Introduction

The human immunodeficiency virus (HIV)/acquired

immunodeficiency syndrome (AIDS) epidemic continues to grow
worldwide and to devastate individuals, communities and entire
countries and regions. Behavioural surveillance measures trends in the
behaviours that can lead to HIV infection. It has been shown to make
an important and useful contribution to national responses to HIV.
Conducting behavioural surveillance requires many skills, including
coordination among various partners. Although there are useful
reference materials available for behavioural surveillance, there has not
yet been a comprehensive effort to train surveillance teams. This
training course aims to help address this. This course is meant primarily
for people involved in planning and using behavioural surveillance.
You should already have a basic understanding of the epidemiology of
HIV/ AIDS and public health surveillance. This module is part of a set
of four modules that have been designed with a focus on the World
Health Organization’s (WHO) Eastern Mediterranean Region. The
modules were designed for use in training workshops. The other
modules are:

● Module 1: Overview of the HIV/AIDS epidemic with an introduction

to public health surveillance

● Module 2: Surveillance of most-at-risk and vulnerable populations

● Module 3: Introduction to respondent-driven sampling.

Similar training modules have been developed for WHO’s African,

Americas, European and South-East Asia regions. Although the overall
framework of the modules is the same, each region has different
patterns of HIV epidemics and distinct social and cultural contexts.
Also, different countries may have different HIV surveillance
capacities and different needs. Thus, these modules were developed
taking into account the specific context of the HIV epidemic in the
countries of the Eastern Mediterranean Region. The modules are also
intended for use in the countries of the Joint United Nations Programme
on HIV/AIDS (UNAIDS) Middle East and North Africa Region. For
the purpose of this training course, all countries in the WHO Eastern
Mediterranean Region plus Algeria are therefore the intended audience.
We refer to these collectively as Eastern Mediterranean Region/Middle
East and North Africa (EMR/MENA) countries.
 HIV

HIV (human immunodeficiency virus) is a virus that attacks cells that

help the body fight infection, making a person more vulnerable to other
infections and diseases. It is spread by contact with certain bodily fluids
of a person with HIV, most commonly during unprotected sex (sex
without a condom or HIV medicine to prevent or treat HIV), or through
sharing injection drug equipment.

If left untreated, HIV can lead to the disease AIDS (acquired

immunodeficiency syndrome).

The human body can’t get rid of HIV and no effective HIV cure exists.
So, once you have HIV, you have it for life.
Luckily, however, effective treatment with HIV medicine (called
antiretroviral therapy or ART) is available. If taken as prescribed, HIV
medicine can reduce the amount of HIV in the blood (also called the
viral load) to a very low level. This is called viral suppression. If a
person’s viral load is so low that a standard lab can’t detect it, this is
called having an undetectable viral load. People with HIV who take
HIV medicine as prescribed and get and keep an undetectable viral load
can live long and healthy lives and will not transmit HIV to their HIV-
negative partners through sex.
 AIDS

AIDS is the late stage of HIV infection that occurs when the body’s
immune system is badly damaged because of the virus.

In the U.S., most people with HIV do not develop AIDS because
taking HIV medicine as prescribed stops the progression of the disease.

A person with HIV is considered to have progressed to AIDS when:

• the number of their CD4 cells falls below 200 cells per cubic
millimetre of blood (200 cells/mm3). (In someone with a healthy
immune system, CD4 counts are between 500 and 1,600
cells/mm3.) OR

• they develop one or more opportunistic infections regardless of

their CD4 count.

Without HIV medicine, people with AIDS typically survive about 3

years. Once someone has a dangerous opportunistic illness, life
expectancy without treatment falls to about 1 year. HIV medicine can
still help people at this stage of HIV infection, and it can even be
lifesaving. But people who start HIV medicine soon after they get HIV
experience more benefits that’s why HIV testing is so important.
 Difference between HIV & AIDS

AIDS HIV
• Acquired
• Human Immunodeficiency
Immunodeficiency
Virus (HIV) is the causal
Syndrome (AIDS) is a
factor (reason) for AIDS.
disease.
• Complications and
• The virus is incapable of
secondary infections from
killing a host by itself.
this disease kill the host.
• AIDS is a condition • HIV is a virus and, like
acquired only after the other viruses, can spread
contraction of HIV. from person to person.
 Life cycle of HIV

• HIV attacks and destroys the CD4 cells (CD4 T lymphocyte) of

the immune system. CD4 cells play a major role in protecting the
body from infection.

• HIV uses the machinery of the CD4 cells to multiply and spread
throughout the body. This process, which is carried out in seven
steps or stages, is called the HIV life cycle. HIV medicines protect
the immune system by blocking HIV at different stages of the
HIV life cycle.

• Antiretroviral therapy (ART) is the use of a combination of HIV

medicines to treat HIV infection. People on ART take a
combination of HIV medicines from at least two different
HIV drug classes every day. Because each class of drugs is
designed to target a specific step in the HIV life cycle, ART is
very effective at preventing HIV from multiplying.

• HIV attacks and destroys the CD4 cells (CD4 T lymphocyte) of

the immune system. CD4 cells play a major role in protecting the
body from infection.

