Human Immunodeficiency Virus: HIV
About the disease
Human Immunodeficiency Virus: HIV
by Meredith Maxey [Honors Tutorial college/BIOS]
According to WHO and UNAIDS…
38.6 Million Living With AIDS
Picture: African man with AIDS Source
- Thought to have a primate origin, although there is no consensus on how it jumped to humans
Earliest Cases of Infection
1959 - Plasma sample from an adult male (Democratic Republic of Congo)
1969 - Tissue sample from a 15 year old African-American in St. Louis
1976 - Tissue sample from a Norwegian sailor
1981 - CDC officially recognized the epidemic; it was originally named GRID (gay-related immunodeficiency)
1982 – CDC renamed the disease from GRID to AIDS (AutoImmunoDeficiency Syndrome) after it was realized that half of the people with the disease were not homosexual
HIV is a retrovirus. This means that the virus has an enzyme called reverse transcriptase that can make DNA from its RNA; then it can use another enzyme (integrase) to integrate the DNA into the host’s genome.
- There are two strains of HIV: 1 and 2. HIV 1 is responsible for the majority of cases, HIV 2 is largely confined to West Africa
- HIV attacks the human immune system. CD4 cells are necessary for proper immune function; they activate all other immune system cells. HIV can indirectly and directly kills CD4 cells.
- Threshold for AIDS classification is when the individual has fewer than 200 CD4+ T cells
HIV Life Cycle
In a nutshell…
- HIV infects CD4 helper T cells
- HIV material enters cell
- Copies RNA to DNA
- Integrates into the host genome
- Under certain conditions, the genes are transcribed into viral RNA
- Some viral RNA incorporated into new virus particles
- Virus particles are released from the cell
- Cycle Source
There are three ways to diagnose HIV:
1) WHO Disease Staging System: HIV-1 Infection and Disease (1990)
- There are four stages in this system.
– asymptomatic; not categorized as AIDS
Stage II – minor symptoms such as recurrent upper respiratory infections
Stage III – more severe symptoms such as unexplained chronic diarrhea, severe bacterial infections, tuberculosis
Stage IV – indicators of AIDS such as fungal infections, Kaposi’s Sarcoma, and toxoplasmosis of the brain
Picture: Kaposi's Sarcoma Source
2) CDC Classification System
- Expanded the classification of AIDS in 1993 to include having a T cell count below 200 per microliter of blood.
3) HIV Tests
ELISA and Western blot assay
- ELISA can sometimes give false positives
- Detects HIV antibodies
- It can take 6-12 months to test positive
- Some commercially available tests that aren’t specifically approved for diagnosis
HIV/AIDS in Africa
24.5 million people currently living in Africa with HIV/AIDS
2.7 million new cases in the past year
2 million killed in the past year
Major Impacts of HIV/AIDS
1) Life expectancy
If the “bread-winners” of the family become ill, then there will be no income. Also, those that are supposed to be making a living may not be able to if they are forced to stay home and care for the sick individual. Furthermore, there are oftentimes multiple members of households that are sick. This leads to the sick caring for the sick – not everyone will get the care they need. Also, children frequently get the disease from their parents. Or, they might have been orphaned by AIDS -- and in the process had to watch their parent suffering. Family structure is affected in this way because children will be left caring for other children.
Picture: African family Source
3) Health care
Healthcare workers are getting the disease at the same time that more healthcare workers are needed! This means, among other things, that there aren't enough workers to distribute medications. Also, there will be a decrease in care available for opportunistic infections
Picture: Education and HIV -- A vicious cycle Source
5) Labor & Economy
AIDS has a domino effect (as shown in the family and education impacts). AIDS prevents people from working, which harms the economy. If the economy is sufficiently weakened, it makes the country less able to cope with the problem. The vast majority of people with AIDS are between 15-49 years old – the working class! The increased mortality rates also results in a smaller skilled population and labor force. The increased sick leave for those that are sick, and for their families, decreases productivity as well. Finally, if there is less of a taxable population, there will be reduced resources available for public expenditures like AIDS education. Essentially, AIDS = loss of income + higher medical bills. Interestingly, there has been a correlation found between lowered life expectancy and the lowering of the gross national product.
