Time to Prepare for “PrEP”

It all began with a 1994 study that showed antiretrovirals given to HIV-positive pregnant women before and during childbirth – as well as to the child upon delivery – reduced the risk of mother-to-child HIV transmission by 50%. Next were the post-exposure prophylaxis guidelines issued by the Center for Disease Control and Prevention in 1998, recommending an antiretroviral regimen for healthcare workers after unintended HIV exposure. Then, 2006 brought exciting data gleaned from a study of monkeys who remained uninfected after repeated exposure to a HIV-like virus as a result of taking the antiretroviral drugs tenofovir and emtrictabine. These studies raised the question: Can drugs prevent HIV? After recent unimpressive results in vaccine and microbicide tests, scientists’ leading hope for stopping HIV infection before it starts seeks to answer that question with pre-exposure prophylaxis, or PrEP.

By the middle of next year, close to 15,000 individuals will be enrolled in PrEP trials. That’s more people than all HIV vaccine and microbicide trials combined. In the PrEP approach, an oral antiretroviral agent (specifically, Viread or Truvada) is taken daily to prevent HIV infection. In theory, this method inhibits HIV replication and permanent infection from the moment the virus enters the body. If proven safe and effective, PrEP could significantly reduce the risk of HIV infection for high-risk individuals all over the world. It would be particularly advantageous for individuals in serodiscordant relationships as well as those unable to negotiate other proven protective measures such as condom use. Perhaps most importantly, PrEP would represent the first female-initiated intervention method.

Currently, three studies conducted by the CDC are underway to test the safety and effectiveness of PrEP. In Thailand, injection drug users are using once-daily Viread. In Botswana, young heterosexual men and women are taking once daily Truvada, and in the US, once-daily Viread is being tested among men who have sex with men.

PrEP is quickly becoming a reality. Over the course of 7 years, the CDC will spend an estimated $53 million researching PrEP. Most importantly, the CDC has recently urged public health leaders to begin planning for PrEP implementation. The time has come to discuss the optimal use and delivery of PrEP if found effective. PrEP raises particularly challenging questions that need attention now. How will we ensure that individuals use PrEP in concert with other proven preventative strategies? Some people may refuse to use condoms if they learn that their partner is taking PrEP and, theoretically, protected from HIV transmission. No single strategy will likely be 100% effective against HIV infection, and reducing transmission will require integration of all biomedical and behavioral methods. How will healthcare providers ensure that PrEP is used before exposure, and not after infection, to prevent drug-resistant HIV? Who exactly would be prescribed PrEP? Would people be required to prove that they are at "high risk," and if so, will that lead to their being stigmatized? What will happen if an individual disregards instructions for daily use and takes the pill before a night on the town? Will this ineffective so-called “disco dosing” become rampant? Already, rumors are emerging of new drug cocktails of Truvada, Viread, Viagra and Ecstasy that are being sold in gay dance clubs.

Clearly, this new strategy will not be a panacea for the difficult issues involved in the HIV pandemic, including stigma, the sexuality of young people, drug use, homophobia and the sex industry. PrEP may one day be an important response to AIDS, but that response will never be equitable nor ultimately successful unless we begin planning for it now.

I’m Charlotte Steelman. Thanks for listening.

New Leadership in South Africa brings hope for AIDS Reform

72% of the 5.5 million South Africans who are HIV-positive are in need of antiretroviral (ARV) drug treatment. In leading the movement against ARV drugs, recently removed South African President Thabo Mbeki denied millions of his people HIV treatment. He believes that the AIDS pandemic was created by Western pharmaceutical companies to take advantage of Africans and maximize their profits. Mbeki also sides with dissident scientists in denying that the HIV virus causes AIDS and in 2003 he was quoted as saying, “Personally, I don’t know anybody who has died of AIDS” and when asked if he knew anyone infected with HIV he responded, “I really, honestly don’t”. Mbeki’s views opposing antiretroviral drugs were echoed by his Health Minister, Manto Tshabalala-Msimang, more commonly known as “Dr. Garlic”, who promotes garlic, olive oil, beetroot, and African potatoes as a cure for AIDS.

Because the South African government has been reluctant to supply its people with antiretroviral drugs, HIV/AIDS activist groups, such at the Treatment Action Campaign (TAC), have been instrumental in the push to allow the distribution of these drugs. It was not until 2004 that the South African government, pressured by HIV/AIDS activist groups, finally began to provide ARVs for its people. It also took a Constitutional Court battle and much lobbying from the TAC to compel the Health Department to allow the administration of AZT and nevirapine to HIV-positive pregnant women to prevent mother-to-child transmission of the virus.

However, the recent resignation of Mbeki as President of South Africa and the September 25th appointment of the ruling African National Congress (ANC) deputy head Kgaleme Motlanthe as interim president, give HIV/AIDS activists hope for change. His first day in office, Motlanthe demoted “Dr. Garlic” to a less important Cabinet position and appointed Barbara Hogan, a senior ANC member of Parliament, as Minister of Health and Dr. Molefi Sefularo as Deputy Minister of Health. The TAC applauded Motlanthe’s change in administration and issued a statement in support of the new appointees. The TAC credits Hogan as being “one of the few Members of Parliament to speak out against AIDS denialism and to offer support to the TAC” and cites Dr. Sefularo as supporting “ARV rollout and the implementation of the Prevention of Mother to Child Transmission” at Health of North West Province.

Hogan has already promised to “champion the issue” of the government increasing spending on providing ARVs to HIV-positive individuals. In an interview just hours before being sworn into office, Hogan was quoted as saying, “I would thoroughly endorse the roll-out of anti-retrovirals and any way that we can accelerate that, the better”.

Looking ahead to the next president’s administration, in the most recent edition of the ANC newsletter Jacob Zuma, current ANC President the expected future South African President, is quoted as wanting “more action with regards to the reduction of HIV infections…widespread HIV prevention, treatment and support programmes”. Yet, Zuma’s infamous statement during his 2006 rape trial that he showered after intercourse with a HIV-positive woman to minimize the risk of becoming infected lingers in the back of my mind. I question that how such change can be implemented when South African government officials still need to be educated about how HIV is transmitted and how to reduce their risk of infection.

World AIDS Day – The Power of One

Today is the 20th annual World AIDS Day, a day set aside to remember those who have died of HIV/AIDS and those who are living with HIV/AIDS. It’s also a day to remind ourselves that we all are affected by this disease. Today, many of us are wearing red ribbon pins. Many of us have placed red ribbon photos on social networking sites. Many of us will be attending HIV/AIDS breakfasts or seminars. Many of us are blogging about HIV/AIDS.

Do any of these events really matter? Roughly 35 million people worldwide are infected. 14,000 people become newly infected every day. Will wearing a red ribbon or attending a breakfast change that? Sometimes, the pessimist in me says no. But then I look around at the various activities going on and think differently. Never underestimate the power of small actions. Never underestimate the power of one.

At Davidson College, groups of students are making a difference. For several years now, the members of Warner Hall, a women’s eating house at Davidson, have hosted the Red and Black Ball, a charity event for HIV/AIDS. This year, the proceeds will benefit Metrolina AIDS Project in Charlotte and Thyatira
Hospital in Mwandi. The members of Warner Hall also help Metrolina AIDS Project in other ways. Recently, I joined them on a Saturday morning to make condom packets – small bags containing condoms and information about getting tested for HIV – to be distributed at local bars and clubs.

Students at Davidson College make condom packets for Metrolina AIDS Project

This effort, though, is not solely an extracurricular activity. In a mutually beneficial partnership, the students in my Biology course on HIV/AIDS cooperate with Warner Hall on some of these projects. Together, we have sponsored screenings of movies like 3 Needles, volunteered at a local HIV/AIDS benefit triathlon, collected toys for the annual Metrolina AIDS Project holiday party, and organized speakers and symposia. Academic and extracurricular activities are wonderfully joined.

Volunteers getting ready for their assignments at a triathlon to benefit Metrolina AIDS Project

None of these events, individually or even in total, will end the AIDS Pandemic. But each and every one of these events does make a difference. Maybe one person will receive a condom packet and, as a result, not become infected. Maybe the money sent to Mwandi will help provide care for a child in need. Maybe one person who listens to a seminar will enter a career of public service. Maybe all of us will be a little more aware.

