AIDS

What is AIDS?
AIDS stands for acquired immunodeficiency syndrome, a pattern of
devastating infections caused by the human immunodeficiency virus, or HIV, which
attacks and destroys certain white blood cells that are essential to the body's
immune system.

When HIV infects a cell, it combines with that cell's genetic material and may
lie inactive for years. Most people infected with HIV are still healthy and can live for
years with no symptoms or only minor illnesses. They are infected with HIV, but
they do not have AIDS.

After a variable period of time, the virus becomes acti-vated and then
leads progressively to the serious infections and other conditions that characterize
AIDS. Although there are treatments that can extend life, AIDS is a fatal disease.
Research continues on possible vaccines and, ultimately, a cure. For the moment,
however, prevention of transmission remains the only method of control.

The route of infection in adults

HIV targets two groups of white blood cells called CD4+ lymphocytes
and monocytes/macrophages. Normally, CD4+ cells and macrophages
help recognize and destroy bacte-ria, viruses or other infectious agents that invade
a cell and cause disease. In an HIV-infected per-son, the CD4+ lymphocytes are
killed by the virus, while the macrophages act as reservoirs, carrying HIV to a
number of vital organs.
HIV attaches itself to the CD4+ lymphocyte and makes its way inside.
This causes the cell to produce more HIV but, in doing so, the cell is destroyed.
As the body's CD4+ cells are deplet-ed, the immune system weakens and is
less able to fight off viral and bacterial infections. The infected person becomes
susceptible to a wide range of "opportunistic" infections, such as
Pneumocystis carinii pneumonia, which rarely occurs in persons with normal
immune systems. Tuberculosis (TB) poses a particular threat to HIV-positive
people, especially in areas of the world where both TB and HIV infection are
increasing at alarming rates. Millions of TB carriers who would otherwise have
escaped active tuberculosis are now developing the disease because their
immune systems are under attack from HIV. TB also progresses faster in HIV-
infected persons, and is more likely to be fatal if undiagnosed or untreated. TB is
now the leading killer of HIV-infected Africans. HIV-infected persons are also more
susceptible to

otherwise rare cancers such as Kaposi’s sarcoma, a tumour of the blood vessels
or the lymphatic vessels. HIV may also attack the brain, causing neurological and
neuro-psychiatric problems.
In general, about 50 percent of HIV-infected adults are likely to develop AIDS
within 10 years after first becoming infected. The good news is that early treatment
with improved drugs is significantly prolonging life for persons with AIDS.

The route of infection in infants and children

Most HIV-infected infants and children acquired the infection from their mothers
before, during or shortly after birth, or during breastfeeding. Only a small proportion
are infected through HIV-contaminated blood transfusions or injections. There are
two patterns of disease progression in children infected from birth. About half these
children progress rapidly to AIDS, but others remain symptom free for years, as
adults do. Studies show that, in developed countries, approximately two-thirds of
infected children are still alive at age 5 years. In developing countries, the figure
ranges between 30 and 65 percent. (For more information, see the section on
mother-to-child transmission of HIV later in this chapter.)

How HIV is transmitted

To date, there are only four primary methods of transmission:

■ sexual intercourse (anal and vaginal);

■ contaminated blood and blood products, tissues and organs;
■ contaminated needles, syringes and other piercing instruments; and
■ mother-to-child transmission (MTCT).
Sexual intercourse

HIV can be transmitted through unprotected sexual intercourse—that is, any

penetrative sexual act in which a condom is not used. Anal and vaginal intercourse
can transmit the virus from an HIV-infected man to a woman or to another man, or
from an infected woman to a man.
The risk of becoming infected through unprotected sexual intercourse depends
on four main factors: the probability that the sex partner is infected, the type of sex
act, the amount of virus present in the blood or sexual secretions (semen, vaginal
or cervical secretions) of the infected partner, and the presence of other sexually
transmitted diseases and/or genital lesions in either partner. Age may also be a
factor as young girls are physiologically more vulnerable.

The probability of HIV infection in the partner

The prevalence of HIV infection among sexually active men and women varies
according to geographical area or population subgroup, such as heterosexuals, men
who have sex with men (MSM), sex workers, or injecting drug users (see page 36).
Generally, the likelihood of becoming infected with HIV sexually is related to the
number of sexual partners and unprotected sex acts you have. In other words, the
more sexual partners you have, the greater your chance of becoming infected.

