I'm Charlie Raver.
One of the distinguishing characteristics between the AIDS epidemic in the developed world and that in Africa and the developing world is a simple lack of the infrastructure to deal with the disease. Infrastructure includes everything from roads to electricity to hospitals. One example that most of us rarely think of as a gift, couldn’t dream of walking into a home and not finding, and would be lost without is something to which many in the developing world do not have access. What am I talking about? Refrigeration. Without this amazing piece of technology we would not be able to easily enjoy fresh meats, fish, dairy, and many simple nutritional luxuries that we as Americans take for granted. In addition to problems with food preservation, hospitals and health clinics would be unable to store blood, vaccines, heat intolerant medicines, and many laboratory supplies.
For many in the developing world that is exactly the problem. Without refrigeration they have no means to store many of the supplies necessary for maintaining a health clinic. Without this infrastructure, access to basic care, essential for the treatment of AIDS, is extremely limited. Recently, the WHO recommended the use of a ritonavir boosted protease inhibitor as part of the drug regimen. Aside from being able to obtain the drug, one problem is that ritonavir requires refrigeration in hot climates. Currently only one of the ritonavir boosted PIs is available in a heat stable form which, obviously puts a huge constraint on the availability of the drug in the developing world. A confounding issue is the high rates of coinfection of diseases such as tuberculosis and malaria in these resource poor areas. In addition to proper care, access to testing for HIV and TB has been cited as one of the first obstacles to fighting the epidemic. The WHO estimates that less than 10% of people living with HIV/AIDS in parts of Sub-Saharan Africa are aware of their HIV status.
In addition to poor access to health care, the epidemic is only made worse by the staggering rates of malnutrition. In their recommendations for antiretroviral therapy, the WHO emphasized the importance of nutrition not just for the overall health of the affected individuals but also because of the link between nutrition and the effectiveness of ART. However, in some parts of Sub-Saharan Africa, it is estimated that as much as 50% of the population is malnourished. Many Africans do not even have the means to buy or grow the most basic foods. This problem is again only made worse by the lack of refrigeration. Some form of food preservation could allow rural communities and individuals to grow crops in excess and store the surplus to either sell and trade with other communities or even just maintain a supply during the non-productive parts of the year. However, when you consider that over 500 million people in Sub-Saharan Africa do not have access to electricity the idea of refrigeration is a long shot.
Unfortunately providing those in rural Africa with electricity is a problem unto itself. Without economic stability there is little room for expansion and improvement of infrastructure whether it is roads, electricity or health care. These lacks in infrastructure only make the AIDS epidemic harder to fight which further hinders economic growth. However, small improvements like access to refrigeration could be a catalyst for change.
One type of refrigeration that requires no electricity is sorption refrigeration. This form of refrigeration works by having two chambers connected by some type of tube. One chamber, the hot side, contains an absorbent material. The other chamber, the cold side, contains a refrigerant. The tube connecting the two would be filled with refrigerant vapor. The vapor in the tube is then absorbed on the hot side causing a drop in pressure in the connecting tube. This causes evaporation of the refrigerant which in the process absorbs heat and causes cooling on the cold side. This continues until all the refrigerant has vaporized and been absorbed on the hot side. To restart the cooling process, the hot side must be heated gently to drive the refrigerant vapor out of the absorbent material and back to the cold side. In the late 1920s, Powell Crosley Jr. developed a commercial version using ammonia and water that was used throughout the rural United States prior to wide-spread access to electricity. Although this is by no means a large scale solution to the infrastructure problem, adaptation of these ideas for use in the developing world could provide one of the basic necessities for health care and food preservation.
Friday, March 30, 2007
Friday, March 23, 2007
AIDS Orphans in Sub-Saharan Africa
I'm Christie Brough
According to the AIDS Epidemic Update of December 2006, about 25 million people are living with HIV in sub-Saharan Africa, comprising 63 percent of all individuals with HIV globally. Approximately 13.3 million, or 59 percent, of these individuals are women, most of whom have children. Although considerable efforts have been made to provide these individuals increased access to antiretroviral therapy, 2.1 million Africans died in 2006, resulting in an increased number of AIDS orphans.
In 2001, 14 million children had already lost one or both of their parents to AIDS. Because of the difficulty of obtaining antiretroviral therapy, many more children will be affected. In fact, one estimate projects that the number of AIDS orphans will increase by approximately 150 percent by the year 2010, leaving 20 million children to raise themselves.