Picture: African people digging graves for those killed by AIDS Source
HIV/AIDS in South Africa
One of Africa’s wealthiest nations, but as of 2005, only about 21% of people were receiving the treatment they need…
History of HIV in South Africa
Map: South Africa Source
1982: First recorded case in South Africa
1990: 0.8% of pregnant women were HIV positive
1991: Homosexual HIV + = heterosexual HIV +
1992: Government makes first response; NACOSA (National AIDS Convention of South Africa)
1993: 4.3% of pregnant women were HIV positive
1994: Minister of Health accepted a criticized NACOSA strategy
1995: International Conference was held in South Africa
1996: 12.2% of pregnant women were HIV positive
1997: 17% of pregnant women were HIV positive; national review of leadership was conducted
1998: TAC (Treatment Action Campaign) formed; 1500 new infections daily Logo Source
1999: 22.4% of pregnant women were HIV positive
2000: Dept. of Health outlined a new plan
2001: 24.8% of pregnant women were HIV positive
2002: High Court ordered that ARV (anti-retroviral) drugs be available to pregnant women
2003: ARV treatment for all public plan was made; 27.9% of pregnant women were HIV positive
2004: ARV drugs were supposed to become widely available
Treatment of HIV/AIDS
- ARV = Anti-RetroViral drugs
- Treatment Action Campaign – led by Zackie Achmat
Picture: Zackie Achmat with Nelson Mandela Source
Achmat had HIV, but refused to take ARV drugs until they become publicly available. His main argument was that ARV/prevention costs were less than the costs of an unchecked AIDS epidemic. In 2003, the TAC even laid homicide charges against the health minister. They claimed she was responsible for all the deaths due to lack of access to ARV.
Government Funding – Main problem facing South Africa was that the government was divided on how to deal with the issue. Since they weren’t united, it took a long time to set up any governmentally supported programs. As a result, even though South Africa is a wealthy county, it is behind when dealing with HIV/AIDS. For example, 400,000 people were supposed to be on ARV by 2005-2006 – only about 80,000 were. It is estimated that only 20% are receiving the treatment they need.
Prison debate – Studies in 2005 suggested that as much as 50% of inmates were HIV positive. Yet, many had no access to ARV drugs. In 2006, inmates even initiated a hunger strike to raise interest and bring attention to the issue of medicating the prisoners.
What’s Necessary for Progression?
- Stabilized government programming and planning
- Altered social climate
- Increased ARV availability
HIV Symptoms and Complications:
3 stages of HIV:
1) Primary HIV infection:
- HIV replicates rapidly
- Flu-like symptoms
- One to two weeks
- Lasts around 10 years
- Virus continues to replicate
- Decrease in CD4 count (from 1000 cells/microliter of blood in uninfected adults)
Image: X-ray of an individual with Pneumocystis jiroveci pneumonia Source
- Opportunistic infections begin to set in after CD4 count has dropped below 200
- Pulmonary: Tuberculosis, Pneumocystis jiroveci pneumonia
- Gastro-intestinal: inflammation of linings due to fungus/virus/mycobacteria, parasitic infections
- Neurological: toxoplasmosis, progressive multifocal leukoencephalopathy, AIDS dementia complex, cryptococcal meningitis
HIV-associated malignancies: Kaposi’s sarcoma, Epstein-Barr virus, human papilloma virus, cytomegalovirus
Image: Toxoplasmosis in brain Source
- With treatment ~ 5 years
- Without treatment ~ 9 months
3 main transmission routes
1) Sexual contact – majority of new cases
2) Exposure to infected body fluids/tissues (can occur when sharing syringes or needles, or during blood transfusions)
3) Mother to fetus during childbirth and via breastmilk
- ABC Approach: Abstinence, Being faithful to your partner, Condom use
- CNN Approach: Condom use, Needles (use clean ones), Negotiating skills (between partners)
- Don’t share needles or syringes
- Sterilize needles
- Wear latex gloves
Mother to Child Prevention
Picture: Administration of ART drugs to a newborn Source
- Administer anti-retroviral drugs after birth (lowers transmission risk from 25% to 1%)
- C-section delivery
- Formula feeding
NO VACCINE OR CURE!