The type of sex act

All unprotected acts of sexual penetration (anal, vaginal, oral) carry a risk of
HIV transmission because they bring body fluids secreted during sex directly into
contact with exposed mucous membranes (the lining of the rectum, the vagina, the
urethra and the mouth).

■ Men and women who engage in unprotected receptive anal intercourse

with an HIV-infected partner run the highest risk of becoming infected.

■ The next highest risk is that associated with unpro-tected vaginal intercourse.

■ Unprotected oral intercourse involves some risk as well, particularly if there

are mouth or throat injuries present such as bleeding gums, lesions, sores,
abscessed teeth, throat infections, oral gonorrhoea or other STDs present.
This risk is reduced, although not entirely elim-inated, by the proper use of
condoms.
Injury to the mucous membrane of the rectum, vagina or mouth may help the
virus enter the bloodstream. However, HIV can be transmitted even through
unbroken mucous membrane.
Kissing has not been shown to transmit HIV, as saliva contains very little of the
virus. Nevertheless, there is a theoretical risk of HIV transmission during deep or
"wet" kissing (tongue kissing) if blood from gum or mouth sores is present in the
salivaThere is no evidence that HIV has actually been transmitted this way.

Self-masturbation involves no risk of HIV transmission. There are no known

cases of transmission through mutual masturbation, either. However,
masturbation of a partner poses a theoretical risk of HIV transmission if his
or her sexual secretions come in contact with mucous membrane or broken
skin.

The amount of virus present in the infected partner

HIV-infected individuals become more infectious as they progress to HIV-relat-

ed disease and AIDS. There is also an early one- to two-week period of infectious-
ness around the time of seroconversion—that is, when antibodies first develop.

The presence of other sexually transmitted diseases

in either partner

There is a strong link between sexually transmitted diseases (STDs) and the
sexual transmission of HIV infection (3). The presence of an untreated STD—such
as gonorrhoea, chlamydial infection, syphilis, herpes or genital warts—can enhance
both the acquisition and transmission of HIV by a factor of up to 10. Thus, STD treat-
ment is an important HIV prevention strategy in a general population.

Contaminated blood or blood products,

tissues and organs

Blood transfusions save millions of lives each year, but in places where a safe
blood supply is not guaranteed, those receiving transfused blood have an increased
risk of being infected with HIV.
In most industrialized coun-tries, the risk of acquiring HIV infection from
transfusions is extremely low .This is due in large part to effective recruitment of
regular, Volunteer blood donors, improved screening of blood and blood products
with highly sensitive and specific tests for the antibody to HIV; and the appropriate
use of blood.
In the developing world, how-ever, the risk is much higher. One estimate is that up
to 5 percent of HIV infections may be caused by transfusions in high-prevalence
areas such as sub-Saharan Africa. The lack of coordinated national blood
transfusion systems, the absence of non-remunerated volunteer blood donors, lack
of testing, and inappro-priate use of blood products compound the problem (4-6).

To prevent transmission by tissue and organ donation, including sperm for artifi-
cial insemination, the HIV-infection status of the donor should be carefully evaluated.

Contaminated needles, syringes or

other piercing instruments

HIV can be transmitted through the use of HIV-contaminated needles or other

invasive instruments. The sharing of syringes and needles by injecting drug users is
responsible for the very rapid rise in HIV infection among these persons in many
parts of the world.
A risk is also attached to non-medical procedures if the instruments used are not
properly sterilized. Such procedures include ear- and body-piercing, tattooing,
acupuncture, male and female circumcision, and traditional scarification. The actual
risk depends on the local prevalence of HIV infection.
HIV transmission by means of injection equipment can also occur in health care
settings where syringes, needles and other instruments, such as dental equipment,
are not properly sterilized, or through injury by needles and other sharps.

Mother-to-child transmission (MTCT)

Mother-to-child transmission (MTCT) is the overwhelming source of HIV

infection in young children. The virus may be transmitted during preg-nancy,
labour, delivery or after the child's birth dur-ing breastfeeding. Among infected
infants who are not breastfed, most MTCT occurs around the time of delivery
(just before or during labour and deliv-ery). In populations where breastfeeding
is the norm, breastfeeding may account for more than one-third of all cases of
MTCT transmission (7,8).
Paediatric AIDS can be difficult to diagnose because some symptoms of
HIV infection, such as diarrhoea, are also common in infants and children
who are not infected.
Therefore, these symptoms cannot be considered a reliable basis for diagnosis.
There are blood-based tests that allow early diagnosis of HIV infection in infants.
These are used extensively in developed coun-tries. However, these tests are quite
expensive and are not readily available in developing countries.