As children watch their parents succumb to AIDS, they often suffer psychological and emotional harm. Once a parent becomes too sick to work, children are forced to work themselves in order to raise money for their families or to take care of younger siblings, causing them to drop out of school. Another factor forcing children to drop out of school is their inability to pay for required items, like school uniforms, pencils, textbooks, and exam fees, which they no longer can afford. If they do not have these items for school every day, they may be sent home and told not to return until they have the proper materials. Children that continue to attend school despite their parent’s illness often display a lack of attention or inappropriate behavior in the classroom, which is thought to result from emotional stress. Academic performance is also negatively affected by child malnutrition. Malnutrition is common in AIDS-related poverty since most of the family’s resources must be spent on medication for the ill parent. As a result, school enrollment rates in sub-Saharan Africa are dropping as the death toll from AIDS continues to rise.
Children that grow up without parents and without an education are “trapped in a social and pedagogical vacuum.” These children are not only more vulnerable to contract HIV/AIDS, but they are also at higher risk of unemployment, exploitation, and other forms of social inequalities. In order to change the outlook for AIDS orphans in sub-Saharan Africa, international and national agencies must aid in providing greater access to antiretroviral treatment. One relatively successful example is the World Heath Organization’s 3-by-5 program. The 3-by-5 plan aimed at providing 3 million individuals worldwide antiretroviral treatment by 2005. Although the program did not meet its goal of treating 3 million HIV positive individuals in the 2-year period, the program successfully provided access to many individuals who were not receiving treatment before. According to the World Health Organization, the number of individuals receiving treatment in sub-Saharan Africa increased by more than 800 percent, increasing the distribution of antiretroviral drugs from 100,000 individuals to 810,000 individuals.
Although the success of the 3-by-5 program will decrease the number of AIDS orphans in future generations, programs must be implemented to save current AIDS orphans. One option is the development of vocational training programs, which could help orphans stay off the streets (especially, young girls who are forced into sex work). If funds from debt relief programs are channeled directly into schools, school enrollment might increase. Another option is to offer government subsidies to extended families, which might help children stay out of work and stay in school. Additionally, providing government subsidies would maintain a family structure for children, keeping them out of orphanages. While these appear to be wonderful programs, the effectiveness of these programs would be difficult to monitor. Thus, before any programs are employed, local, national, and international governments and agencies want to ensure their success. However, it is imperative that these agencies act quickly before it is too late.
According to the AIDS Epidemic Update of December 2006, about 25 million people are living with HIV in sub-Saharan Africa, comprising 63 percent of all individuals with HIV globally. Approximately 13.3 million, or 59 percent, of these individuals are women, most of whom have children. Although considerable efforts have been made to provide these individuals increased access to antiretroviral therapy, 2.1 million Africans died in 2006, resulting in an increased number of AIDS orphans.
In 2001, 14 million children had already lost one or both of their parents to AIDS. Because of the difficulty of obtaining antiretroviral therapy, many more children will be affected. In fact, one estimate projects that the number of AIDS orphans will increase by approximately 150 percent by the year 2010, leaving 20 million children to raise themselves.
As children watch their parents succumb to AIDS, they often suffer psychological and emotional harm. Once a parent becomes too sick to work, children are forced to work themselves in order to raise money for their families or to take care of younger siblings, causing them to drop out of school. Another factor forcing children to drop out of school is their inability to pay for required items, like school uniforms, pencils, textbooks, and exam fees, which they no longer can afford. If they do not have these items for school every day, they may be sent home and told not to return until they have the proper materials. Children that continue to attend school despite their parent’s illness often display a lack of attention or inappropriate behavior in the classroom, which is thought to result from emotional stress. Academic performance is also negatively affected by child malnutrition. Malnutrition is common in AIDS-related poverty since most of the family’s resources must be spent on medication for the ill parent. As a result, school enrollment rates in sub-Saharan Africa are dropping as the death toll from AIDS continues to rise.
