Module 17 : HIV and AIDS Lecture 27 : HIV and AIDS HIV and AIDS We will begin this chapter by reviewing the history of HIV and AIDS. Then we will go on to describe what is HIV and AIDS and the distinction between the two. Then we will discuss the risk factors and prevention strategies. We will review some successful treatment and prevention programs. Finally we will discuss the HIV-AIDS situation in India.Then we will discuss the HIV-AIDS situation in India. And in the last section we will consider the psychological impact of HIV and AIDS on the individual. History of HIV (Adapted from Avert 1986-2013) By 1980 HIV had spread to North America, South America, Europe, Africa and Australia. This is know as the period of silence as the disease spread quietly and had no name. In 1981 in New York city an aggressive form of Kaposi s Sarcoma (benign cancer in older men) was found among young gay men and simultaneously there was an increase in incidence of a rare lung infection called Pneumocystis carnii pneumonia (PCP) in California and New York. The Center for Disease Control published a report about this and this is often referred to as the beginning of the awareness of HIV. A task force on Kaposi s sarcoma and opportunistic infections was formed. At first it was presumed to be restricted to the gay community as all the patients were gay, it was called GRID (gay related immune deficiency) and was believed to be transmitted through the sexual route. However by 1982 reports of the disease among Haitians and Haemophiliacs disabused the notion of a gay disease. The acronym AIDS (Acquired Immune Deficiency Syndrome) was defined by the CDC in 1982 September. When a 20 month old child died of the disease after receiving multiple blood transfusions, the role of blood as a carrier of the infection became clear and the safety of blood supply became a concern. Meanwhile in Uganda, a fatal wasting disease called slim was being observed. There was increasing concern about transmission, and the disease began showing up among heroin addicts and sex workers. Since there were different diseases it was difficult to make the connection, although the CDC had recognized that it was an Immune compromise syndrome it was difficult to gauge it's spread. In May 1983, a new virus named Lymphadenoapthy associated virus was identified and patented as a suggested cause of AIDS and a sample was sent to the National Cancer Institute in the U.S. In Zambia and Zaire, an aggressive form of Kaposi s Sarcoma was resulting in fatalities, that had never happened previously. By 1984, Robert Gallo at the National Cancer Institute isolated the Human Immunodeficiency Virus. However the next step was a commercially viable test to be made available that could be used by the public. By January 1985 a test became available and blood could be tested for HIV. The realization that LAV and HIV were the same came about and Gallo & Montaigner of Pasteur institute are considered the co-discoverers of the virus. What is HIV? HIV is present in body fluids. It can be transmitted in 3 ways By blood transfusions Mother to child transmission at birth or through breast feeding Sexually The viral load is the highest in blood followed by sexual fluids. HIV is a member of the retrovirus family and it enters the host body and uses the host s genome to replicate itself. It attacks the cells of the immune system especially the CD4+ T cells and causes the body to become immune compromised eventually. When the body is in a state of immune compromise the body is prone to opportunistic infections and cancer. Opportunistic infections are infections that are around and we are always exposed to but successfully resist because of the immune system. How is HIV detected? (Adapted from Avert 1986-2013) HIV testing involves using the Enzyme Linked Immunosorbent assay - ELISA, which tests for antibodies (to the HIV) in blood serum. ELISA is 99.5% accurate. If this test is positive it is followed by the Western Blot test which is the most accurate (but is expensive and hence used as a follow up).
The other tests are the Indirect Immunofloroscence Assay which uses a microscope to check for HIV antibodies. The Line Immunoassay is a variation of this test that is used commonly in Europe. In settings where a Western Blot assay is not available then a second ELISA is used to cross check. With the two tests combined the chance of an inaccurate result is 0.1%. For babies the Polymerase Chain Reaction test is used to test the DNA. The Window Period The body takes about 3 months to generate antibodies to the virus after it is infected and in some rare cases it even takes 6 months. Since most of these tests test for antibodies, the test can be used effectively only 3 or 4 months after the exposure. This is called the Window Period as during this time if testing is conducted the results will be negative. When is a person said to have AIDS and how is it different from being HIV+? HIV attacks the CD4+ T cells the most amongst the cells of the immune system. The normal CD4 count is 500 per cubic mm of blood, so if the count falls to below 350 or 250 per cubic mm of blood that is taken as one sign that the body is becoming immunocompromised. The viral load and level of opportunistic infections are also considered before the person is considered as having AIDS. There is no technical point at which a person is declared as having AIDS, but on average it takes about 10 years for a person who has been infected with HIV to develop AIDS. This period can fluctuate depending on many factors, the two important ones are the base health status of the person and the base rate of infections in the environment. All the factors discussed previously in the immune system are implicated here. Nutrition, smoking, drinking, exercise, stress levels, exposure to germs, access to health care thus lifestyle and environment together contribute to the development of the disease after infection. Access to treatment (AntiRetroviral drugs) can prolong this period). If the CD4 count drops this treatment can be started, although it cannot cure or eliminate HIV it retards the growth of the virus. Prevention (Adapted from Avert 1986-2013) HIV cannot be cured it can only be prevented. The risk of