Only preventative methods and antiretroviral treatment:
Post-exposure prophylaxis (PEP)
Highly active antiretroviral therapy (HAART)
including nucleoside analogue
reverse transcriptase inhibitors (NARTIs) and non- nucleoside reverse transcriptase inhibitors (NNRTIs)
United Nations Programme on HIV/AIDS
World Health Organization
More than 75 countries involved through these two organizations with the mission of uniting the world against AIDS.
Prevention of HIV
- Condom use
- Counseling/testing: VCT (voluntary counseling and testing centers)
- Treatment for mother/child
- Treatment of HIV/AIDS
- Antiretroviral drugs (ARV)
*Senegal is a good example of how effective early and sustained prevention efforts can be. Less than 1% of Senegal’s population has HIV/AIDS. Uganda also is a good example. They went from 15% to 5% of the population with HIV/AIDS in about ten years. Picture Source
What’s necessary for improvement?
- 4 main things that need to be accomplished
1) Gain international support
- The WHO has a set a target for everyone to have access to treatment by 2010
- The US is helping via PEPFAR (President’s Emergency Plan for AIDS Relief)
2) Ensure a domestic commitment
3) Reduce stigma/discrimination
4) Focus on women/girls and gender inequality issues
How about some numbers?
Countries with 5-10% of population infected:
- Kenya, Uganda
Countries with 15-20% of population infected:
- South Africa, Zambia
Countries with over 20% of population infected:
- Botswana, Lesotho, Swaziland, Zimbabwe
South Africa is a good example to look at because it is a wealthy country with a significant HIV/AIDS burden.
Picture: South Africa Source
Prevention of HIV
Diverse population = difficult to influence
Voluntary Counseling and Testing Centers
Picture: VCT sign I photographed during my travels in Africa
New Prevention of Mother to Child Transmission (PMTCT) centers
- There are now over 18 of these in South Africa. There is still debate on how many women are actually receiving treatment though. In 2004, the South African government said that 79% of women were getting the drug. But in 2006, UNAIDS found that only about 14.6% of women were being treated.
Picture: HIV Awareness Supporters Source
LoveLife – Geared towards the “younger crowd” It is the most prominent campaign in South Africa. However, in 2005, Global Fund withdrew support from the campaign.
GASA 6010 – A gay men’s association; it is a counseling/medical service aimed at bar and club go-ers.
ACT —Set up in 2001 by the government, it was supposed to educate people on the dangers of HIV
Barriers to South African Efforts
Picture: Thabo Mbeki Source
Including the misconception that AIDS can spread through casual contact and that sexual intercourse with a virgin will cure AIDS. For a long time, Thabo Mbeki, the President, argued that HIV did not cause AIDS. He also claimed that the ARV drugs were unsafe. Not until 2002 did the government actually acknowledge that their efforts would be based on the premise that HIV causes AIDS.
- Instrumental AIDS stigma; results from fear or apprehension that is associated with any deadly/transmissible disease.
- Symbolic AIDS stigma; deals with the use of AIDS to express feelings about lifestyles that are supposedly associated with the disease
- Courtesy AIDS stigma; stigmatism associated with people connected to the issue of AIDS, or those that are HIV +
- In a male dominated society, many women don’t feel like they can use condoms.
Sexual Abuse and Rape
Other National Concerns