Today, I’m wearing my red ribbon. Today, I’m blogging about HIV/AIDS. Today, I’m attending an HIV/AIDS breakfast. Today, in some small way, some almost imperceptible way, I’m making a difference. We all can make a difference. Never underestimate the power of one.

The role of concurrent relationships in the spread of HIV in Africa

I'm Courtney Sanders.

According to the 2008 UNAIDS Report on the Global AIDS Epidemic, countries in Sub-Saharan Africa continue to bear a disproportionate share of the global HIV/AIDS burden. In all, an estimated 67% of people living with HIV reside in Sub-Saharan Africa. In 2007, three-quarters of all deaths resulting from AIDS occurred in Sub-Saharan Africa. Though the first HIV cases in the United States were noted in 1981, HIV was not seen in African countries until the late 80s. From its first appearance, the infection rate has soared with unequivocal momentum. Currently, the infection rate in Sub-Saharan Africa falls in the range of 15-28%. Just to give you a point of comparison in understanding the magnitude of this statistic, the HIV infection rate in the United States has never exceeded 1%.

Nevertheless, public health officials will never be able to tackle the problem in Africa using methodologies which have proven successful in the United States. Rather, they must craft a solution tailored specifically to causes of the epidemic in Africa. With the statistics which I mentioned above, I think that we can all agree that there is more to the problem than simply poverty. There are a number of theories which have been proposed in trying to explain the astronomical infection rate, the majority of which pertain to African sex practices.

One theory, which initially seemed quite logical hypothesized that African people had a unique “sexual system” which was characterized by high rates of casual and premarital sex. Though this theory initially seemed intuitive given the polygamous traditions and the cultural pressure to bear many children, it gave rise to much controversy. Contrary to many stereotypes regarding African sexual behavior, studies have shown that Africans are no more promiscuous than men and women in the Western world. Children in Africa, Europe and the United States usually become sexually active around the same age—late teens. In addition, African males usually report fewer lifetime sexual partners than do heterosexual men in the west. Because African heterosexual men and women are no more promiscuous than men and women in the west, this theory raises doubt.
Another theory supposes that Africans’ weakened immune systems as a result of malnutrition and infection (common among the poor) cause them to be more vulnerable to HIV infection. This theory received attention in the wake of a study in 2006 which discovered that malaria enhances the transmission of HIV. The major weakness in the theory is that it does not explain why many poorer countries have lower rates of infection. For example, the supposition fails to explain why some of Africa’s most impoverished, worn-torn and parasite-infested countries like Ethiopia and Somalia have lower rates of infection than the richer, more peaceful countries like Botswana and Zambia.

The most widely accepted theory for explaining Sub-Saharan Africa’s disproportionate share of the global AIDS burden is the model of “concurrent partnerships.” Literature defines concurrency as having “multiple relationships which overlap in time.” According to many informed sources, having many ongoing relationships at one time is fairly common among African men and women, regardless of their marriage status. Unlike the “serial” or “sequential” nature of sexual relationships common to polygamous men and women in the United States, African men and women may have sex with the same man or woman in addition to their marriage partner for a lifetime. The serial nature of the sexual practices in the United States may actually help to protect men and women from contracting the virus since the likelihood of infection when having sex with an HIV positive person is only about 1 in 100 acts.

The theory of concurrency has been defended by numerous studies and was even touted in the most recent edition of the UNAIDS Report on the Global AIDS Epidemic. A few studies, the first of which debuted in 1992, attempt to use mathematical modeling to investigate the effect of concurrency on the prevalence of HIV infection. The majority of these studies have concluded that, when the number of sexual partners is held constant, concurrent relations are associated with higher rates of HIV infection than serial relationships. According to one author, these concurrent relationships are incredibly dangerous since they “link people in a giant web of sexual relationships that create ideal conditions for the rapid spread of HIV” (from The Invisible Cure by Helen Epstein).

Recognizing how exactly the sexual practices of Africans contribute the incredible rate of HIV/AIDS infection in Sub-Saharan African is a vital part of implementing a successful plan to combat the pandemic.

The reality of HIV/AIDS: It hasn't gone away

In a recent episode of the television show South Park, one of the main characters is infected with HIV. In an attempt to find a cure, he must continually deal with the public opinion that AIDS is no longer a threatening condition. He is told that his disease is “a disease of the 80s and 90s” and even that he is “retro” for being infected with HIV. But has this retrovirus truly become retro to Americans? If we take South Park as a social barometer, then it seems that the disease has been marginalized in the public eye. Public interest on the Internet regarding AIDS is declining as well. A recent government blog about Google search hits for the terms “HIV” or “AIDS” shows a declining trend over the past four years. Each year, fewer people searched for the terms “HIV” or “AIDS” on December 1st (World AIDS day) than the previous year. Why has the US public marginalized this disease, which twenty years ago was the terror of the nation?

Searches for “AIDS” and “HIV” have decreased for four years running now. Have Americans stopped caring about this disease? Photo courtesy of Google, Inc.

A simple reason may be that the media sensationalism of the disease has settled down. As people become accustomed to news, it ceases to be news, no matter how horrible the reality of the situation may be. The early media coverage of the AIDS epidemic focused on the fact that the disease seemed to infect only gay men. Some even believed that AIDS was the punishment for the lifestyles of gay men, and AIDS became known as the “gay cancer” by many after its initial discovery. In this way, AIDS aided U.S. society in demonizing the gay population in the early 1980s. AIDS was deemed a gay problem, and the rest of society could forget about it. Ryan White’s struggle against the disease helped dispel some of these myths, but many fallacies have persisted regardless, even to the present day. Many choose to ignore the AIDS epidemic, as they believe that they will not come in contact with the disease if they are not homosexual.

AIDS may also be ignored because its prevalence in the U.S. is perceived to be decreasing. In South Park, the public seems surprised when the main character is newly infected with AIDS. In many regions of the U.S., taboo prevents open discussion about AIDS, and if people aren’t hearing about a problem, they tend to imagine that it is going away. In reality, 56,000 new cases of AIDS are diagnosed in the U.S. every year. This figure only represents the number of cases detected; the true occurrence is likely higher. Why does the public believe, then, that AIDS is on the decline?

The apparent decrease of infection rate is caused by the fact that infected individuals generally live longer and healthier lives than they would have in the 80s, when the average lifespan following diagnosis was approximately three months. This fact is largely due to the success of many drugs in delaying the onset of AIDS after exposure to HIV. AIDS advocates are victims of their own success, then, as the myth has arisen that AIDS will no longer kill infected individuals. This belief is wrong; AIDS is a lethal disease. Drugs do a great deal these days to slow its progress, but HIV has the uncanny ability to develop resistance to these drugs and overwhelm the body’s immune system, which invariably leads to death.

One additional aspect of fading public interest in AIDS, sadly enough, may be the lack of infection of a public figure. The movie star Rock Hudson was a famous AIDS victim in his time, and his death helped shock the nation into action against HIV. Rock Hudson is relatively unknown by today’s youth, who grew up after the passing of the star. These days, when most people think of celebrities with AIDS, Magic Johnson is the first name that pops to mind. This former basketball superstar retired after being diagnosed with HIV and began working towards a cure for the deadly virus. Indeed, in the South Park episode, the character with AIDS must travel to find Magic Johnson who may have the cure for AIDS. Magic Johnson faded from public view when his basketball career ended. The fact that no Hollywood star or public figure of great significance has recently been diagnosed with AIDS means that the disease is no longer the vogue disease it once was.

Rock Hudson (left) and Magic Johnson (right) are two of the most famous AIDS patients. Neither are well-known by much of today’s younger generation. Photos courtesy of Wikipedia.

As is typical for the satirical style of South Park, the characters discover that the cure for AIDS is to inject large quantities of cash directly into the bloodstream. While there is no real cure for AIDS, the biting commentary of this cartoon is telling. Wealthy AIDS patients, like Magic Johnson, often live the longest and healthiest lives following their infection. Many AIDS patients do not have access to the resources that Magic Johnson enjoys, and are therefore much more susceptible to the disease. The average cost of a year’s supply of antiretroviral drugs is between $10,000 and $15,000, which means that those living near the poverty line with AIDS must devote an enormous portion of their income to their drug regimen. Some of the hardest hit regions of the world with regards to AIDS are also the poorest. Sub-Saharan Africa is among the worst regions, with up to 30% infection rates in the population. The disease is therefore easier to ignore for U.S. citizens, who are more likely to be wealthy enough to afford treatment.