How HIV is not transmitted

Family, friends and co-workers should not fear becoming infected with HIV through
casual contact with an HIV-infected person at home, at work, or socially. These
activities will not transmit the virus:

■ shaking hands, hugging or kissing

■ coughing or sneezing
■ using a public phone
■ visiting a hospital
■ opening a door
■ sharing food, eating or drinking utensils
■ using drinking fountains
■ using toilets or showers
■ using public swimming pools
■ getting a mosquito or insect bite.

AIDS and work

For the vast majority of occupations, the workplace does not pose a risk of
acquiring HIV. The exceptions include laboratory workers, health care workers, per-
sons dealing with hospital waste products, emergency medical
response personnel and any other occupationwhere there is a
possibility of exposure to blood. Their risk is very low, but real.
Among the hazards to which these persons may be exposed are
needle-stick injuries and other skin-piercing accidents, and blood
splashing into the eyes while they are administering treat-ment or
otherwise performing their duties.
AIDS and sports

There are no documented cases of HIV being transmitted during

participation in a sports activity.

The very low risk of transmission during sports participation would involve sports
with direct body contact in which bleeding might be expected to occur .
It is theoretically possible for the virus to be transmitted if an HIV-infected
athlete had a bleeding wound or skin lesion with fluids that came in contact with
another athlete's skin lesion, cut or exposed mucous membrane. Even in such an
unlikely event, risk of transmission would be very low. However, in sports involving
direct body contact or combative sports where bleeding might occur, it is sensible to
follow two simple procedures:

■ cleanse any skin lesion with antiseptic and cover it securely; and
■ if a bleeding injury occurs, interrupt participation until the bleeding has stopped
and the wound has been both cleansed with antiseptic and securely covered.

Preventing HIV Transmission

Preventing sexual transmission of HIV

Know your partner

Whether you are male or female—heterosexual, homosexual or bisexual—

your risk of acquiring HIV infection is directly related to the likelihood that your
partner is infected. Your risk is substantially higher if your partner has ever
injected drugs, has unprotect-ed sex with casual partners, or has a sexual
history unknown to you.

Understand which sexual acts put you at most risk

All forms of penetrative sexual intercourse (anal, vaginal, oral) with an HIV-
infected man or woman carry a risk of transmission. Unprotected anal intercourse is
one of the riskiest practices. This is true even when a condom is used because of
the increased likelihood that the condom will be damaged during this form of sex.
Unprotected vaginal intercourse carries the next highest risk of
infection. Oral sex also carries a small risk of transmission,
particu-larly if there are mouth or throat injuries pre-sent
such as bleeding gums, lesions, sores, abscessed teeth,
throat infections, or oral STDs present.
What you need to know about condoms
To protect
Latex condoms your-self, always
lubricated usesilicone
with a con-dom
or during penetrativelubricant
a water-based sexual acts
are
recommended as a barrier method to reduce the risk of HIV
transmission during anal, vaginal and oral intercourse. (If additional
lubricant is desired, a water-based variety such as K-Y
Lubricating Jelly® should be used rather than an oil-based lubricant such
as Vaseline®, which can break down the latex.) Latex con-doms are only
effective if they are used prop-erly and do not break.
Natural membrane condoms, often made from sheep gut, are not
recommended because they have tiny pores through which HIV could pass.

For maximum effectiveness, the condom

must be put on before the penis touches any Male

condom part of the rectum, vagina or mouth. It
should be put on when the penis is erect, taking
care to leave a reservoir at the tip to contain
the semen. Care should be taken during withdrawal
of the penis (with the condom still in place) to
avoid spillage.

Female condoms, such as the REALITY® condom, are now available.

The female con-dom is a soft, loose-fitting plastic pouch made of
polyurethane (not latex) that lines the vagina. It has a semi-stiff plastic
ring at each end. The inner ring is used to insert the device inside the
vagina and hold it in place. The outer ring part-ly covers the labia area
and holds the condom open.
 Or, to be even safer, you can engage in sexual practices that involve no
penetration such as caressing or massaging any part of the body, masturbation
(provided that sexual secretions do not come in contact with cuts or sores on the
other partner's skin), and kissing that does not involve heavy exchange of
saliva and possibly blood. The safest course of all is abstinence.