infection can be reduced by Awareness & Education Testing & Counseling Treatment Awareness about the infection through media campaigns, health educators, doctors and nurses in the health care setting, at school, in the work place can improve people s understanding about the virus and its transmission. The Education component would aim to educate people on how to minimize risk. Education would include how to avoid getting infected the precautions necessary and knowledge about the illness and its consequences and the available treatment. Testing and Counseling involves providing testing facilities that are free and voluntary. Making testing accessible to all increases the likelihood of people testing themselves voluntarily and taking precautions if they are infected. Testing facilities have to be coupled with counseling services to help people cope with the fact that they may be infected and the situation if they are infected. Counseling helps people realize that a HIV positive result does not mean a death sentence and there is hope and there are things they can do to improve their health and delay the development of AIDS. They also realize the value of not infecting others and containing the disease. The higher the awareness, more people will voluntarily get tested, the more people who know their HIV status the greater will be the containment of the disease. Mandatory testing cannot be imposed and is not the solution. Mandatory testing is both unethical as well as logistically impossible because of the window period. Thus the only way is to educate people and encourage them to utilize the voluntary testing services if they have reason to believe that they might be infected. Testing and counseling needs to be followed by treatment. Centers that provide free Anti retroviral treatment (ART) must be accessible to all, also centers where the CD4+ count can be done must be routinely available. When there is treatment which is easily available then the disease looses the stigma attached to it and becomes just another disease.
Sexual Transmission can be prevented by the ABC program where A stands for abstain, B stands for Be faithful to one partner and C stands for using condoms if you are not faithful. Awareness can be created by media campaigns which can reach a wide audience and these messages need to be continually played to remind people about the issue. Special programs are tailored for specific groups such as drug addicts for whom the risk factors are different, as compared to sex workers who have different risk factors. Programs that are specifically suited to the needs of the group are more effective in the long run. Counseling of small groups is another method used to reach as many people as possible, homogenous groups can be counseled together. Condoms must be made available everywhere and at a very low cost to encourage their use. Thus condom vending machines are now installed at public places. Mother to Child Transmission (Adapted from Avert 1986-2013) HIV can be transmitted during pregnancy, labour and delivery. HIV testing has been made a routine test during pregnancy and thus people may first know of it during pregnancy. However there are ways to deal with it if the mother chooses to go ahead with the pregnancy. There are antiretroviral drugs which can cause a 50% reduction in transmission rate. Having a planned caesarian section reduces the chances of transmission and avoiding breast feeding also improves the chances of reducing transmission. Thus a pregnant mother can take steps to reduce the risk of transmission to the unborn child to some extent. However in practice there are many obstacles at every stage to begin with the mother must receive some form of ante natal care where testing is offered, they must agree to be tested, they must get the results and if they are positive and if they are offered drugs they must be willing to take it and then they should have a safe and viable alternative to breast feeding. If the baby can be administered antiretroviral drugs, then the mother should allow it. Thus at every stage a potential barrier exists that prevents moving to the next stage Success Stories in Dealing with HIV and AIDS (Adapted from Avert 1986-2013) Uganda, Botswana and Thailand are low and middle income countries that have dealt with the AIDS epidemic rather successfully. In Uganda in the nineties about 800,000 people died from AIDS. Houses were empty and grandparents became caregivers to children. To confront this enormous problem the government, NGOs, the church and other faith based organizations and musicians came together and a multipronged approach was used. Innovative approaches were used to break down stigma people living with HIV & AIDS became peer educators and what was perceived as their problem was reframed as our problem. The issue of HIV was brought into the mainstream. Voluntary testing and counseling centers were established and treatment facilities with ART were accessible and free. With the availability of ART the perception that AIDS is a death sentence gradually changed and the issue became part of the mainstream. Once something is in the mainstream it is always easier to address. In Thailand, the sex industry posed a large threat however the government addressed it with a campaign for 100% condom use. Condoms were distributed free in the red light areas and a norm of condom use was developed through media campaigns. Condom use rose over a 5 year period and the number of new infections reduced. However with time the funding reduced and complacency developed which resulted in a slight rise in the number of new infections. Thus a continuous vigil needs to be maintained to keep the number of new infections as low as possible. In Botswana the government recognized the magnitude of the problem in the nineties and was quick to act by providing testing and free treatment it was the first country to provide ART to all its citizens and is an example for the other African nations. Thus low and middle income countries with limited infrastructure and healthcare have also managed to address and to some extent contain the spread of the disease. The Situation in India (Adapted from NACO, 2007) Untill 1986, there were no cases of HIV reported but the first case was reported in Tamil Nadu of a sex worker and was probably due to sexual contact with a foreigner. There was a demand to test all foreigners entering the country at that time, although it did not happen. In 1987 the National Aids Control Program (NACP) formulated and testing was provided and then of 52,907 people tested 135 people were found to be infected. From that point on through the nineties the infection spread widely
