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1. 409 Woolwich St. Guelph , ON, N1H3X2 519.763.2255 / 800.282.4505 www.aidsguelph.org We dream of a time and place where everyone is free to live healthy, vital lives.

3. HIV/AIDS Introduction to HIV Disease and AIDS

4. What is HIV? • HIV stands for the Human Immunodeficiency Virus : • Can only infect humans • Virus attacks the Immune System making it weaker • Virus, antibiotics don’t work

5. HIV Disease consists of 5 basic stages, of which AIDS is the final stage To be diagnosed with AIDS, an individual must be HIV+ and…. Have a special infection or cancer that only affects those with severely weakened immune systems: OPPORTUNISTIC INFECTIONS HIV vs. AIDS: What’s the Difference?

6. HIV CD4 Cell CD4 cell (T-cells) • The “quarterback” or “brain” of the immune system: it coordinates your body’s response to infections • The cell that HIV targets, infects, and kills” • “Normal” range can be anywhere from 500-1500 CD4 cells per teaspoon of blood • A routine blood test for PHAs to assess immune function (~every 3 months)

7. Viral Load • Refers to the amount of HIV in an individuals blood • Amount can vary over time and with HIV medicine • Goal of treatment is to reduce the viral load to “undetectable”. Even at the undetectable level, the virus is still present in “reservoirs” like the lymphatic system and some organs. • “Undetectable” range is less than 50 copies of virus per mm3 • A routine blood test for PHAs to assess when to start treatment, assess treatment effectiveness

8. Primary Infection (Acute) • Seroconversion • Asymptomatic Infection • Symptomatic Infection • AIDS

9. Primary (Acute) Infection • Virus multiplies rapidly • 2. CD4 cell count drops during this period and Viral Load can be very high as the body has not yet responded to the infection • 3. Individual may test negative for HIV antibodies, but VIRUS IS EASILY TRANSMITTED

10. CD4+/Viral Load: HIV Disease

11. HIV Treatment • HIV meds can reduce the amount of HIV in the blood to an undetectable (but still present) level which allows the body’s CD4 cells to replenish to a “healthy” level. • Undetectable viral load reduces the likelihood of transmission • People usually start meds around 500 CD4 cell count and this can basically prolong (possibly indefinitely) the asymptomatic phase. (most major OIs occur at <200 CD4 cells) • Adherence must be greater than 95% to prevent virus from becoming resistant to the medications (right dose, right time, right amount of food/no food). • Side effects to treatment can be serious and difficult to endure , though many of the newer medications have improved tolerability. Long term toxicities are also a concern with some medications

12. HIV Transmission

13. Body Fluids (cont’d) • Not all body fluids can transmit HIV • The ONLY body fluids that can transmit HIV are: • BLOOD • SEMEN • VAGINAL FLUIDS • RECTAL FLUIDS • BREAST MILK

14. HIVTransmission Equation • There are certain things that must be in place for HIV to transmit from one person to another. It is sometimes called the TRANSMISSION EQUATION HIV + Body Fluid Means of Transmission Entry Into the Body Possible HIV Transmission • Blood • Semen • Vaginal Fluids • Rectal Fluids • Breast Milk • Sexual Transmission • Sharing Needles and Works • Mother to Child • Break in the Skin • Mucosal Lining Contact** • Direct Contact with Blood Stream (IV)

15. Mucous Membranes (MMs) • Form the surface of body cavities • (nostrils, vagina, anus, mouth, throat, respiratory/digestive/reproductive systems) • MMs cover 400m2 surface area (1 and ½ tennis courts) • It is wet, and in some places, secretes mucous that helps keep out foreign invaders • Lined by an epithelium (protective layer of cells); similar to skin but alive • Many immune cells within and right below the surface of MMs to protect against possible infection • Since HIV can infect immune cells, it provides many targets for HIV in exactly the areas of the body that it will contact

17. ANUS/RECTUM • Many immune cells in the anus, rectum, and large intestine to protect against high number of invaders • Easier for HIV to find a target • Epithelium of rectum is only 1 cell thick, so it is easier to get through • Large surface area • Lots of room for HIV to come into contact with an immune cell

18. FEMALE REPRODUCTIVE TRACT – Vagina, Cervix, and Uterus • HIV can transmit through any part; but most easily through the cervix • Vaginal wall has multiple overlapping layers of epithelial cells, so it is a bit harder to cross • Epithelium in the upper part of the cervix and uterus is 1 cell thick, like the anus, so it is more vulnerable to HIV and STIs • Many immune cells naturally present at cervix to protect a potential fetus

19. THE UNCIRCUMCISED PENIS • The urethra is lined with mucous membrane • The area under the foreskin is a mucous membrane with lots of dendritic cells*

20. MOUTH AND THROAT • Saliva has a MUCH lower viral load than blood or genital fluids • Activities involving the mouth are generally considered low risk activities • Oral mucosa is tough and quick to heal • Tonsils are most vulnerable to HIV • Risk increases with ejaculation, menstruation, poor oral health, or inflammation

21. Role of Inflammation • Body’s immune response to injury, irritation, or infection by foreign object/organism • Causes: • Redness and heat : increased blood flow which brings immune cells to the region • Localized swelling as walls of blood vessels become thinner : allows more immune cells to migrate from the blood into the MM to find invaders