Seek medical advice or treatment for STDs

The presence of an untreated sexually transmitted disease—such as

gonorrhoea, chlamydial infection, syphilis, herpes or geni-tal warts—can
enhance both your acquisition and transmission of HIV by a factor of up to 10. If
you suspect you have an STD, or have been exposed to one, it is imperative that
you seek medical advice and treatment immedi-ately.

Common symptoms include an unusual discharge from the vagina or penis,

burning or pain during urination, and sores or blisters near the mouth or genitals.
Other symptoms in women may include unusual bleed-ing (other than the
menstrual cycle) and vaginal pain during intercourse.

Preventing transmission of HIV via blood and

blood products

In industrialized countries, the risk of transmission of HIV via blood and blood prod-
ucts is very rare for each unit of blood transfused.
It is also very rare to contract HIV in the health care setting. For example, evi-
dence from the USA indicates that health care workers who accidentally puncture
their skin with a needle contaminated with HIV have an estimated risk of less than
five in a 1000 (0.5 percent) of developing HIV infection.
Also, HIV is a fragile virus, meaning it is vulnerable to changes in temperature
and other environmental factors, and has been shown not to be viable in dried blood
for more than an hour. The concentration of virus particles of HIV per millilitre of
blood is also very low in contrast to other viruses. Despite the low level of occupa-
tional risk posed by HIV, safe work practices should be followed at all times by lab-
oratory personnel and health workers. Don't be afraid to ask your health care
professional, clinic or hospital if they follow "universal precautions”, or safety mea-
sures to prevent the transmission of HIV in health care settings.
If you must travel to areas of the world where the safety of the blood supply is
not guaranteed, you should follow these measures
Protecting children
Parents should make sure that children know the facts about HIV transmission and
how they can protect themselves against infection. Specifically, children should:
■ be aware that HIV is transmitted through blood;
■ avoid any skin-piercing procedures or accidental injury from unsterilized needles
and other sharp instruments;
■ receive injections or other medical or dental treatment only when necessary and
only with properly sterilized equipment;
■ receive blood transfusions only when medically necessary and only with proper-
ly screened blood; and
■ avoid the risk of traumatic injury necessitating blood transfusion.
Older children need information and encouragement that will help them avoid

becoming infected through unprotected sexual intercourse or through sharing drug-

injecting equipment. Children also need to be reassured about the ways
in which HIV cannot be transmitted they should be encouraged to
be sym-pathetic toward children and adults who are infected, and should
not fear becoming infected through casual contact with these persons.

Being Tested
What the HIV antibody test can tell you
The standard tests to determine whether you are infected with HIV are based on
detection of antibodies to HIV in the blood, not of the virus itself (11). Different types
of antibody tests exist such as the enzyme-linked immunosorbent assay (ELISA)
and simple rapid (S/R) tests. In recent years, tests have been developed that detect
HIV antibodies in saliva and urine.
The first antibody test a person gets is called a screening test. If the screening
test is negative, it means that no antibodies were found. The person tested is con-
sidered HIV-negative and confirmatory tests are not necessary. If the screening test
is repeatedly positive, it must be confirmed.
Confirmation can be done by using special tests, e.g. Western Blot or line
immunoassays (LIA). It is also possible to confirm a positive result by using
combinations of ELISA or S/R tests. Although the confirmation can be done on the
same sample of blood, it is preferable to do the confirmation on a second blood
sample in order to avoid any errors. HIV screening tests can sometimes give false-
positive readings, especially in populations where HIV is not present in high
numbers, which is why confirmatory testing is always done on positive screening test
results. This confirmation is need-ed to rule out false-positive screening results.
 In regard to the accuracy of the antibody tests:
■ It takes, on average, 25 days for an HIV test to show positive after a person
becomes infected with HIV. This is a much shorter timeframe than before the
introduction of very sensitive tests now used.
■ If a person has been infected very recently, the test may show a negative result.
■ When saliva and urine are tested, it takes longer for antibodies to become
detectable.
■ More than 99 percent of infected persons will show positive after three months.