South Park offers one final shot at society, stating, “Americans have forgotten that AIDS is a serious disease.” Decreasing public interest in the AIDS epidemic is apparent, which is unfortunate both for affected individuals and the general public alike. AIDS continues to rage as a fearsome epidemic, and the number of infected individuals continues to grow. Society needs to wake up again and face the reality that AIDS is still here, and is still a terrible disease.

HIV/AIDS in South Africa: Past, Present, and Future

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Kara Earle.

Since the diagnosis of the first case of HIV in 1982, infection rates in South Africa have skyrocketed. It is currently estimated that one in five South Africans, or approximately 5.7 million people, are living with HIV. In addition, there are nearly 1,000 AIDS-related deaths occurring daily. Many AIDS experts around the world blame the South African government for their lack of appropriate response to this nationwide epidemic. Until 2003, South Africans using the public health system could only receive treatment for the opportunistic infections acquired as a result of being HIV positive, but not the antiretroviral drugs that fight the virus itself. As a result of slow government action, the HIV prevalence rate among pregnant women in South Africa increased from 0.8% in 1990 to 29.1% in 2006.

Since the end of Apartheid in 1993, South Africa has been governed by a popularly elected President. Beginning in April 1994, the African National Congress, or ANC, has consistently won a majority of votes to become the governing party, with the President of the ANC serving as President of South Africa. Thabo Mbeki was elected following Nelson Mandela in June 1999, and was forced to resign by the ANC September 24th, 2008, a mere 6 months before the end of his second term in office. With the election of Jacob Zuma as ANC President in December 2007, it is likely that when new national elections are held in April of 2009, the ANC will again be the victorious party and Zuma the new South African president. Until then, the South African Parliament has chosen Kgalema Motlanthe to lead the country.


Kgalema Motlanthe

As Deputy President under Nelson Mandela, Mbeki initially acknowledged widely-held views about the spread of HIV/AIDS in South Africa. However, shortly after his election to the presidency, Mbeki increasingly cited poverty, not HIV, as the primary cause of AIDS. He began to side with dissident scientists and did not believe antiretroviral drugs could help in the treatment of AIDS; rather, he believed the commonly used drugs were toxic. His beliefs were shared by the South African Minister of Health, Dr. Manto Tshabalala-Msimang, who advocated good general nutrition and a combination of lemon juice, garlic, and alcohol as treatment for HIV/AIDS. In 2001, the South African government, independent of President Mbeki, declared that AIDS is in fact caused by HIV and shortly thereafter the High Court ordered the government to make antiretroviral drugs available publicly. Even so, it is estimated that only 28% of South Africans who need treatment for HIV/AIDS are actually receiving the drugs.

President Mbeki was forced to resign due to allegations that he had interfered in a corruption case against ANC President Jacob Zuma. Since taking office September 25, 2008, President Motlanthe has replaced Health Minister Tshabalala-Msimang with Barbara Hogan, an advocate for the treatment of HIV/AIDS. In combination with increased awareness and involvement by the government in recent years, this change is seen as a step in the right direction for the HIV epidemic in South Africa. However, the expected next President, Jacob Zuma, arrives with a considerable amount of controversy. In addition to the recent corruption case brought against him, Zuma was tried in 2006 for raping an HIV positive family friend. He was acquitted of the charges by explaining that the victim was wearing a short skirt and sitting provocatively. He also told the court that he reduced the risk of HIV infection by showering afterwards. Despite these previous comments, he seems to address the HIV/AIDS epidemic in a reasonable manner.

It is impossible to know what changes the next six months will bring in South Africa as a result of the sudden change in government. In recent years, the country has shown a desire to take on the HIV epidemic through both prevention and treatment methods, regardless of the beliefs held by its President. It is widely believed that a country with as much wealth as South Africa should be able to provide antiretroviral drugs to all who need them, and not merely the 28% who are currently receiving them. In order to slow this epidemic, the incoming administration will need to devote significant time and funding to the development of prevention and treatment programs throughout South Africa.

I’m Kara Earle, thanks for listening.

Blog Action Day 2008: Poverty and HIV/AIDS

Today is Blog Action Day 2008, a day in which bloggers throughout the world are blogging about a single issue - poverty. It is the hope of the organizers that this concerted effort will raise awareness about this important issue, lead to increased donations to groups combating poverty, and, ultimately, lead to some real changes. I am happy to be a part of this year’s effort.

While many of us this week are concerned about our shrinking 401(k) accounts, the situation is much more dire for millions of people throughout the world. According to the U.S. Census Bureau, 37.3 million Americans were living in poverty in 2007 and over 45 million Americans lacked health insurance. Nearly 1 in 4 African Americans are living in poverty.



According to Global Issues, over 3 billion people worldwide live on less than $2.50 a day. Every day, the deaths of 25,000 to 30,000 children can be attributed to poverty.

Inadequate financial resources also contribute to the spread of HIV/AIDS. In the US, HIV/AIDS increasingly is becoming a disease of lower socio-economic classes. Throughout the world, women who are not economically independent or empowered are more likely to engage in survival sex, or the exchange of sex for food, clothing, or shelter. One study in North Carolina found that roughly 28% of street youths engaged in some form of survival sex. In some parts of the world, children in impoverished families may be forced into a marriage with an older man. In this situation, the girls or young women are not in a position to abstain from sex or practice safer sex. In these situations, the children and young women clearly have an increased risk of becoming infected with HIV.

So what can we do? Each of us can contribute to groups who advocate for the poor. Each of us can contact our elected representatives and urge them to support the Millenium Development Goals, a United Nations program to eliminate poverty by 2015. Each of us can write about this issue and talk about this issue. Each of us can help a neighbor in need.

To find out how other bloggers are addressing poverty, please visit the Blog Action Day web site.

Until next time, I'm Dave Wessner.

AIDS-related dementia

I’m Bevin English

Since the early stages of the AIDS pandemic, doctors have known about an important neurological complication of HIV infection. This condition, known as AIDS-related dementia, AIDS dementia complex (ADC), or HIV-associated dementia (HAD), is a complex and poorly understood disease, and has the potential to greatly impact many people’s lives, including HIV-positive individuals and their families and close friends. In the United States, HIV-1 is the most common cause of dementia in adults under the age of 40. Also, neurological impairment affects roughly 60% of HIV-positive patients throughout the world. The major causes of neurological impairment include opportunistic infections, such the parasite toxoplasmosis, and AIDS-related dementia.

The primary symptoms of AIDS-related dementia include cognitive impairment, such as the inability to concentrate and impaired short-term memory; motor dysfunction, including leg weakness, affected gait, and slow hand movements; and behavioral changes, such as depression, apathy, and social withdrawal. In rare cases, the dementia progresses so that the patient is in a nearly vegetative and mute state. Before the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, AIDS-related dementia affected up to 30% of HIV-positive individuals, but the current prevalence has dropped to approximately 10% in areas with high HAART availability. However, a less-severe form of the disease, called minor cognitive motor disorder (MCMD), has become more prevalent in regions where HAART is widely available, with estimates ranging up to a 30% prevalence rate. This high prevalence rate shows that HAART is not sufficient in reducing neurological impairment in HIV-positive individuals.

Despite years of research and progress, much remains unknown about HIV’s interaction with central nervous system (abbreviated CNS; this includes the brain and spinal cord), and this lack of knowledge has serious implications for treatment. HIV is found in the CNS of all AIDS-related dementia patients, but there is still controversy regarding how HIV enters the CNS. The brain is protected by the blood-brain barrier, which is a selectively permeable layer of tightly-linked endothelial cells that carefully regulate what enters and exits the CNS. While many things are excluded from the brain by the blood-brain barrier, some immune system cells are allowed to cross the barrier. The most widely accepted theory to explain HIV’s entry into the brain is the “Trojan horse hypothesis,” which states that infected monocytes (cells that later mature into macrophages) cross the barrier and carry HIV into the CNS. However, there are other possible explanations for the presence of HIV in the brain. For example, infected CD4+ T-cells may also carry the virus into the brain. It is also possible that the virus may be able to directly cross the blood brain barrier, especially if the barrier’s integrity is compromised, or that the cells that make up the barrier ingest the virus and expel it in the brain in a process called transcytosis. Because the virus may enter the CNS through many pathways, most of which are not fully understood, it will be difficult for scientists to come up with treatments to prevent the entry of HIV into the brain in the near future.