Children that grow up without parents and without an education are “trapped in a social and pedagogical vacuum.” These children are not only more vulnerable to contract HIV/AIDS, but they are also at higher risk of unemployment, exploitation, and other forms of social inequalities. In order to change the outlook for AIDS orphans in sub-Saharan Africa, international and national agencies must aid in providing greater access to antiretroviral treatment. One relatively successful example is the World Heath Organization’s 3-by-5 program. The 3-by-5 plan aimed at providing 3 million individuals worldwide antiretroviral treatment by 2005. Although the program did not meet its goal of treating 3 million HIV positive individuals in the 2-year period, the program successfully provided access to many individuals who were not receiving treatment before. According to the World Health Organization, the number of individuals receiving treatment in sub-Saharan Africa increased by more than 800 percent, increasing the distribution of antiretroviral drugs from 100,000 individuals to 810,000 individuals.
Although the success of the 3-by-5 program will decrease the number of AIDS orphans in future generations, programs must be implemented to save current AIDS orphans. One option is the development of vocational training programs, which could help orphans stay off the streets (especially, young girls who are forced into sex work). If funds from debt relief programs are channeled directly into schools, school enrollment might increase. Another option is to offer government subsidies to extended families, which might help children stay out of work and stay in school. Additionally, providing government subsidies would maintain a family structure for children, keeping them out of orphanages. While these appear to be wonderful programs, the effectiveness of these programs would be difficult to monitor. Thus, before any programs are employed, local, national, and international governments and agencies want to ensure their success. However, it is imperative that these agencies act quickly before it is too late.
Friday, March 16, 2007
Stigma in the Lives of HIV+ Healthcare Workers
I'm Pete Levandoski
Advances in HIV related pharmacology have given HIV patients extended lifetimes, turning them from dead men walking to living individuals with a debilitating condition. In treating any patient, HIV status not withstanding, the American Dental Association states that dentists should practice, “high ethical standards which have the benefit of the patient as their primary goal” (Rhode Island Dental Association, 2006). If the maxim is adhered to, dentists should have no problems treating HIV positive individuals who come to them seeking care. The fear of exposure to the virus however, has led some dentists to refuse treatment. In these instances, the Supreme Court has stepped in, ordering treatment and protecting the rights of patients. However, in jumping to the aid of patients, the High Court may have inadvertently aided efforts to discriminate against those living with HIV.
A landmark case for HIV patients was the 1998 affirmation of the ruling in Abbott vs. Bragdon. Sidney Abbott, an HIV positive individual, successfully argued that in refusing to treat him because he was HIV positive, Dr. Rondon Bragdon had violated the Americans with Disabilities Act. Bragdon’s unsuccessful defense was that Abbott’s HIV represented a “direct threat” to his own health (Sfikas, 2002).
In May of 2002, the “direct threat” defense was again used, this time in the case of Waddell vs. Valley Forge. The Court ruled that Spencer Waddell, an HIV positive dental hygienist, could be removed from his job because his disease was a “direct threat” to the health of his patients (Sfikas, 2002). The sum of these two decisions is that the idea of “direct threat” can legally be used to protect patients but not to protect dentists.
The same code of ethics that puts patients first also claims that this goal has lead to, “…society affording to the profession the privilege and obligation of self-government” (Rhode Island Dental Association, 2006). Above all, dentists want to retain autonomy and self regulation. In the process of trying to protect patients, these two court decisions have reduced the autonomy of dentists. Decisions in the cases of Waddell and Abbott should have been made by dental professionals, argues Peter Sfikas in his article in the March 2002 Journal of the American Dental Association (Sfikas, 2002).
In the Abbott case, the procedure being performed was a cavity filling, which involves little to no blood. In the Waddell case, root planning, which involves a large amount of blood, was being done. The courts made the correct decision in siding with the patient when looking at the evidence in each specific case (Sfikas, 2002). However, instead of maintaining a case by case system, the courts have set precedents which issue blanket statements without regard for case specifics. This has lead to the reality that the only way a dentist can refuse treatment is by preemptively providing evidence of a “direct threat” to his or her health from the patient (Sfikas, 2002).
These two court cases have gone a long way to advancing the rights of HIV positive patients. The Supreme Court stepped in and set a precedent to prevent HIV positive individuals from being denied healthcare. The Waddell case however, could be spun to deny rights to HIV positive individuals (Sfikas, 2002). The Court gave Spencer Waddell’s employer the right to fire him because he was HIV positive. In trying to protect the rights of patients, the court system has set a legal precedent which discriminates against HIV positive workers if they pose a “direct threat” to the health of their customers (Sfikas, 2002).