22. Inflammation • ANYTHING that increases inflammation increases and HIV+ person’s chance of transmitting it to someone else, AND increases an HIV- person’s vulnerability to infection • Infl. increases viral shedding in genital/rectal tracts of HIV+ persons • Some proteins in immune response increase ability of HIV to reproduce • Activated target cells (CD4,macrophage, dendritic cell) come to the area and have increased chance of contact with HIV

23. INFLAMMATION – Influx of Immune Cells

24. Biological Factors in HIV Transmission • What bio. factors increase the infectiousness of an HIV+ person? • Viral Load in semen, vaginal fluids, anal fluids • Affected by changes in blood VL, coinfection with an STI, inflammation, or stage of HIV disease • HIV+ people are more likely to transmit in the first 5 months after being infected • Astronomically high VL, unaware of infection, sexually active, sometimes with multiple partners

25. HIV and Women • It is 4-6 x easier for a man to infect a woman, than vice versa: • Vagina is very large mucosal area • Semen has, on average, a higher viral load than vaginal fluids • Up to 75% of some STIs show no symptoms in women (vs. 40% in men), women are more likely to be infected and be unaware • Socio-economic factors can make women more vulnerable to infection • Women are not being educated about their increased risk for HIV infection in schools

26. Transmission Basics • CAS categorizes activities into risk levels: • No risk, Negligible Risk, Low Risk, High Risk • 1. Is it theoretically possible? (exchange of body fluids) • 2. Have their been documented cases? How many? • Helps people make knowledgeable choices as to how much risk they are willing to take • HOWEVER: • Quantifying risk is very difficult and these categories are not clear or absolute • HIV risk is a continuum based on various social and biological vulnerabilities, as well as the infectiousness of the HIV+ partner

27. High Risk • Penile – Vaginal Sex (without condom) • Penile – Anal Sex (without condom) • Receiving shared sex toys • Injecting with shared needles

28. Low Risk • Kissing (with exchange of blood) • Performing fellatio/cunnilingus (no barrier) • Vaginal/Anal Sex with a condom • Injecting with cleaned needles • Tattooing with non-professional equipment • Taking blood in the mouth • Occupational Exposure

29. Negligible/Theoretical Risk • Receiving fellatio/cunnilingus • Performing fellatio/cunnilingus with barrier • Anilingus • Fingering, fisting • Vulva-vulva rubbing • Docking • Taking breast milk into the mouth • Using drugs with shared pipe or straw • Sharing toothbrushes/razors • Fighting

30. No Risk • Kissing (no visible blood) • Non-insertive masturbation • Receiving unshared sex toys • Injecting with new needles

31. WARNING: Spermicide and Condoms • Spermicidally-lubricated condoms should not be used*. • They provide no extra (statistically significant) protection against pregnancy than regularly-lubed condoms. • The N-9 (spermicide) inflames the vaginal and rectal mucosa and can increase the chance of acquiring HIV should the person be exposed to HIV after using N-9 • The WHO and CONRAD have called for the removal of these products, and all but Trojan volunteered to stop making these products

32. HIV and the Criminal Code

33. HIV & the Criminal Law: An Introduction R.v.Currier (1998) People living with HIV can be found guilty of a criminal offence if they fail to disclose their HIV status before engaging in behaviours that pose a “significant risk” of HIV transmission to another person. Aggravated Sexual Assault (max. life imprisonment) Transmission not required (“Attempted”)

34. HIV & the Criminal Law: An Introduction “Significant risk” is where things get hazy. It definitely includes unprotected anal or vaginal sex (the details of the case). It MAY mean lower risk activities like unprotected oral sex, or protected anal or vaginal sex. The supreme court in 1998 said that “the consistent use of condoms may so reduce the risk that the duty to disclose would not arise” They also hinted that if a person feared violence upon disclosing their status, the duty may not arise Each case would need to be examined on its own merits

35. HIV & the Criminal Law: An Introduction • An assault charge requires no consent • The majority opinion stated that not disclosing a significant risk of transmission was fraud and therefore vitiated consent • Some justices were very concerned about the use of a “broad” statement (like significant risk) rather than a clear line as it could trivialize the charge of assault • If someone doesn’t disclose they are married or lies about birth control, does that mean the consent is vitiated and the act is assault? They argued for a clear line in the sand. Condoms? We won’t prosecute

36. Criminal charges laid (1989 – 2007) Canadian HIV/AIDS Legal Network, 2008.

37. Sex of accused and complainant Canadian HIV/AIDS Legal Network, 2008.

38. Changes in HIV Science since 1998 • We better understand the realities/risks of transmission: • Viral Load / Treatment • How effective condoms really are (hint: very)

39. Recent scenarios in case law • An appeals court acquitted an HIV+ gay man who had unprotected anal sex (he received/bottomed). • The judge found the science showed a risk for that particular activity and with his particulars a risk of 0.12% chance of transmission • Judge found that was NOT significant risk • Case is being appealed to SCC

40. Recent scenarios in case law • Condom Use • Most cases/judges/appeals courts have concluded that condom use reduces the risk to such an extent that the duty to disclose does not arise (not sufficient to convict) • Oral Sex • Fewer cases; one case found that unprotected oral sex on an HIV+ man low risk and therefore not enough for the duty to disclose • Aziga case (Hamilton) jury did convict; however, not the best case to differentiate as there was other egregious behaviour that they were distracted by

41. Why this is a problem • Unfair/Inconsistent treatment across Canada • Misuse of the charge (Mabior) • Will do nothing to prevent further HIV transmissions; criminalizing only makes society less safe • Drives people away from being tested • Ignores the responsibility we all have to protect our own sexual/reproductive health • Creates a false sense of safety