Once in the CNS, HIV’s most devastating effect is the sheer loss of neurons. For example, 20-40% of neurons are lost in the frontal cortex, a region of the brain that is involved in planning, coordinating, controlling, and executing behavior (or more specifically, impulse control, judgement, language production, working memory, motor function, and socialization). This large loss in neurons can be seen in the CT scans below (image courtesy of AIDS Images Library )



However, HIV cannot infect neurons because they do not express CD4, but instead HIV persists in the CNS by infecting other cells; thus, neurodegeneration is not a result of active infection of neurons. There are two major pathways for neuropathogenesis in AIDS-related dementia: direct and indirect. The direct pathway includes the effects of different viral proteins on neurons. For example, three HIV proteins, gp120, Tat, and Vpr, have been shown to cause neuronal cell death through many different pathways. Further, Tat has been shown to increase the permeability of the blood-brain barrier, thus increasing the amount of HIV that can enter the CNS. The indirect pathway of neuropathogenesis involves infected cells’ secretion of chemicals that harm neurons. For example, when activated by infected macrophages, astrocytes, which normally provide support for neurons, actually secrete neurotoxins. Thus, HIV causes neuronal cell death through many different mechanisms, making AIDS dementia extremely difficult to treat.

Despite these difficulties, many scientists have been investigating treatments to prevent or slow the progession of AIDS-dementia. Many antiretroviral treatments currently in use cannot penetrate the blood brain barrier, and the few that can enter the CNS do so very inefficiently. For example, protease inhibitors, an entire class of drugs, are actively pumped out of the CNS. The ineffectiveness of current antiretroviral treatments in penetrating the blood-brain barrier has led scientists to investigate other means of preventing neuronal cell death. Many different compounds that block different steps in the pathways that cause neuronal death have been tested in AIDS-related dementia patients, but so far none have shown any significant therapeutic benefits. However, progress is being made in understanding the processes involved in HIV’s interaction with the CNS, and these new discoveries may open the door for new treatments for AIDS-related dementia.

The Presence of HIV/AIDS in Prison Populations

Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Ali Cundari.

U.S. prison populations are at a record high today, with barely enough room to house incarcerated individuals. Due to the close proximity and high-risk behaviors of inmates, as well as a lack of intervention from authorities, the transmission of HIV in prisons is a major problem today. A combination of both pre-existing and new infections plague prison populations, making them one of UNAIDS’ four major at-risk groups for HIV/AIDS.

In 2005, 1.8% of all state inmates and 1.0% of all federal prison inmates in the U.S. were believed to be HIV positive, leading to a total of 22,480 infected individuals behind bars. These percentages are disproportionate to the rest of the general population, making HIV/AIDS about four times as common among inmates than the population at large. Around 25% of all HIV infected people have spent time in a correctional facility, and these HIV infections are often accompanied and exacerbated by high rates of hepatitis and tuberculosis.

There are several means of transmission regarding the spread of HIV/AIDS in prisons, both primary and secondary. Injection drug use is one major cause of transmission, as sharing of dirty needles and syringes (estimated to be greater than 70%) is a common practice. Sharing items such as razors and toothbrushes contributes to the spread of other germs. Along with injection drug use there is tattooing and body piercing, a widespread activity among many inmates. Typically, it is performed through multiple skin-punctures and without sterile instruments, causing the inmates to resort to recycled, make-shift tools such as staples, paper clips, and plastic ink tubes from ballpoint pens. Finally, various sexual activities and rape directly contribute towards the problem. It is difficult to obtain accurate statistics regarding this area, due to fear and embarrassment, but consensual and non-consensual sex are both quite prevalent among prisoners. Boredom, identity issues, and the desire to assert dominance all contribute towards sexual activity. Types of sexual activities include consensual same-sex activity, sex between prisoners and staff, conjugal visits, and rape or other forms of sexual violence. Rape is a particularly complex problem, often brutal and gang related, and the violent nature of it makes recipients more prone to vaginal or anal tears, and thus increases the chances of HIV transmission.

Also contributing to the spread of HIV/AIDS, and co-infection with other STI’s, is the absence of condoms or clean needles. Additionally, a lack of information is a major problem, with many inmates being forced to live in a state of silence and fear, and a third major confounding factor is the lack of people getting tested. Currently, very few inmates get tested due to the large stigma surrounding it and fear of ridicule or violence if their test results confidentiality were to be violated. Additionally, the prison lifestyle and rapid turnover of inmates makes consistently adhering to ARV therapy difficult. Thus, the major hesitations to reform in U.S. prisons come from a lack of political will, security concerns, and false assumptions that such programs will encourage injection drug use and sexually risky behavior. Also, many opponents believe there is a lack of resources and technology to meet the overwhelming need in prisons.

In recognizing these problems, many ideas have been proposed for prevention and change. The main goal would be to develop a multi-pronged approach to enhance detection, prevention, and the reduction of sexual violence. Next, condoms, clean needles and syringes, and bleach kits must be distributed. Many advocates of reform also believe post-exposure prophylaxis (PEP) should be made available to victims of sexual encounters. Additionally, health education and support programs, and the strong encouragement to get tested would both serve to be useful. Finally, once diagnosed, HIV positive individuals must be able to receive consistent drug treatment.

Many model prisons show promising results in their quest to enact some of these changes, including the Hampden Country, MA, Correctional Center and Brown University’s Rhode Island Prison. Further lessons can be learned from countries like England who successfully prevented problems by targeting injection drug users early on in the epidemic, and Cuba, who was able to keep HIV under control through superb penitentiary health and clean conditions.

Overall, change is a daunting challenge due to the rapid turnover of inmates and the large sense of stigma and secrecy within prison walls. In order for change to be effective, it must occur on multiple levels. Officials can no longer turn a blind eye to this problem. Prisoners are ethically entitled to the same safety, health care, treatment, and support as the rest of society. Reforming the current state of correctional facilities would not only help these facilities run smoother, but according to the UNAIDS and WHO Framework, good prison health would equate to good public health. The vast majority of all incarcerated individuals will eventually return to society, bringing with them any known and unknown diseases they may have acquired in prison. If officials can bridge these barriers, they can indeed have a lasting impact on the spread of HIV/AIDS in the U.S. as a whole.

Thanks for listening. Until next time, this is Ali Cundari.


For more information:
• Jürgens, Ralf. “Interventions to Address HIV in Prisons – Prevention of Sexual Transmission.” World Health Organization. . 2007.
• Kanter, Elizabeth. “HIV Transmission and Prevention in Prisons.” HIV InSite Knowledge Base Chapter. . April, 2006.
• Lines, Rick, et al. “HIV/AIDS Prevention, Care, Treatment, and Support in Prison Settings.” WHO & UNAIDS Framework for an Effective National Response. . 2006.
• Maruschak, Laura. “HIV in Prisons, 2005.” Bureau of Justice Statistics Bulletin. . September, 2007.
• Polonsky, S., et al. “HIV Prevention in Prisons and Jails: Obstacles and Opportunities.” Public Health Rep. 109(5): 615–625. . September-October, 1994.
• “Prisons.” Joint United Nations Programme on HIV/AIDS. .

Impacts of HIV/AIDS on Economic Development

In 2000, the United Nations created a list of 8 Millennium Development Goals to help promote economic growth and development among developing countries. One of these goals is to combat HIV/AIDS by stopping and reversing its spread and providing universal access to drugs for those infected. While this is definitely a worthwhile goal, why is it included among a list of targets to support growth? Well it turns out, that the impact of HIV/AIDS on the economy can be substantial.

