HIV/AIDS

Human Immunodeficiency Virus: HIV

About the disease 

Human Immunodeficiency Virus: HIV


by Meredith Maxey [Honors Tutorial college/BIOS]

References

According to WHO and UNAIDS…

38.6 Million Living With AIDS

Picture:  African man with  AIDS  Source    

 
HIV History
  • 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 Infection
  • 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.                                      
      Picture Source

  • 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.

Stage I – 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
Epidemiology: 
Click Here

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

Graph Source

2) Family 

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

4) Education

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

2)   Asymptomatic

  • Lasts around 10 years
  • Virus continues to replicate
  • Decrease in CD4 count (from 1000 cells/microliter of blood in uninfected adults)

3)   AIDS              

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

Survival
  • With treatment ~ 5 years
  • Without treatment ~ 9 months
HIV Transmission                                        

   Picture Source     

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

HIV Prevention
  • ABC Approach: Abstinence, Being faithful to your partner, Condom use             

Picture Source

  • 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
HIV Treatment

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)

Picture Source

 

UNAIDS/WHO

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

Key components

  • 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  

Some standards:

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.
Other initiatives:     

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

Denial/Misconceptions 

                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.

Stigmatism

  • 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 +

Gender Inequality

  • In a male dominated society, many women don’t feel like they can use condoms.

Sexual Abuse and Rape

 

Other National Concerns
 
 
 
 
 
 
 
 
 
 
 
 
 

Above right:  Child with HIV   Source
Above left:  Child orphaned by AIDS  Source