Waddell’s case was denied writ of certiorari by the Supreme Court, so it will be up to future cases to decide whether or not firing an employee because they have HIV is legal (Waddell v. Valley Forge Dental Assocs. 2002). Whatever decisions are made in future cases; these two examples highlight the complex interplay between human rights and stigma that HIV positive individuals still face in the United States today.
Sources
Sfikas PM. “HIV and discrimination: A review of the Waddell case and its implications for health care professionals”. The Journal of the American Dental Association. Vol. 133, March 2002. (pp. 372-374).
Rhode Island Dental Association. “Principles of Ethics & Code of Professional Conduct”. 2006.< http://www.ridental.com/ethics.cfm>. (29 November 2006).
Waddell v. Valley Forge Dental Assocs. 535 U.S. 1096. US Supreme Court. 2002.
Advances in HIV related pharmacology have given HIV patients extended lifetimes, turning them from dead men walking to living individuals with a debilitating condition. In treating any patient, HIV status not withstanding, the American Dental Association states that dentists should practice, “high ethical standards which have the benefit of the patient as their primary goal” (Rhode Island Dental Association, 2006). If the maxim is adhered to, dentists should have no problems treating HIV positive individuals who come to them seeking care. The fear of exposure to the virus however, has led some dentists to refuse treatment. In these instances, the Supreme Court has stepped in, ordering treatment and protecting the rights of patients. However, in jumping to the aid of patients, the High Court may have inadvertently aided efforts to discriminate against those living with HIV.
A landmark case for HIV patients was the 1998 affirmation of the ruling in Abbott vs. Bragdon. Sidney Abbott, an HIV positive individual, successfully argued that in refusing to treat him because he was HIV positive, Dr. Rondon Bragdon had violated the Americans with Disabilities Act. Bragdon’s unsuccessful defense was that Abbott’s HIV represented a “direct threat” to his own health (Sfikas, 2002).
In May of 2002, the “direct threat” defense was again used, this time in the case of Waddell vs. Valley Forge. The Court ruled that Spencer Waddell, an HIV positive dental hygienist, could be removed from his job because his disease was a “direct threat” to the health of his patients (Sfikas, 2002). The sum of these two decisions is that the idea of “direct threat” can legally be used to protect patients but not to protect dentists.
The same code of ethics that puts patients first also claims that this goal has lead to, “…society affording to the profession the privilege and obligation of self-government” (Rhode Island Dental Association, 2006). Above all, dentists want to retain autonomy and self regulation. In the process of trying to protect patients, these two court decisions have reduced the autonomy of dentists. Decisions in the cases of Waddell and Abbott should have been made by dental professionals, argues Peter Sfikas in his article in the March 2002 Journal of the American Dental Association (Sfikas, 2002).
In the Abbott case, the procedure being performed was a cavity filling, which involves little to no blood. In the Waddell case, root planning, which involves a large amount of blood, was being done. The courts made the correct decision in siding with the patient when looking at the evidence in each specific case (Sfikas, 2002). However, instead of maintaining a case by case system, the courts have set precedents which issue blanket statements without regard for case specifics. This has lead to the reality that the only way a dentist can refuse treatment is by preemptively providing evidence of a “direct threat” to his or her health from the patient (Sfikas, 2002).
These two court cases have gone a long way to advancing the rights of HIV positive patients. The Supreme Court stepped in and set a precedent to prevent HIV positive individuals from being denied healthcare. The Waddell case however, could be spun to deny rights to HIV positive individuals (Sfikas, 2002). The Court gave Spencer Waddell’s employer the right to fire him because he was HIV positive. In trying to protect the rights of patients, the court system has set a legal precedent which discriminates against HIV positive workers if they pose a “direct threat” to the health of their customers (Sfikas, 2002).
Waddell’s case was denied writ of certiorari by the Supreme Court, so it will be up to future cases to decide whether or not firing an employee because they have HIV is legal (Waddell v. Valley Forge Dental Assocs. 2002). Whatever decisions are made in future cases; these two examples highlight the complex interplay between human rights and stigma that HIV positive individuals still face in the United States today.
Sources
Sfikas PM. “HIV and discrimination: A review of the Waddell case and its implications for health care professionals”. The Journal of the American Dental Association. Vol. 133, March 2002. (pp. 372-374).