The first immediate effect of HIV is a drop in household productivity as the working members of the household succumb to the disease. One study by UNAIDS estimated that household production could drop anywhere between 30%-60% due to an AIDS death in the family. Another study from the Ivory Coast examined what implications this could have on other aspects of the families’ lives. It was estimated that “families with a member sick from AIDS cut spending on their children's education in half and reduced food consumption by about 40 percent as they struggled to cover health expenditures that soared to four times their usual level.” Unfortunately this leads to a vicious cycle as these countries are often already experiencing higher malnutrition rates and lower education levels.

Individual companies will be affected by high levels of HIV as well. Not only will the actual amount of workers decline due to more AIDS deaths, but their quality of work will also decline due to ill-health and increased absenteeism. Companies will incur direct costs in order to hire and train new workers. Additionally, due to an inexperienced work force, productivity will decrease and the potential for accidents will increase. Finally, as AIDS deaths increase in number, employees will experience a loss of morale and labor cohesion.



These losses in household and company productivity have important implications for the national economy. One important indicator for development is domestic savings and investment. Households that are able to save money are better able to start their own business or finance their education in the future. Additionally, companies that invest in new plants or equipment can grow at a faster rate. However, with high levels of HIV, households are forced to spend more money on healthcare and companies have less to invest due to higher costs and lower productivity. As a result, the country experiences a much lower rate of growth.

Government expenditures will also be affected by HIV. Tax revenues will drop as companies and households are earning less money. At the same time, the government will be increasing health expenditures to help those affected by AIDS. With less revenues being generated and a higher percentage being spent on healthcare, government programs to promote infrastructure and growth will diminish in quantity and quality.

Economists have developed models that predict the growth domestic product (GDP) both with and without HIV/AIDS. Most of these models indicate a rather small drop, on the order of 0.5% to 1% per year. While this may seem small, when this drop is compounded over many years, the impacts can be substantial. One study estimated that due to HIV’s extensive impact on the economy, expenditures on HIV prevention would be 17 times more effective at promoting development than similar expenditures on capital investment. As a result, slowing the spread of HIV and treating those with AIDS will be an integral part of any development plan.

This is Ben Young, thanks for listening.

HIV/AIDS: The role of abstinence only programs

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Amy Jendrek.

In fiscal year 2005, President Bush requested $270 million to fund abstinence-only education programs in the U.S. While Congress did not appropriate the full amount requested, they did allocate $167 million to support these programs. There are three principal programs that use federal funds to support abstinence-only education.

The first of these is SPRANS, Special Programs of Regional and National Significance, which has a sub-program devoted to Community-Based Abstinence Education. In 2001, its first year of funding, 33 SPRANS recipients received $20 million in grants. By 2004, the program had over 100 grantees and a budget of $75 million.

The second program is Section 510 of the 1996 Welfare Reform Act, which provided $250 million over five years for programs with “the exclusive purpose” of promoting abstinence. The law has since been extended in June 2004, providing $50 million per year.

The third program, the Adolescent Family Life Act (AFLA) was originally passed in 1981 to promote “prudent approaches” and self-discipline to adults. In 2004, it provided $13 million for abstinence-only education programs, and the same amount was again appropriated in 2005.

In 2004, California Representative Henry A. Waxman led an investigation of abstinence-only education programs funded by the federal government. The investigation, titled “The Content of Federally Funded Abstinence-Only Education Programs,” found that 80% of curricula used by two-thirds of SPRANS grantees contained false, misleading, or distorted information about reproductive health.

The report looked at 13 abstinence-only sexual education curricula, and found errors in scientific information presented by 11 of them. Many contained errors regarding HIV prevention and the effectiveness of condoms.

According to the CDC, “Latex condoms, when used consistently and correctly, are highly effective in preventing the transmission of HIV.” According to the Waxman report, multiple abstinence-only curricula use a 1993 study by Dr. Susan Weller which found that condoms reduce risk by 69%, using an analysis which both the FDA and the CDC found erroneous. One abstinence-only curriculum, “I’m in charge of the FACTS” claims that “The actual ability of condoms to prevent the transmission of HIV/AIDS, even if the product is intact, is not definitively known.”

These curricula fail to mention the multiple studies showing the effectiveness of condoms against transmission of HIV, as well as the rigorous standards the FDA holds for testing contraceptives.

Another area in which the Waxman report found many errors was in curricula’s analysis of HIV risk behaviors. Data on exposure risks is presented in a confusing and exaggerated manner. Data from CDC chart titled “HIV infection cases in adolescents and adults under age 25, by sex and exposure category,” is presented by FACTS as “Percent HIV Infection.” This means that, where the CDC chart showed that nearly 50% of male teens living with HIV reportedly acquired it through homosexual contact, the curriculum’s chart shows that 50% of homosexual male teens are HIV+. In a similar fashion, it implies that 41% of heterosexual female teens are also HIV+. After the Waxman Report, a caption was added to include the original title of the chart.

Many curricula use a one in ten infection ratio for HIV-risk activities, ignoring the fact that even with a high estimate, one in 300 people in the US are infected with HIV.

WAIT (Why Am I Tempted?) Training, a program used by 19 SPRANS grantees, places sweat, tears, and saliva in the “At Risk” category for HIV transmission. Since the Waxman report came out, WAIT Training has changed its curriculum to put sweat in the “No Risk” category, but maintains that there is risk of contracting HIV through tears and saliva, as the disease can be isolated from them, despite the CDC’s assertion that there is no risk of transmission from these fluids.

In some cases, even discussion of HIV and AIDS are not allowed under abstinence-only guidelines. The Franklin County, NC, school board had three chapters cut out of a ninth grade textbook because they did not adhere to state laws mandating abstinence-only programs. The chapters covered marriage and partnering, contraception, and HIV. In Orlando, Florida, a high school teacher was suspended when he chose to show a student-made video about HIV prevention. In Illinois and New York, AIDS-prevention presentations by an AIDS task force and the CDC were cut from programming because they were not “consistent with an abstinence-only message.”

Other errors are more simple. In what is probably a typo, but one that should have been caught, Tree of Life Preventative Health Maintenance, Inc., a grantee in Arkansas, tells teens on its website that “AIDS is the result of HPV.” One student handbook, from the FACTS curriculum, defines AIDS as “Acquired Immune Disease.”

Currently, only 12 states have not accepted federal abstinence-only money. That does not necessarily mean that all these states provide a comprehensive sex education, or that those states that have accepted money teach a strictly abstinence-only curriculum. However, 35% of school districts with a sex education policy require abstinence to be covered and either do not allow discussion of contraceptives or allow discussion only of their failure rates.

According to Planned Parenthood, “most reputable sexuality education organizations in the U.S., as well as some prominent health organizations, including the American Medical Association, has denounced abstinence-only sexuality programs.” In 1997, the National Institutes of Health concluded that “Abstinence-only programs cannot be justified in the face of effective programs and given the fact that we face an international emergency in the AIDS epidemic.”

I’m Amy Jendrek. Thanks for listening.

Opportunistic Infections in Developing Nations: A World Away

In the United States and other developed nations, for many people, AIDS has become a manageable disease. With adequate care and lots of medication, HIV positive individuals can live with relatively few serious complications for a long time. In the US, 71% of HIV-infected individuals have at least started HAART therapy, decreasing deaths per infected individuals per year from 30/100 to 5/100 since the 1980’s. In developed nations, however, HIV positive individuals do not have the luxury of adequate care. In areas like Africa where the burden of disease is highest, HIV positive individuals must face an array of opportunistic infections as their CD4 counts dip lower and lower.

Because these opportunistic infections are generally localized to areas where HAART is not available, it is both hard for us to understand the difficulties in treatment and to determine which infections are endemic to what populations. For example, MAC (for Mycobacterium avium complex) is a common, life-threatening opportunistic infection in Asia causing a significant portion of AIDS-related mortalities. In Africa, however, MAC is rare. In addition, tuberculosis is a particularly life-threatening coinfection that is particularly common in many developing areas, especially Sub-Saharan Africa and Asia. Many opportunistic infections in these nations have developed resistance to the drugs typically used to treat them. Determining which disease populations have resistance to what medications can be exceptionally difficult given how isolated some of these areas are.

