number of viruses a person is exposed to, or the inoculum size. Living with a person with influenza is obviously more likely to result in successful transmission than simply working with that person in the same office. And being sneezed upon poses a greater risk than passing someone in a hallway. In short, how efficiently a virus is transmitted depends both on the number of influenza viruses and the type of contact.
A person, once infected, may continue to feel well for a day or two but, during this time, can still pass the virus to others. This early period between infection and the beginning of symptoms is called the incubation period.
HIV, like influenza, follows the same general principles of contagion. An infected person is the source of HIV. HIV is contagious if a person is susceptible and the contact is of the kind necessary for transmission. And HIV has a certain efficiency of transmission and a certain incubation period. There the resemblance ends.
This point deserves emphasis. Much of the misunderstanding about AIDS is based on the assumption that HIV is transmitted like other common infectious diseases. It isn’t. In brief, for HIV, the types of contact are very specific, transmission is inefficient, and HIV’s incubation period is very long.
*23/191/2*

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PREVENTING TRANSMISSION OF HIV INFECTION: UNDERSTANDING HOW HIV IS SPREAD
Principles of contagion
Preventing transmission through sex, drugs, or pregnancy
Preventing transmission during home care
HIV is a virus that infects white blood cells, primarily those called CD4 cells (also called T4 cells or T-helper cells). CD4 cells are found in several body fluids, but mainly in blood and in genital secretions. HIV is passed, or transmitted, when the CD4 cells from one person’s blood or genital secretions get inside the body of another person. This method of transmission does not account for every case of HIV infection, but it does account for 97 percent of those people who have AIDS and would probably account for most of the remaining 3 percent if the necessary information could be reliably obtained.
The scientific evidence to support this method of transmission is compelling. What is known about the risk of transmitting HIV has come from two types of scientific studies: partly from studies of the virus, called virology; and principally from studies of the people who are infected with the virus, called epidemiology. The epidemiologic studies came first in time. In 1981, epidemiologists began tracking cases of pneumocystis pneumonia in gay men; by 1983, when HIV was finally discovered, epidemiologists knew most of what was necessary to know about the spread of the disease. They knew that the disease, whatever its cause, was transmitted by sexual intercourse and by blood and by passage from an infected mother to her unborn child. They knew that this sort of transmission suggested that a microbe was responsible (other microbes, including cytomegalovirus and hepatitis B virus, are transmitted in precisely the same ways). In 1983, a French researcher, Luc Montagnier, reported the virology studies that described the virus that came to be called HIV.
But whether the scientific evidence is compelling or not, misunderstanding of how HIV is transmitted is widespread and causes people a lot of worry. The purpose of this chapter is to discuss, first, what is known and what is not known about the risk of transmitting HIV, and second, how to prevent transmission. In other words, it is about how not to give someone else HIV and about how not to get it yourself.
Most of the public’s misconception is based on the belief that HIV is transmitted the way more common viruses, like the influenza virus, are transmitted. We think it is important to emphasize that viruses like the influenza virus and HIV are enormously different, not only in the way they are transmitted, but in the way they behave to cause disease.
*22/191/2*

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HEPATITIS: TYPES AND SYMPTOMS
There are 3 types of hepatitis – types ?, ? and the new type C. These are viral infections which cause an inflammation of the liver. Type A is the infectious one which is thought to be caught from contact with faeces via food, poor sanitation, not washing the hands after going to the toilet, polluted water, or seafood caught near an ocean outfall. If a child has been in contact with an infected person it is wise to take the precaution of having a preventative injection. The period of incubation is 2 to 7 weeks in which time the child will become irritable. The symptoms are malaise, loss of appetite, fatigue, vomiting, headaches and chills and fever. Jaundice will appear – the child will go yellow and the liver enlarges painfully.
Type ? is harder to contract as it is transmitted through contaminated syringes or blood transfusions. It takes 7 to 26 weeks to develop. Symptoms are dark urine and pale stools, fever, jaundice, fatigue, weakness and drowsiness. Recovery is certain but the liver needs help and the process is slow.
The liver is the second largest organ in the body and it produces and stores glycogen which is made from glucose and used by the muscles for energy. It produces bile which breaks down fats in the body and is important in the absorption of vitamin ? from the intestines. It manufactures cholesterol which aids in the production of bile salts and steroid hormones. Drugs and chemicals are broken down in the liver and detoxified, including the body’s own adrenalin which is recycled through the liver. It stores vitamins ?, ?12 and D, iron and copper, to feed the body. It forms new blood cells, destroys old red cells and ‘throws them out’, makes the protein in blood plasma, and produces the clotting agents in the blood.
Hepatitis inflames the liver and slows its functioning. If this happens, the liver, which normally helps remove toxins, stops work and the toxins build up in other organs, such as the skin, causing dermatitis and acne. The liver responds well to herbal treatment. Dandelion and milk thistle act as cholagogues. Dandelion has been said to be able to dissolve gallstones. Boldo is another powerful herb for the restoration of liver health. The vitamin ? group is vital to liver health as is vitamin A. All these supplements are available for children and will be far more potent in a child recovering from hepatitis. Clinical studies have shown that Sylibum marianum helps reduce damage to the liver by some infections and toxins. This herb is therefore invaluable in the treatment of hepatitis.
*34/199/5*