Rhode Island Dental Association. “Principles of Ethics & Code of Professional Conduct”. 2006.< http://www.ridental.com/ethics.cfm>. (29 November 2006).
Waddell v. Valley Forge Dental Assocs. 535 U.S. 1096. US Supreme Court. 2002.
Friday, March 09, 2007
AIDS dementia: Current findings
Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Steve Halliday.
One of my most striking memories from my time spent in the hospital in Mwandi was towards the end of my stay when I saw a woman suffering from AIDS dementia who was in the courtyard screaming at the top of her lungs. I asked one of the hospital employees what was going on, and he responded “oh, she is confused.” Since that moment I’ve been interested in this symptom of late stage AIDS, and in today’s installment I am going to look at a paper that examines one possible cause of AIDS dementia, titled HIV-1 Promotes Quiescence in Human Neural Progenitor Cells by Krathwohl and Kaiser.
AIDS dementia is a purely clinical diagnosis, based on observations of cognitive decline and motor dysfunction, and occurs in approximately 6-15% of AIDS patients. The pathology of AIDS dementia remains elusive, however, and this article represents only one theory of how it is caused.
The article examines the possibility that HIV could inhibit the activity of recently discovered neural progenitor cells. These cells have been found to be capable of differentiating into new astrocytes and neurons, which are thought to then form synaptic connections with other neurons, increasing memory and replacing lost neurons in the hippocampus.
These progenitor cells exist in quiescent states until they are needed, and it has been found that these cells can be forced into quiescence by chemokines, which can be mediated by CXCR4 or CCR3. Because HIV-1 uses chemokine coreceptors it is thought that it may inhibit proliferation of progenitor cells and force them into quiescence.
To test whether HIV-1 could induce quiescence, the researchers used purified recombinant coat proteins from several stains of HIV-1 using proteins that signal through either CXCR4 or CCR3. They found that two strains caused plated progenitor cells to enter a quiescent state, reducing proliferation by 67 and 74%, while a third strain had no visible effect. They also discovered that by washing the plates the cells were able to begin differentiating again. The researchers went on to determine that the coat proteins of the effective strains induced expression of cyclin-dependent kinase inhibitors p21 and p27.
The researchers then sought to prove the HIV-1 coat proteins were mediated by chemokine receptor binding. They found that by adding pertussis toxin, which affects the G-proteins linked to chemokine receptors, the inhibitory effects of both effective strains were blocked, suggesting the suppressive effects of HIV-1 are mediated by chemokine receptors.
In addition to direct inhibition, HIV-1 was found to suppress phosphorylation of ERK, which stimulates neural progenitor cells. The two effective strains of HIV-1 were found on to inhibit ERK by 34 nad 77%. This was also shown to occur by signaling through chemokine receptors.
Having established that HIV-1 can inhibit neural progenitor cell differentiation, the researchers examined CerebroSpinal Fluid from patients suffering from AIDS dementia, and discovered that the CSF from patients suffering from dementia was able to suppress progenitor cells by 67% whereas CSF from patients without dementia showed no inhibitor effect.
They also determined that gp120 was responsible for this inhibition. Furthermore they determined that viral load for patients with and without dementia was similar, and presence or absence of antiretroviral therapy had no effect on the inhibitory effect of the CerebroSpinal Fluid.
The researchers then proved that both the HIV-1 coat proteins and the CSF from patients with dementia could reduce neural cell proliferation in human hippocampal tissue in vitro, and that autopsied hippocampal tissue from patients with dementia was found to contain 75% fewer neural progenitor cells than in patients without dementia.
This paper provides seemingly very conclusive evidence for the role of neural progenitor cells in AIDS dementia, but this is by no means the only area of research going on in AIDS dementia. Another paper, Pharmacological frontiers in the treatment of AIDS dementia by McGuire and Marder, discusses possibilities that reactants to viral products and macrophages may cause neuronal cell death, leading to dementia via a more direct route.
The pathology of AIDS dementia is complex and not easily deciphered, but hopefully with this continuing research an effective treatment can be found for this devastating AIDS related illness.
This is Steve Halliday signing off.