The HIV/IDS prevalence is highest in sub-Saharan Africa

The most reputable source for information like this is undoubtedly the World Health Organization. The WHO publishes information on the geography, morbidity, symptoms and treatment of various opportunistic infections for different nations and settings. While it is hard to determine where exactly the WHO gets their sources for information from developing nations, it is clear that they get their information from all parts of the globe. However, it is also hard to pick apart the complicated interactions of HIV and opportunistic infections in a multitude of settings, and even harder when there are additional complicating factors such as malnutrition, social unrest, and a lack of medical infrastructure for reporting treatment schemes. Many times, the WHO provides useful information about the scope of opportunistic infections in developing nations, but they often miss the deeper and more individual issues that a given region may have. If first-line drugs for opportunistic infections are not available in these developing areas (due to oppressively high costs or restrictive storage conditions), the WHO lacks vital information on how to cope.

The availability of antiretrovirals in lowest in sub-Saharan Africa

While it is not the fault of the WHO that there is a dearth of useable information for medical workers in low-resource environments, it is clear that there is a lack of necessary medical care in these nations that perpetuates a cycle of poverty and illness and that millions of HIV-positive individuals are dying as a result of a lack of ARVs. In a situation where prohibitively high costs of necessary drugs prevents individuals from being treated for HIV, we need to focus more on preventative efforts and HIV prophylaxis in the form of vaccines or microbicides. In this sense, the US and other developed nations are providing a massive amount of resources in trying to find a vaccine and developing useful microbicides to prevent HIV infection from happening in the first place. Because of the massive amount of people infected in areas that lack the resources to treat them, the disease needs to be treated when it is least expensive to do so. While it is hard to know what the future holds for those with HIV in developing nations, it is sure that we need to develop better ways of treating opportunistic infections and preventing the development of AIDS from HIV.

For more information on the global context of the AIDS pandemic, please visit:
Avert.org
WHO

Themes from the International AIDS Conference

Today marks the end of the 17th International AIDS Conference. 25,000 delegates were in Mexico City this week to discuss the current state of the pandemic. While I was not able to attend this year’s conference, I have been following the proceedings online. What were some of the major themes? The infection rate in the US is higher than previously thought. We need to do a better job reaching out to men who have sex with men. We need to develop an effective microbicide. We need to serve our children more effectively. New media – blogs, podcasts, twitter, mobile phones – may help us get the message out.

Because of AIDS conference, there have been numerous reports about HIV/AIDS this week. Here are a few that I found interesting.

At InsideBayArea.com, Josh Richman tells us that Representative Barbara Lee (D – Oakland) has called for a domestic PEPFAR, stating that we need to spend billions here to fight HIV/AIDS.

At HuffingtonPost.com, Tamsin Smith urges us to develop intervention programs specifically designed to empower girls.

Also at HuffingtonPost.com, James Boyce makes a strong argument in favor of (RED). He argues that programs like this, termed Creative Capitalism by Bill Gates, work.

I hope you take the time to read this articles. And feel free to comment. I’d love to hear your thoughts.

Until next time, I’m Dave Wessner.

US to lift HIV travel ban

“This week, Congress voted to expand a vital program that is saving lives across the developing world — the Emergency Plan for AIDS Relief, also known as PEPFAR. I thank members of Congress from both sides of the aisle for working with my Administration to pass this important bill, and I will be honored to sign it into law next week.”

With those words, President Bush on Saturday indicated his strong approval of the PEPFAR legislation passed last week by Congress. The bill provides an additional $48 billion over the next 5 years to fight HIV/AIDS, primarily in sub-Saharan Africa. According to Pres. Bush:

“When we first launched this program five-and-a-half years ago, the scourge of HIV/AIDS had cast a shadow over the continent of Africa. Only 50,000 people with AIDS in sub-Sahara Africa were receiving antiretroviral treatment. Today, PEPFAR is supporting treatment for nearly 1.7 million people in the region. PEPFAR has allowed nearly 200,000 African babies to be born HIV free. And this program is bringing hope to a continent in desperate need.”

But this legislation does more than provide much needed money. The bill also repeals the 20 year ban on travel into the US by HIV positive people. Enacted in 1987, the current policy prevents HIV positive foreigners from obtaining visas as tourists, immigrants, or students. The US is among only a small number of countries worldwide with such a ban. According to Senator Gordon Smith, a Republican from Oregon, “Our government still treats individuals with HIV/AIDS as modern-day lepers, categorically banning these individuals from entering into the US.”

More information about how this new legislation will affect travel to the US by people with HIV/AIDS can be found at the Immigration Equality web site.


Until next time, I’m Dave Wessner.

National HIV Testing Day

Today, Friday, June 27th, is National HIV Testing Day. Many of us, I would guess, have become somewhat desensitized to these types of events. We are inundated by days or weeks or months dedicated to various causes. It would be easy to ignore National HIV Testing Day or view it as just another event on an already overcrowded calendar.


But I encourage all of you to pay attention to this special day. Why? Because HIV/AIDS is preventable. It is only preventable, though, if all of us know our HIV status. Today, the CDC estimates that roughly a quarter million people in the US are HIV+ and do not know it. We need to decrease this number. If we are going to beat HIV/AIDS, it’s important that people know their status.

Where can you get tested? If you don’t know of a local testing site, simply go to www.hivtest.org. Type in your zip code, and you will be provided with a list of nearby sites. Or, you can find a test site by texting your zip code.



If you have never been tested, or if you haven’t been tested in a while, get tested today. It’s the only way we can end this pandemic.


Until next time, I’m Dave Wessner.

Kwame Dawes reports on HIV/AIDS in Jamaica

In a recent installment of The AIDS Pandemic, Tamar Odle described the stigmatization of homosexuals and people living with HIV/AIDS in Jamaica. As she reported, the discrimination against homosexuals stems from deep-rooted cultural beliefs and values. And this discrimination against homosexuals has increased the stigma associated with HIV/AIDS in this country.

Recently, Kwame Dawes, a poet and professor at the University of South Carolina, reported in The Washington Post on the current state of people living with HIV/AIDS in Jamaica. With funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Jamaican government has been able to supply free or low-cost antiretroviral drugs to many Jamaicans living with HIV/AIDS. But public perception of HIV/AIDS remains a problem. And because of this public perception, adequate treatment remains an issue.

A young HIV+ Jamaican woman, Annesha Taylor, became the face of successful treatment. The government used her story in various ad campaigns to show people that it now was possible to live with HIV. But according to Dr. Dawes, when she became pregnant, “her role as the campaign’s public ambassador was over.” The story is poignant and telling. Despite our scientific understanding of the virus and the growing number of antiretroviral drugs at our disposal, stigma, misunderstanding, distrust, and fear remain the biggest obstacles to preventing new infections and treating those already infected.

I encourage you to read Dr. Dawes’ piece.

I also encourage you to read and listen to his moving poetry on HIV/AIDS in Jamaica at www.livehopelove.com.

His trips to Jamaica have been supported in part by the Pulitzer Center on Crisis Reporting.




Until next time, I’m Dave Wessner.

HIV/AIDS Outreach in African American Communities using Barbershops and Hair Salons

Historically, barbershops and hair salons have served as hubs in the African American community where people go to discuss issues in the community, politics, family, and life issues. Within these establishments there is a sense of community, and it provides opportunities for African Americans to develop ideas and form a sense of identity. African Americans usually build relationships with their stylists where they are comfortable enough to gossip and share personal information. As a result, HIV/AIDS Outreach Programs have begun to use barbershops and hair salons to get through to the African American community. Such unconventional outreach locations are effective in providing prevention efforts that is culturally relevant, non-intrusive, and accommodating for sharing information and learning.

Barbershops are significant in facilitating important discussions and community within the African American population. One great example of this was in the 2002 Motion Picture, “Barbershop”, in which conversation and discussion by African American customers and employees within the shop was the basis of the film. The prominence of conversation/ discussion within barbershops was also highlighted in the book, “Barbershops, Bibles, and BET”, written by Victoria Harris-Lacewell. Lacewell states that, “They talked about White power structures, the relationship of African Americans to the state and to capitalism... critiqued black leaders, discussed political power in the black church, argued about reparations and cheered on African American Olympic athletes.”