The HIV antibody test and employment

In the vast majority of occupations and occupational settings, work does not involve
a risk of transmitting HIV between workers or from worker to client. The following
recommendations have been put forward on AIDS and the workplace.
■ Pre-employment HIV/AIDS testing as part of assessing fitness to work is unnec-
essary and should NOT be required. This applies to both direct methods such
as HIV testing and indirect assessment of risk behaviours and questioning the
applicant about HIV tests already taken. Pre-employment HIV/AIDS screening
for insurance or other purposes raises serious concerns about discrimination,
and merits close scrutiny.
■ For persons currently employed, HIV/AIDS screening, whether direct or indirect,
should NOT be required.
■ All medical information, including HIV/AIDS status, must be kept confidential.
■ Employees should not be required to inform the employer regarding their
HIV/AIDS status.
■ Persons in the workplace who are HIV-infected (or perceived to be) must be pro-
tected from stigmatization and discrimination by co-workers, unions, employers
and clients. Information and education are essential to maintain a climate of
mutual understanding necessary to ensure this protection.
■ HIV-infected employees should not be discriminated against with respect
to their access to and receipt of benefits from statutory social security
programmes and occupationally-related schemes.
■ HIV infection alone does not limit fitness to work. If fitness to work is
impaired by HIV-related illness, reasonable alterna-tive working
arrangements should be made.

■ HIV infection is not a cause for termination of employment. As with many other
illnesses, persons with HIV-related illnesses should be allowed to work for as
long as they are medically fit for available, appropriate work .
While these measures are designed to protect your rights if you are HIV-infect-ed,
you also have a responsibility to adopt behavior that does not put others in your
workplace at risk of infection.

The HIV antibody test and pregnancy

If you or your partner are concerned about your HIV status, and you are thinking
about having a baby, the HIV antibody test may help clarify your choices.
HIV testing should be available, with pre- and post-test counselling, on a vol-
untary, confidential basis. You and your sex partner should be counselled on the
implications that a positive test result will have for both of you, for the fetus and for
the infant if pregnancy is considered.

An HIV-infected woman can transmit HIV to her infant. The most likely time for
an HIV-infected pregnant woman to pass the virus on to her baby is either in the very
early stages or in the advanced stage of her infection. Thus, the risk of transmission
ranges from low (if the HIV-infected woman has no signs and symptoms) to high (if
she has AIDS). The transmission rate ranges from 12% to over 30%.
If you are pregnant and HIV-infected, you should be counselled on the options
of continuing or terminating your pregnancy (where abortion is legal) and about
reducing mother-to-child transmission (MTCT) through treatment with zidovudine
(sometimes called ZDV or AZT) during your pregnancy (see page 32 for more
information).
Pregnancy does not appear to accelerate the progression of the clinical course
of HIV infection.

Living with HIV and AIDS

Coping with confirmed HIV infection

Learning that you are infected with HIV will change your life dramatically. You may
experience a wide range of emotions—fear, loss, grief, depression, denial, anger,
anxiety. No matter how reassuring the doctor, how effective drug therapies are now
and will become, how minimal the physical impact of the infection, or how intellec-
tually prepared you may be, your need for counselling and support will be great.
The psychological issues faced by most persons with HIV infection revolve
around uncertainty. Your future hopes and expectations, your relationships and your
career will all require some adjustment in
order for you to cope with your illness and lead a happy, productive life.
The impact on your health

The impact to your health is likely to depend on the stage of infection you
have reached when you discover you are HIV- positive, the
psychological support available to you, and your access to good
medical care.Soon after becoming infected with the virus, some
people experience a brief flu-like illness with fever, swollen
lymph glands, skin rash or cough. You may then remain perfectly
fit and healthy for many years despite being infected. For
approximately 50 percent of infected persons, the time between
becoming infected and the appearance of the oppor-tunistic infections
that characterize AIDS is more than 10 years.
Antiretroviral combination therapy, while expensive, has been shown
to slow the onset of AIDS and prolong life expectancy. Your
quality of life could also be improved by the preventive and
therapeutic use of drugs that fight off common opportunistic
infections and other diseases to which HIV-infected person are
vulnerable, such as tuberculosis. Active TB screening and contact
tracing through sputum examination are also important for families
with an HIV-positive member.