One of my most striking memories from my time spent in the hospital in Mwandi was towards the end of my stay when I saw a woman suffering from AIDS dementia who was in the courtyard screaming at the top of her lungs. I asked one of the hospital employees what was going on, and he responded “oh, she is confused.” Since that moment I’ve been interested in this symptom of late stage AIDS, and in today’s installment I am going to look at a paper that examines one possible cause of AIDS dementia, titled HIV-1 Promotes Quiescence in Human Neural Progenitor Cells by Krathwohl and Kaiser.
AIDS dementia is a purely clinical diagnosis, based on observations of cognitive decline and motor dysfunction, and occurs in approximately 6-15% of AIDS patients. The pathology of AIDS dementia remains elusive, however, and this article represents only one theory of how it is caused.
The article examines the possibility that HIV could inhibit the activity of recently discovered neural progenitor cells. These cells have been found to be capable of differentiating into new astrocytes and neurons, which are thought to then form synaptic connections with other neurons, increasing memory and replacing lost neurons in the hippocampus.
These progenitor cells exist in quiescent states until they are needed, and it has been found that these cells can be forced into quiescence by chemokines, which can be mediated by CXCR4 or CCR3. Because HIV-1 uses chemokine coreceptors it is thought that it may inhibit proliferation of progenitor cells and force them into quiescence.
To test whether HIV-1 could induce quiescence, the researchers used purified recombinant coat proteins from several stains of HIV-1 using proteins that signal through either CXCR4 or CCR3. They found that two strains caused plated progenitor cells to enter a quiescent state, reducing proliferation by 67 and 74%, while a third strain had no visible effect. They also discovered that by washing the plates the cells were able to begin differentiating again. The researchers went on to determine that the coat proteins of the effective strains induced expression of cyclin-dependent kinase inhibitors p21 and p27.
The researchers then sought to prove the HIV-1 coat proteins were mediated by chemokine receptor binding. They found that by adding pertussis toxin, which affects the G-proteins linked to chemokine receptors, the inhibitory effects of both effective strains were blocked, suggesting the suppressive effects of HIV-1 are mediated by chemokine receptors.
In addition to direct inhibition, HIV-1 was found to suppress phosphorylation of ERK, which stimulates neural progenitor cells. The two effective strains of HIV-1 were found on to inhibit ERK by 34 nad 77%. This was also shown to occur by signaling through chemokine receptors.
Having established that HIV-1 can inhibit neural progenitor cell differentiation, the researchers examined CerebroSpinal Fluid from patients suffering from AIDS dementia, and discovered that the CSF from patients suffering from dementia was able to suppress progenitor cells by 67% whereas CSF from patients without dementia showed no inhibitor effect.
They also determined that gp120 was responsible for this inhibition. Furthermore they determined that viral load for patients with and without dementia was similar, and presence or absence of antiretroviral therapy had no effect on the inhibitory effect of the CerebroSpinal Fluid.
The researchers then proved that both the HIV-1 coat proteins and the CSF from patients with dementia could reduce neural cell proliferation in human hippocampal tissue in vitro, and that autopsied hippocampal tissue from patients with dementia was found to contain 75% fewer neural progenitor cells than in patients without dementia.
This paper provides seemingly very conclusive evidence for the role of neural progenitor cells in AIDS dementia, but this is by no means the only area of research going on in AIDS dementia. Another paper, Pharmacological frontiers in the treatment of AIDS dementia by McGuire and Marder, discusses possibilities that reactants to viral products and macrophages may cause neuronal cell death, leading to dementia via a more direct route.
The pathology of AIDS dementia is complex and not easily deciphered, but hopefully with this continuing research an effective treatment can be found for this devastating AIDS related illness.
This is Steve Halliday signing off.
Friday, March 02, 2007
HIV/AIDS in Prisons
Welcome to this installment of the AIDS Pandemic, a podcast hosted by Dave Wessner of the Department of Biology at Davidson College. I am Justin Fried.