Specifically, the purpose of Outreach programs through barbershops and hair salons is to target high risk groups like drug, alcohol users, homosexuals, heterosexuals, and men who have sex with men, to inform them about HIV/AIDS prevention. Some of the professionals that work towards these efforts include: public health experts, behavioral scientists, business owners, hairstylists and barbers. Some of the programs targeted towards HIV/AIDS prevention outreach are: The Down Low Barbershop Project and the Barber and Beautician STD/HIV Peer Education Program with Project StraighTalk. There are several other Outreach programs that use barbershops and hair salons as channels of outreach around the country in states like New York, Nevada, North Carolina, and Vermont.

The Down Low Barbershop Project is located in Seattle and Washington, DC is funded by the Center for Disease Control. The purpose of this project is to train barbers and stylists in Black communities to provide black men with HIV education, condoms, and referrals for free HIV counseling and testing. It is estimated that more than 1,000 people have participated in this program thus far. The Barber & Beautician STD/HIV Peer Education Program with Project StraighTalk began in 1989 with a poll that asked African American barbers and beauticians “what their clients talked about?” The results of the poll showed that 80% of the clients talked about sexual issues which urged Project Straightalk to begin their first training of stylist in HIV Outreach in 1990.

The training of barbers and beauticians in STD/HIV Peer Education is very critical to the success of these Outreach programs. It is important that the stylists are adequately equipped with facts, advice, and resources that are correct and beneficial to their clients. The training for these programs consists of: an overview of program, discussion of their role as educators, teaching of peer education skills and STD/HIV facts, a demonstration of correct prevention method use, instruction on providing client referrals, and role plays. At the end of training, the stylists are given a certificate, resources such as pamphlets and posters, and an “Ask Me About AIDS” Button.

The U.S. is not the only country that has decided to use barbershops and hair salons to target the black community. Similar efforts are taking place in Nigeria, Zimbabwe, and Canada, to name a few. In Canada, the peer led health promotion initiative called, Operation Hairspray, has begun. The goal of this program is to provide HIV/AIDS outreach for African American and Caribbean hairdressers and clients.

There are several implications related to the success, future, and long-term effect of Barbershop and Hair Salon HIV/AIDS Outreach Programs in the African American Community. These programs are culturally relevant to the African American community and provide outreach in non-intrusive informal setting. Likewise, they are specifically tailored to incorporate social norms and values; this is beneficial to targeted outreach for any group. Some critics argue that quality, content, and intensity varies in different outreach programs, as a result there efficiency is unclear. However, all of these programs provide much needed education, testing information, awareness, and support for African Americans which are all beneficial. Although the long-term effectiveness of these HIV/AIDS outreach programs is not apparent, the initiative that these programs have taken is positive and can ultimately help the African American community and aid in decreasing the number of HIV/AIDS cases.



Website Links Related to the Topic

http://www.newsobserver.com/664/story/543765.html
http://seattletimes.nwsource.com/html/photogalleries/northwestlife88/2.html
http://ottawa.ca/residents/health/living/sexual/hairspray_en.html

Social Components of HIV/AIDS Transmission in Mwandi, Zambia

I'm Dominique Maietta.

Mwandi is a relatively rural village in the South-Western corner of Zambia. The town is home to the Mwandi Christian Hospital, which has a catchment area of approximately 25,000 individuals. During the summer of 2006, I traveled to Mwandi in order to study the psychological and social components associated with HIV/AIDS there. Here I will talk about some of my findings.

The incidence of HIV in the village is around 30-40% and the percentage of HIV positive people is larger within the Mission Hospital patient population according to interviews with medical officers on the hospital staff. The majority of the interviewees expressed their feelings that economic hardship is a major social component of the spread of HIV in Mwandi, just as it is in the rest of Sub-Saharan Africa. Despite the influx of education and knowledge regarding HIV and it’s spread, including mandatory classes in the schools and public service campaigns around the country, the low financial status of the Mwandi community is the root cause for many of the risky behaviors associated with HIV transmission, such as multiple partners and non-use of condoms. This need to engage in risky behaviors appeared to be a particular problem for women and girls who have no other way of making an income other than through sex. Sex for them is not about emotion, but instead about survival.

The problem of poverty affecting HIV rates in Mwandi has further been exacerbated by the construction of a new paved road linking this relatively rural village to other towns and countries. The relatively recent accessibility of Mwandi to the outside world has introduced truckers and migrant workers as passer-bys to the village, and thus created a uniquely new set of problems for HIV transmission in Mwandi. These migrant individuals provide both a source of income for the impoverished village, but also a ready supply of HIV positive individuals to transmit the disease to villagers. As one social worker explained to me, when people come, they come looking for women. Thus the presence of the road, and the truckers from neighboring countries provide a source of income for destitute women and girls with no other means of providing income for their families. Interestingly, the use of sex for money in Mwandi is not so much acceptable, but merely a behavior that occurs, and according to one nurse I spoke with, “this is one of the poorer parts of Zambia, and if a woman has to keep her family, especially if her husband is not around, she will do it somehow”.



Gender disparity issues, then, apart from womanizing on the part of men, is also seen as a major social component of HIV transmission in Mwandi. While men have the power and social standing to hold jobs and make money, women and children have no similar means of providing for their families. Furthermore, although some male orphaned heads of household are given governmental support such as fishing nets which can be used to make a living, young females in similar situations are given minimal support. Thus when husbands die or children are left orphans due to the death of their parents, (generally as a result of AIDS), there is little those children or women can do to raise money other than to fall back to prostitution.

The lack of finances for much of the Mwandi community was also linked by many of the people I spoke with to excessive alcohol consumption, which contributes to promiscuous sexual behavior among Mwandi townspeople. A majority of village leaders perceived that the paucity of jobs and alternative activities in Mwandi village led to the abuse of alcohol followed by unscrupulous sexual activity, (especially by men), which in turn exacerbated the already present problem of HIV transmission. The custom of casual sex and multiple partners was prevalent among men before the HIV pandemic, and is viewed in Mwandi as the “normal mode of boy existence”. This acceptance of male promiscuity also appears to be a key contributor to the continuance of HIV transmission in Mwandi. Lack of sexual control exerted by women, (especially wives), combined with a lax view of expected fidelity in men has resulted in a growth of HIV transmission as husbands will sleep with several partners, become infected, and then infect their wives.

Although it was generally recognized that women lacked the social dominance and power necessary to prevent their husbands from suffering the results of their risky behavior, there were conflicting views as to whose behavior was “responsible” for the spread of HIV. Many of the male interviewees implicated the social behaviors of young people and prostitutes in the spread of HIV. In Mwandi many traditional family cultural values are being challenged with the introduction of the “modern life. As a result, many perceive that young people and their rampant and unprotected sexual behavior is a major social problem contributing to the spread of HIV. This behavior is most often the result of children behaving in a manner mimicking their adult counterparts.

Thus, in Mwandi, extreme poverty combined with alcohol abuse, accessibility to outsiders, and a lack of role models attempting to change behavior are the main factors contributing to the spread of HIV. As the village and the rest of the world becomes more aware of these social factors, changes can be gradually made to stop those underlying social behaviors that support transmission of HIV. Already in Mwandi village leaders have begun to address the issues of poverty and gender disparity by supporting religious and governmental run support groups and clubs to promote sustainable income by women there. Furthermore, use of traditional drama has been incorporated in order to increase public knowledge about the connection between underlying social factors and the spread of HIV in order to stop the cycle of transmission. Although there is much work to be done, the residents of Mwandi are moving in the right direction to combat the social facets contributing to HIV transmission in Mwandi.

HIV/AIDS in China

In 2006, official estimates put the number of HIV-positive individuals in China at about 650,000. This figure – reached by the World Health Organization – means that China, holding roughly 1/6th of the world’s population, contributes to only 1/60th of the cases of HIV/AIDS globally. However, it has also been estimated that if rising infection rates are not curbed, the HIV-positive population could breach 10 million by 2010. This has sparked a more liberal attitude from Party leadership toward sex education, which until a year ago, made possession of a condom adequate evidence for prostitution charges.

In developed nations, MSM can account for 70% of HIV infections, while in sub-Saharan Africa, which bears the brunt of HIV infections, heterosexual contact is a major route of transmission. But China’s battle with HIV/AIDS is unique. When HIV first surfaced in China in the 1980’s, it was associated largely with drug use and other practices deemed to be of Western origin. AIDS was known as aizibing, meaning the “loving capitalism disease,” and Party officials did not deem it a serious threat to the general population.