and rapidly and in 1992 the government set up the National Aids Control Organization (NACO) to plan prevention and treatment and State Aids Control Societies were also set up. Through the nineties the infection spread from high risk groups (sex workers and their clients and injecting drug users) to the mainstream population. Surveillance sites were set up at STD (sexually transmitted disease) clinics and at ANC (Ante natal care) clinics in all the districts and testing was carried out to estimate of the number of infections. Current estimates indicate that we have about 2.4 to 3 million HIV infections and even a point increase translates into large real number given the huge base population. We now rank third for the largest number of people living with HIV. The highest numbers are in Andhra Pradesh and Tamil Nadu followed by Karnataka and Maharashtra and the North Eastern States of Manipur and Mizoram. The main route of the disease is from sex workers and their clients who are the bridge population and transmit the disease to their wives and unborn children. The focus of the NACP is on awareness and health education and setting up VCTCs and centers for CD4+ count and ART which are accessible to all. However more than 50% of the estimated HIV infected are probably not aware of their status (given that it is a estimation). And treatment is also not available to all (probably less than half) and there is no palliative care being provided to those in the terminal stages of the disease. The public health scenario in India is rather bleak with poor access to health care, inadequate medical personnel, poor base health levels, high levels of infection, poor hygiene and sanitation. Thus the prognosis for those with HIV among the lower SES is not very good and hence given the situation and the large population a gigantic effort at prevention needs to be in force. Sex education in schools must be made compulsory. Preventive education at the work place would help to create a sense of self efficacy in people rather than fear and allow people to take the right precautions to protect themselves and their families. (This section is adapted from Taylor, S. E. (1995). Chapter 15 in Health Psychology (3rd ed). New York: McGraw Hill.) Individual Behavior We have discussed HIV from a public health perspective, but at an individual level- how risky sexual behavior can be changed is addressed by interventions. Knowledge about HIV and transmission is the first step, however knowledge does not necessarily translate into safe sexual behavior. A feeling of vulnerability along with perceived self efficacy about one s ability to control one s sexual behavior predicts actual behavior. Research (as cited in Taylor, 1995) indicates that self efficacy beliefs are the most important predictor of sexual behavior. The theory of reasoned action has been used somewhat successfully, to predict condom use and other safe sexual behaviors, as the theory considers attitude and subjective norms (norms of important others). Sexual behavior is very private and especially in India it is difficult to bring a discussion about sexuality into the mainstream. HIV to be addressed effectively needs to be brought into the mainstream. To change the behavior in the case of such private behavior is difficult. Interventions that enhance safe sexual behavior, teach people to be self aware about the meaning of the sexual relationship in their life, to exercise control in having sexual relationships and resist pressure in engaging in unsafe or risky sexual behaviors by negotiating with their partners (about using condoms for example). These skills are taught through modeling, role playing and feedback (Kelly et al as cited in Taylor, 1995). Behaviors that are associated with risky sexual behavior such as drinking and drug use also need to be addressed as they are often the triggers for risky sexual behavior. Research indicates that appeals to different groups have to be sensitive to their value systems and culture thus for some groups upholding family responsibility may be more effective than individual health and well being. Coping with the HIV status and AIDS People react to testing HIV positive with distress but there is research that seems to indicate that people are able to cope (Kessler et al, 1988 as cited in Taylor, 1995). Counseling at this stage helps people to take charge of their life and get some perspective. An HIV positive diagnosis is no longer a death sentence and people are counseled to lead a healthy lifestyle to improve their chances of delaying the development of AIDS. Research indicates that perceptions of personal control were associated with
better adjustment to AIDS (Weitz, 1989 as cited in Taylor, 1995). Of those who were able to survive longer with AIDS, active coping strategies were found to be used (Solomon et al, as cited in Taylor, 1995). Social support plays an important role in the lives of people with AIDS. Those with better practical, emotional and informational social support seemed to cope better and were less depressed (Hayes et al, 1992 as cited in Taylor, 1995). In India, wives infected by their husbands often continue to live with the husband and care for them through their illness. This brings us to the issue of caregivers of AIDS patients and especially those who are also HIV positive. It becomes a tremendous strain for them and may affect their health. Support groups for caregivers may help them air their frustration and deal more effectively with the situation. References Avert (1986-2013). Last accessed September 24, 2013 from http://www.avert.org/ National Aids Control Organisation (2007). Last accessed on September 24, 2013 from http://www.naco.gov.in/naco/nacp-iv/ Taylor, S. E. (1995). Health Psychology (3rd ed). New York: McGraw Hill.