Prisons have become a fertile ground for the HIV epidemic in the United States. In fact the Joint United Nation Programme on AIDS (UNAIDS) listed prisoners as one of the four "major at-risk and neglected populations" in the HIV/AIDS pandemic (2006 Report on the Global AIDS Epidemic). The other three categories included men who have sex with men, injection drug users, and sex workers (2006 Report on the Global AIDS Epidemic). Recent figures show that 2.3 percent of state prison inmates, and 1.0 percent of federal prison inmates in the United States are HIV positive, and an estimated 20 to 26 percent of people living with HIV have spent time in the correctional system (2006 Report on the Global AIDS Epidemic and Kantor 2006). The overcrowded and typically understaffed prisons in the United States are ideal breeding grounds for HIV. HIV is transmitted through bodily fluids with sharing needles and unprotected sex being the leading causes of virus transmission. Despite strict regulations against drugs in prisons, intravenous drug use still occurs. Clean needles are almost impossible to find and needles or improvised injection devices are often shared by inmates. These needles may also be shared for tattooing, another common practice in prisons. In addition to drugs, many inmates turn to sex to escape the boredom of prison life. Because distribution of condoms is prohibited in most penal institutions across the United States, safe sex is not even an option for most inmates. Sexual assault and rape, which are common intimidation tactics used by inmates, are also potential sources of transmission of HIV in correctional facilities (2006 Report on the Global AIDS Epidemic).
While high risk behaviors common to prisons put inmates at a higher risk for HIV infection while incarcerated, most HIV positive prisoners were infected before being sent to prison (HIV/AIDS Prevention). Indeed, the populations most vulnerable to the HIV infection are the same communities at high risk for criminalization and incarceration (HIV/AIDS Prevention). Fear of discrimination deters prisoners from accessing the voluntary HIV testing available in most prisons. Test result confidentiality is a major issue in a prison environment where even the suspicion of a positive test result can lead to stigmatization, bringing social isolation and violence from other inmates and sometimes even prison staff. The fear of stigmatization also discourages many inmates living with HIV from seeking medical services and treatment. Prison conditions also undermine the dosing schedules that are important for the effectiveness of antiretroviral therapy. Transfers of inmates to different correctional institutions or to and from courthouses can cause gaps in treatment. Searches for contraband may also result in medicine confiscation (Kantor 2006).
Addressing the problem of HIV and AIDS in prisons requires a multifaceted approach. UNAIDS believes that it is essential that prisoners be allowed access to prevention materials, including condoms, safer-sex supplies, and bleach kits for cleaning needles (HIV/AIDS Prevention). Increasing HIV and AIDS awareness through prisoner health education programs is crucial to decreasing the stigmatization of HIV inside prisons that prevents many inmates from seeking testing or treatment. For inmates living with HIV, provisions must be taken to ensure the regular interruptions of a prisoner’s life do not interrupt his or her antiretroviral therapy.
The Hampden County Correctional Facility in Massachusetts is a prison which is taking steps towards providing preventive education and effective health care to its inmates. This prison has adopted a health care program based on a public health model that provides inmates with a community-based standard of care (Kahn 2000). This program is based around five basic tenets: detection, effective and prompt treatment, education, prevention, and continuity of care. Prisoners undergo a three-day orientation upon admission and are given a full physical exam including tests for common communicable diseases. After attending an intensive peer-led educational session on HIV and AIDS, new inmates are encouraged to take an HIV test. Inmates that test positive for HIV then undergo additional tests to determine how best to proceed with treatment. Doctors, nurses, and case managers from the community are brought into the jail to deliver services to inmates. After the prisoners are released they have the option of continuing with the same primary care providers through a comprehensive discharge plan that includes Medicaid benefits and other supportive services (Kahn 2000).
The Hampden County Correctional facility is taking steps in the right direction, but fighting HIV in prisons is an uphill battle that will require revolutionizing prison health care. For changes to be made, Americans must first recognize that prisons are not isolated from the world, and that most inmates will eventually be released and infections acquired inside prison walls can be transmitted to the society outside. Preventing and treating HIV in prisons will benefit society as a whole and is important in the fight against AIDS.
Until next time, I am Justin Fried.
References
At Risk and Neglected: Four Key Populations. 2006 Report on the Global AIDS Epidemic. Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from http://data.unaids.org/pub/GlobalReport/2006/2006_GR_CH05_en.pdf
HIV/AIDS Prevention, Care, and Treatment in Prison Settings: A Framework for an Effective National Response. Health Organization and Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from
http://data.unaids.org/pub/Report/2006/20060701_HIV-AIDS_prisons_en.pdf.
Kahn, Stanya. Fire in the belly: A model program stresses community involvement. AIDS Info NYC. January 2000. Retrieved Dec 2, 2006 from http://www.aidsinfonyc.org/hivplus/issue6/report/model.html.