When four hemophiliacs were infected with the virus in the late ‘80s by imported Factor VIII, the government prohibited the use of imported blood products. This allowed for the development of a new for-profit blood collection industry based on the exploitation of poor peasants. Throughout the 1990’s blood collection units popped up throughout rural villages in China, paying peasants the equivalent of $5 for blood. Some would give several pints a day in order to feed their families. In order to keep the donors from becoming anemic, blood was returned to donors after removing the plasma, but the blood of multiple donors was commonly mixed before returning it, and no tests for HIV were conducted. While conservative estimates put the number infected through this route of transmission at under 100,000, others argue that more than a million were infected in Henan province alone. To this day, no government officials have been punished, despite the fact that even police and military units would set up collection stations to raise money.

After the backlash to the SARS outbreak in 2003, government officials in Beijing have opened up slightly, but many activists believe official cover-ups are responsible for preventing treatment to millions of sick villagers. Chinese Premier Wen Jiabao visited Henan Province on World AIDS Day this year to help spread awareness about the disease, but many sick villagers claim they were put on house arrest in order to prevent him from seeing the true state of the epidemic. In some of the worst areas, the so-called “AIDS villages,” activists believe up to 80% of the residents are infected. Gao Yaojie, a retired physician who has won several human rights awards for her work on uncovering the HIV epidemic in China said this of the Chinese Government:

The government's AIDS policy is superficial. It cannot really be implemented. There is a saying in the countryside. The village tells lies to the township government; the township tells lies to the county government; the county tells lies to the state council; the state council issues a document; the document is read by all levels of the government. After they finish reading it, they go into a restaurant, and the document is never put into practice.

Gao Yaojie’s books on the Aids Villages are banned in Henan Province.

In 2003, the government announced the Four Frees and One Care Policy, promising, among other things, free access to anti-HIV drugs for those who could not afford them. But many of those affected claim that these policies do not make it to the level of local implementation. Villagers protest that many hospitals do not offer HIV testing, or that they sell the drugs for their own profit, but their protests fall on deaf ears. Zhou Xihong, a lawyer who has worked with families in Henan trying to access the promised drugs, complains that the courts routinely dismiss their pleas. “They said AIDS patients can get free treatment, so the court doesn’t have to process their cases,” he said.

The Chinese government is now at a crossroads; their desire to control information must be reckoned with their growing integration into the global community. Reports of police violence and strong-armed tactics to quell protests of HIV activists at the local level suggest that international pressure will be the key to tackling the epidemic among China’s peasants head on. Policy changes enacted early this year provide hope that this needed change may be coming. To allow for better coverage of the upcoming Beijing Olympics, resident correspondents no longer need a government OK to go on reporting trips to provinces. But according to some recent reports, villagers who grant interviews to discuss the HIV epidemic still face intimidation and threats from local officials.

Read more about Gao Yaojie’s efforts in China.

Cancer in AIDS Patients

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Mike Neri.

In this episode, I will talk about a topic that is gaining increasing interest from the AIDS community: cancer. This podcast goes over why cancer is becoming more of an issue for AIDS patients, why some cancers occur more often in HIV-positive people, the complications of treating people with AIDS for cancer, and what needs to be done in the fight against cancer and AIDS.

Most people following the evolution treatment of AIDS patients focus on the development of more effective drugs against HIV as the main battle in the war against this disease. Certainly, finding medicines that can lessen HIV’s ability to destroy the immune system and function inside the body is critical to making progress in the treatment of this pandemic. However, many people don’t realize that prolonging the lives and improving the quality of life for people with AIDS is not the end of fight. In fact, newer drugs can often complicate treatment of other diseases later on down the road and contribute to more health issues as AIDS patients get older.

Cancer is one of the best examples of the problems that people with AIDS face even after their medication has allowed them to live a somewhat normal life. It is well known that as a person ages, his or her susceptibility to cancer increases. This is no exception in AIDS patients, and as more patients survive longer due to new medicines, cancer and cancer treatment of the immunosuppressed of the AIDS community will continue to become a bigger issue.

In the public eye, cancers are not normally associated with immunodeficiency or infectious particles, but rather with carcinogens, heredity, and genetic mutations. However, cancer statistics show that viruses are responsible for as many as 15% of cancers in humans, not to mention other infectious particles like bacteria that have been linked to some cancers. This fact may help to explain the increased occurrences of some cancers in the immunosuppressed of the AIDS community.

Certain types of cancers have been associated with AIDS since the first cases of the disease. In these early days of the pandemic, a very rare cancer called Kaposi’s sarcoma was often a tell-tale sign of AIDS, and thus became known as an AIDS-defining cancer. Some other AIDS-defining cancers were non-Hodgkin’s lymphoma and cervical cancer, both of which are associated with viruses (as is Kaposi’s sarcoma) and took advantage of a host’s decreased immune defenses. In contract, non-AIDS-defining cancers are those not associated with immunodeficiency and therefore were not indicators of HIV infection. However, research has shown that some cancers that were originally considered non-AIDS-defining, such as Hodgkin’s disease and lip cancer, are in fact associated with immunosuppression and thus could be moved from the non-AIDS-defining to the AIDS-defining cancer group. This association with decreased immune function may suggest either that these cancers are also associated with viruses or that an underperforming immune system makes a person susceptible to more types of cancer than just those caused by infectious particles.

Another study from 2005 looked at how the survival of people with AIDS from cancer has changed since the first cases of AIDS compared to the general population. While this only looked at survival for 24 months after cancer diagnosis, significant improvements were seen since the 1980s in the survival of AIDS patients with certain cancers. In particular, the time period since 1996 and the introduction of HAART (or highly active antiretroviral therapies) has seen marked increases in survival rates, suggesting that if HIV is treated with more effective drugs and the immune system is better protected, then more powerful anti-cancer drugs can be used, which translates to better survival.

A recent article from the Washington Post by Mark Wainberg does a good job of looking at some of the most recent and pressing issues surrounding cancer in people with AIDS. First of all there is the troubling fact that there have been increased cases of severe and untreatable cancers in AIDS patients above the levels in the general population. He attributes this trend to the fact that while antiretroviral drugs can help fight HIV, they cannot repair the immune system to pre-infection levels, and thus may leave a person with a decreased defense against cancer.

This fact and others are cause for concern in the AIDS community. For one, there is always the issue of treating two diseases at once – doctors have to be very careful about the side-effects of mixing powerful drugs in patients while weighing them against the effect of not giving the patient that drug at all. In addition, there is cause for concern about the rising number of cancer cases in people with HIV who have been infected for 5-15 years. Researchers are unsure about what this means for other groups, such as those infected for a longer time. There is always the worry that more and more different types of cancers will start to affect AIDS patients, which makes it harder to treat cancer since almost all types require different treatment regimens and finding drug combinations for AIDS and many different cancers could be a daunting task. These are just some of the many possible challenges that physicians and researchers face in fighting both AIDS and cancer in the coming years.

Wainberg’s article ends by emphasizing the importance of finding drugs that not only help fight HIV replication and spread, but also help repair damage already done to the immune system by the virus. In addition, there is a lot more research that needs to be done in this area to determine whether all the cancers that are occurring in higher numbers in AIDS patients are related to infectious particles or if there is some other way that HIV is causing an increased occurrence of cancer in its hosts. And physicians who deal with AIDS patients need to cooperate with those who treat cancer patients to find effective and safe drug therapies that can treat both diseases at the same time.

With a large portion of the HIV-positive population reaching the age of increased cancer susceptibility, this issue will become more significant in the AIDS community in the coming years. The sooner doctors and researchers start to take on this coming problem, the better the chances that we can find ways to prevent cancer from becoming a huge obstacle in AIDS treatment. While advances in antiretroviral therapy are great steps forward for the fight against AIDS, we need to keep making strides in treatment beyond just controlling the virus and look to anticipate and deal with issues in the treatment of HIV-positive people before they become critical.

That ends this installment of The AIDS Pandemic. I’m Mike Neri, and thanks for listening.