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WHEN FIRST DIAGNOSED: UNDERSTANDING AND COMMUNICATING ABOUT
HIV-TELLING PEOPLE ABOUT THE DIAGNOSIS: HOW OTHERS REACT
Often, these worries are without foundation, and people, when told, react much differently from how we expect them to react. Alan’s mother says she feels guilty for not having somehow protected him against the virus, but she is able to talk freely to him and thinks of ways for him to get out of the house. Dean’s mother had stopped going to church, but when she noticed that the other members of her church were still talking to her, she began going again. Steven’s sister makes a point of leaving her children with him, and his co-workers asked the social worker at the local hospital how to help Steven out if he got sick. Helen’s father, who had always been reserved with her, “dropped his mask,” she said, “and changed. He became warm and loving.” Alan says not to underestimate your family and friends.
Unfortunately, worries about other’s reactions are sometimes justified. Just as sympathy and sensitivity are part of human nature, so are fear, discrimination, and avoidance of illness. After the newspaper article on Lisa was published, she talked to her friends about her husband’s illness: “I said, ‘I want to tell you, I learned my husband has AIDS.’ And my friends said, ‘Why are you telling us this?’ And I said, ‘I love my husband, now he’s going to die, and I need your help.’ But they couldn’t help. They couldn’t call, not even the priest.”
Sometimes, as with Lisa’s friends and priest, these unpleasant reactions come from those you most count on. Alan’s dentist refused to treat him, and his pastor barred him from church. Dean said, “My dentist told me to go somewhere else. My father went behind me and cleaned the phone with disinfectant. My pastor didn’t want me touching anything he had to touch.” Helen’s stepmother insisted on protective papers over the toilet seat; Helen said, “She acted like my house had a plague in it, like it had devils in it.” Lisa went to the hospital for a chest x-ray and found written on the orders for the x-ray, “Husband has AIDS”; the nurses held her hospital gown by their fingertips. When June’s son was in the hospital, the staff left meal trays outside the door of his room; the same thing happened to Dean in a different hospital.
In some people, these reactions are only temporary: Lisa’s friends finally began visiting and bringing in meals; Dean’s father and Helen’s stepmother both stopped worrying about the telephone and the toilet seat. For other people, these reactions, in spite of being unpleasant, are probably not going to change. Inevitably, you will tell someone who cannot handle the news.
This starts a series of reactions in you. You may feel rejected, angry, isolated. Sometimes these feelings are reinforced by other worries: that people are right to reject you, that you brought the virus on yourself, that you are to blame for your diagnosis. This series of reactions is understandable; people are especially vulnerable when the diagnosis is still new.
But these reactions confuse issues that are really separate and unrelated. People who cannot handle your diagnosis are probably not rejecting you personally. In any case, their actions toward you have no bearing on your worth or your good opinion of yourself. Instead, people who reject you are rejecting what they fear. HIV infection reminds them of fears they have?about contagion, illness, sexuality, mortality, dependency?which they cannot face. Rejecting you because you remind them of their fears helps them keep their fears at a distance. They are not thinking about you at all; they are concerned only with their own problems, they are only protecting themselves.
Perhaps, while you are still vulnerable to people’s reactions, it is best to keep silent. Wait until your feelings stabilize and you feel more sure of yourself. Then decide who to tell. If people disappoint you, the best policy might be to accept them as they are and, if necessary, avoid them.
*20/191/2*