In addition to good medical care, psychological support—from family, friends and

counselling—is critical. In many coun-tries, there are support groups made up of
persons living with HIV and AIDS. There are also numerous support groups and
resources to be found on the Internet

The impact on your personal relationships

Partners are likely to suffer the conse-quences of HIV infection and disease as
much as the infected person, albeit indirectly. This is
so even if partners know that they are not HIV-
infected themselves. Their lives are likely to experience the same kind of
pressures and
upheavals, and they can experience similar feelings of uncertainty, grief, loss
and anger. Communication between the two partners and between partners and
profes-sional counsellors is important to foster understanding of the adjustments that
will be needed. For example, adjustments in sexual behaviour are necessary to stop
further
transmission of infection. Counselling can also address the physical and psycho-
logical changes and needs that the partners will experience.
If you have HIV, you have an opportunity to make others more aware of the dis-
ease. By educating others, you may decrease the prejudice against persons with
HIV or AIDS. However, consider carefully to whom you reveal your HIV status.
Misunderstanding and discrimination do exist, and can affect you and the ones you
love. Again, professional counselling can help with these issues.
Often, families are the main source of care and support for HIV-infected per-
sons, and the type of care required may change depending on the stage of the infec-
tion. Counselling for family members, both as individuals and as the family unit, can
be very important, particularly as the disease progresses.

The impact on your work life

How your work life is impacted will depend on how you feel physically and men-
tally, and at what stage your infection is discovered. Experience has shown that per-
sons with HIV infection, with or without symptoms, should keep working as long as
possible. After the initial period of coming to terms with HIV infection, there usually
comes a period of wanting to move on with life—and work can be an important part
of this transition.
Although you are not obliged to inform your employer and colleagues of your
HIV status, certain circumstances may make it necessary for you to do so. If your
job calls for you to travel, for example, you may need to go to countries where entry
depends on a certificate that shows you are not HIV-infected. In addition, you may
require certain vaccinations. Theoretically, you could become infected by the "live"
but weakened pathogens in certain vaccines, particularly if your immune system has
already been damaged by HIV. It is always best to consult your physician to deter-
mine the risks involved with vaccines or if alternatives exist.

HIV and your infant's health

Having a baby

Pregnancy is something you and your partner will need to discuss very careful-
ly with your physician and possibly your counsellor if either or both of you are infect-
ed. It is very important to receive medical care early in your pregnancy.Your HIV
treatment should not change very much from what it was before you became preg-
nant. If you decide to continue your pregnancy, talk with your doctor about how
you can prevent giving HIV to your baby. The chances of passing HIV to your
baby before or during birth are about 15-25 percent in developed countries and
25-45 percent in developing countries.
 Treatment with zidovudine (sometimes called ZDV or AZT) associated
with replacement feeding has been shown to greatly lower this risk.
Although you are pregnant, you should still use condoms each time you have
sex to avoid contracting other diseases and to avoid spreading HIV. Even if
your partner already has HIV, he should still use condoms.

After birth, your baby should be tested for

HIV, even if you took ZDV and/or other drugs during pregnancy. Talk with your
doctor about your baby's special medical needs and any medications he or she
will need .

Breastfeeding

Breastfeeding is normally the best way to feed an infant. However, if a

mother is HIV-infected, it may be prefer-able to replace breastmilk to reduce the
risk of HIV transmission to the infant. The risk of replacement feeding should

be less than the potential risk of HIV transmission through infected breastmilk, so
that infant illness and death from other causes do not increase. Otherwise, there is
no advantage to replacement feeding. According to joint guidelines from UNAIDS,
UNICEF and WHO (20), the following issues should be considered:

■ replacement feeding needs to provide all the infant's nutritional requirements as

completely as possible;
■ breastmilk substitutes must be prepared and given hygienically to avoid conta-
mination with bacteria. This requires access to clean water and fuel;
■ breastmilk substitutes must be affordable to families; and
■ affordable family planning must be accessible, as women who do not breastfeed
lose the child-spacing benefits that breastfeeding can provide.
Childhood immunizations

Some parents may worry that their HIV-infected children might be adversely
affected by routine childhood immunizations. In response, WHO and UNICEF have
issued the following guidelines. HIV-infected children should be immunized against
diphtheria, tetanus and pertussis (with DTP); poliomyelitis (with OPV or IPV); and
measles (with measles vaccine), according to standard schedules. Children with
known or suspected HIV infection are at increased risk of severe measles, and
these children should be given an extra dose of measles vaccine as soon after six
months as possible, with the scheduled dose given at nine months as usual.
 Parents of HIV-infected children are often HIV-infected themselves and have a
higher incidence of tuberculosis than the general population. Early protection
against tuberculosis with BCG immunization is therefore recommended for HIV-
infected children who are not symptomatic. Symptomatic HIV-infected children,
however, should not be immunized with BCG (21) or yellow fever vaccine.