• The seven stages of the HIV life cycle are: 1) binding, 2) fusion,
3) reverse transcription, 4) integration, 5) replication,
6) assembly, and 7) budding.
 Transmission

HIV can be transmitted via the exchange of a variety of body fluids

from infected people, such as blood, breast milk, semen and vaginal
secretions. HIV can also be transmitted from a mother to her child
during pregnancy and delivery. Individuals cannot become infected
through ordinary day-to-day contact such as kissing, hugging, shaking
hands, or sharing personal objects, food or water.

It is important to note that people with HIV who are taking ART and
are virally suppressed do not transmit HIV to their sexual partners.
Early access to ART and support to remain on treatment is therefore
critical not only to improve the health of people with HIV but also to
prevent HIV transmission.
 Symptoms

The symptoms of HIV vary depending on the stage of infection.

Though people living with HIV tend to be most infectious in the first
few months after being infected, many are unaware of their status until
the later stages. In the first few weeks after initial infection people may
experience no symptoms or an influenza-like illness including fever,
headache, rash or sore throat.

As the infection progressively weakens the immune system, they can

develop other signs and symptoms, such as swollen lymph nodes,
weight loss, fever, diarrhoea and cough. Without treatment, they could
also develop severe illnesses such as tuberculosis (TB), cryptococcal
meningitis, severe bacterial infections, and cancers such as lymphomas
and Kaposi's sarcoma.
 Treatment

HIV disease can be managed by treatment regimens composed of a

combination of antiretroviral (ARV) drugs. Current antiretroviral
therapy (ART) does not cure HIV infection but suppresses viral
replication and allows an individual's immune system recovery to
strengthen and regain the capacity to fight off opportunistic infections
and some cancers.

Since 2016, WHO has recommended Treat All: that all people living
with HIV be provided with lifelong ART, including children,
adolescents, adults and pregnant and breastfeeding women, regardless
of clinical status or CD4 cell count.

By June 2022, 189 countries had already adopted this recommendation,

covering 99% of all people living with HIV globally. In addition to
the Treat All strategy, WHO recommends a rapid ART initiation to all
people living with HIV, including offering ART on the same day as
diagnosis among those who are ready to start treatment. By June 2022,
97 countries reported that they have adopted this policy, and almost
two-thirds of them reported country-wide implementation.

Globally, 28.7 million people living with HIV were receiving ART in
2021. Global ART coverage was 75% [66–85%] in 2021. However,
more efforts are needed to scale up treatment, particularly for children
and adolescents. Only 52% [42–65%] of children (0–14 years old) were
receiving ART at the end of 2021.

Advanced HIV disease remains a persistent problem in the HIV

response. People continue to present or re-present for care with
advanced immune suppression, putting them at a higher risk of
developing opportunistic infections. WHO is supporting countries to
implement the advanced HIV disease package of care to reduce illness
and death.
 Prevention

Individuals can reduce the risk of HIV infection by limiting exposure

to risk factors. Key approaches for HIV prevention, which are often
used in combination, include:

❖ male and female condom use;

❖ prevention, testing and counselling for HIV and STIs;
❖ voluntary medical male circumcision (VMMC);
❖ use of antiretroviral drugs (ARVs) for prevention (oral PrEP and
long acting products), the dipivefrine vaginal ring and injectable
long-acting cabotegravir;
❖ harm reduction for people who inject and use drugs; and
❖ elimination of mother-to-child transmission (MTCT) of HIV.

HIV is not transmitted if a person’s sexual partner is virally suppressed

on ART, so increasing access to testing and supporting linkage to ART
is an important component of HIV prevention.
 Conclusion

Global health sector strategies on, respectively, HIV, viral hepatitis,

and sexually transmitted infections for the period 2022–2030 (GHSSs)
guide the health sector in implementing strategically focused responses
to achieve the goals of ending AIDS, viral hepatitis B and C and
sexually transmitted infections by 2030.

The 2022–2030 strategies recommend shared and disease-specific

country actions supported by actions by WHO and partners. They
consider the epidemiological, technological, and contextual shifts of
previous years, foster learnings across the disease areas, and create
opportunities to leverage innovations and new knowledge for effective
responses to HIV, viral hepatitis, and sexually transmitted infections.

The strategies call for a precise focus to reach the people most affected
and at risk for each disease that addresses inequities. They promote
synergies under a universal health coverage and primary health care
framework and contribute to achieving the goals of the 2030 Agenda
for Sustainable Development.

The Seventy-fifth World Health Assembly requested progress reports

on the implementation of the strategies in 2024, 2026, 2028 and 2031,
noting that the 2026 report will provide a mid-term review based on the
progress made in meeting the strategies’ 2025 targets.
The strategic directions of the GHSSs 2022–2030 are to:

• deliver people-cantered evidence-based services

• optimize systems, sectors and partnerships for impact

• generate and use data to drive decisions for action

• engage empowered communities and civil society

• foster innovation for accelerated action.

As a founding cosponsor of the UNAIDS Joint Programme, WHO

takes the lead on HIV testing, treatment and care, resistance to HIV
medicines and HIV/TB co-infection. WHO jointly coordinates work
with UNICEF on EMTCT of HIV and paediatric AIDS and works with
UNFPA on the integration of SRHR and HIV. With the World Bank,
WHO convenes actions to drive progress towards achieving universal
health coverage, including, and with UNICEF, through primary health
care. WHO also partners with UNODC on harm reduction and
programmes to reach people who use drugs and people in prison and
other closed settings.
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