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WHEN FIRST DIAGNOSED: UNDERSTANDING AND COMMUNICATING ABOUT
HIV-TELLING PEOPLE ABOUT THE DIAGNOSIS: YOU NEED NOT TELL EVERYONE AND ALTERNATIVES TO OUTRIGHT TELLING
Once a nurse said that Helen ought to tell her sons about her diagnosis, and Helen got so angry she asked the nurse to leave. Whether she told her sons, she thought, was her decision alone. Helen was right: you are the best judge of who to tell and who not to tell. Your diagnosis is not everyone’s business. In fact, you might find it refreshing to have a group of people?say,
co-workers?who treat you as though you were completely healthy. Alan looks healthy and strong, and people tell him he looks good. When his partner asked if this bothered him, Alan replied, “Not at all. I love it.”
Alternatives to Outright Telling-People also decide to avoid the problem of who to tell and who not to, and find ways around making the decision. Some people do not tell, but instead let their friends and families ask. These people leave clues?they may talk about friends who have AIDS, leave pamphlets and books on AIDS where others can find them, buy grave plots and talk about funerals, say someone at work told them a story about a person with AIDS, and talk about TV programs on AIDS and recommend their families watch them. The families and friends sense the truth. Then, if they can handle the information, they will ask; if they can’t, they won’t.
Some people do trial runs of telling, testing for rejection before telling. One woman was so afraid her children would reject her that she thought she could not tell them without breaking down. So she rehearsed by telling a cousin whose rejection she feared less, and when she finally told her children, she could keep the composure she wanted. Some people, like those who let their friends and families ask, leave clues. Then, they judge by reactions to the clues whether telling will be safe or will result in rejection.
Other people find alternatives to the outright facts. If they become sick, they say they have pneumonia or a lung disease, herpes, leukemia, ulcers, meningitis, or hepatitis, or a cancer, or an infection of the nervous system. They choose whatever disease is most appropriate to their
symptoms. Helen said, “I read in a medical book about a blood disease that can be either acute or fatal. As long as I’m alive, I’ll say it’s acute.”
*21/191/2*

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WHEN FIRST DIAGNOSED: UNDERSTANDING AND COMMUNICATING ABOUT
HIV-TELLING PEOPLE ABOUT THE DIAGNOSIS: REASONS FOR KEEPING SILENT
Some people who made their diagnoses public have compromised their jobs, their ability to get mortgages, and their ability to keep their insurance. For this reason, lawyers often advise their clients with HIV infection to tell as few people as possible: tell those they are obliged to tell, tell those they love and whose support and help they need, and then tell no others. You are certainly under no obligation to tell your neighbors, your employer, your landlord, or, unless you are filing HIV-related claims, your insurance agent.
The reason most people cite for keeping silent is worry about others’ reactions. “I don’t make a point of the truth about my son,” said June, “but I would answer if asked. So far, no one has. I’m not ashamed of the truth, but it bothers other people.”
The particular truth of HIV infection does indeed bother people. When Dean Lombard first told his mother, she stayed out of church for a long time because she was afraid the other members would not talk to her; Dean’s sister was afraid of being rejected by her friends. Alan Madison worried that his mother would feel guilty, overreact, and make his life more difficult by “asking me questions and giving me orders.” Alan also stopped inviting friends over because he thought that when they found out about his infection, they would worry because they had used his coffee cups. Steven Charles worried that his co-workers would no longer want to work with him. He thought that his sister would no longer invite him to dinner or allow him to play with her children. He was worried about how much he would hurt his relatives and about how much pain he would cause them.
Other people have related reasons for keeping silent. Helen Parks worried that people would find out without her telling them: “Psychologically,” she says, “that plays on my nerves.” Her sons, she thought, could not keep confidences. She was afraid that those she told would gossip, and she would lose control over who knew and who did not. She even bought the drugs to control her infection in a nearby city rather than risk being seen in her local pharmacy. She worried about having to tell her insurance company. June Monroe did not want to tell her mother-in-law, her son’s grandmother; the old woman was in failing health, and June did not want to add to her troubles. Lisa’s husband did not want to tell his daughter: “He told me he just couldn’t, and started crying,” she said. “He said he was so ashamed.”
*19/191/2*