Kantor, Elizabeth. HIV Transmission and Prevention in Prisons. HIV Insight. April 2006. Retrieved Dec 2, 2006 from http://hivinsite.ucsf.edu/InSite?page=kb-07-04-13
Prisons have become a fertile ground for the HIV epidemic in the United States. In fact the Joint United Nation Programme on AIDS (UNAIDS) listed prisoners as one of the four "major at-risk and neglected populations" in the HIV/AIDS pandemic (2006 Report on the Global AIDS Epidemic). The other three categories included men who have sex with men, injection drug users, and sex workers (2006 Report on the Global AIDS Epidemic). Recent figures show that 2.3 percent of state prison inmates, and 1.0 percent of federal prison inmates in the United States are HIV positive, and an estimated 20 to 26 percent of people living with HIV have spent time in the correctional system (2006 Report on the Global AIDS Epidemic and Kantor 2006). The overcrowded and typically understaffed prisons in the United States are ideal breeding grounds for HIV. HIV is transmitted through bodily fluids with sharing needles and unprotected sex being the leading causes of virus transmission. Despite strict regulations against drugs in prisons, intravenous drug use still occurs. Clean needles are almost impossible to find and needles or improvised injection devices are often shared by inmates. These needles may also be shared for tattooing, another common practice in prisons. In addition to drugs, many inmates turn to sex to escape the boredom of prison life. Because distribution of condoms is prohibited in most penal institutions across the United States, safe sex is not even an option for most inmates. Sexual assault and rape, which are common intimidation tactics used by inmates, are also potential sources of transmission of HIV in correctional facilities (2006 Report on the Global AIDS Epidemic).
While high risk behaviors common to prisons put inmates at a higher risk for HIV infection while incarcerated, most HIV positive prisoners were infected before being sent to prison (HIV/AIDS Prevention). Indeed, the populations most vulnerable to the HIV infection are the same communities at high risk for criminalization and incarceration (HIV/AIDS Prevention). Fear of discrimination deters prisoners from accessing the voluntary HIV testing available in most prisons. Test result confidentiality is a major issue in a prison environment where even the suspicion of a positive test result can lead to stigmatization, bringing social isolation and violence from other inmates and sometimes even prison staff. The fear of stigmatization also discourages many inmates living with HIV from seeking medical services and treatment. Prison conditions also undermine the dosing schedules that are important for the effectiveness of antiretroviral therapy. Transfers of inmates to different correctional institutions or to and from courthouses can cause gaps in treatment. Searches for contraband may also result in medicine confiscation (Kantor 2006).
Addressing the problem of HIV and AIDS in prisons requires a multifaceted approach. UNAIDS believes that it is essential that prisoners be allowed access to prevention materials, including condoms, safer-sex supplies, and bleach kits for cleaning needles (HIV/AIDS Prevention). Increasing HIV and AIDS awareness through prisoner health education programs is crucial to decreasing the stigmatization of HIV inside prisons that prevents many inmates from seeking testing or treatment. For inmates living with HIV, provisions must be taken to ensure the regular interruptions of a prisoner’s life do not interrupt his or her antiretroviral therapy.
The Hampden County Correctional Facility in Massachusetts is a prison which is taking steps towards providing preventive education and effective health care to its inmates. This prison has adopted a health care program based on a public health model that provides inmates with a community-based standard of care (Kahn 2000). This program is based around five basic tenets: detection, effective and prompt treatment, education, prevention, and continuity of care. Prisoners undergo a three-day orientation upon admission and are given a full physical exam including tests for common communicable diseases. After attending an intensive peer-led educational session on HIV and AIDS, new inmates are encouraged to take an HIV test. Inmates that test positive for HIV then undergo additional tests to determine how best to proceed with treatment. Doctors, nurses, and case managers from the community are brought into the jail to deliver services to inmates. After the prisoners are released they have the option of continuing with the same primary care providers through a comprehensive discharge plan that includes Medicaid benefits and other supportive services (Kahn 2000).
The Hampden County Correctional facility is taking steps in the right direction, but fighting HIV in prisons is an uphill battle that will require revolutionizing prison health care. For changes to be made, Americans must first recognize that prisons are not isolated from the world, and that most inmates will eventually be released and infections acquired inside prison walls can be transmitted to the society outside. Preventing and treating HIV in prisons will benefit society as a whole and is important in the fight against AIDS.
Until next time, I am Justin Fried.
References
At Risk and Neglected: Four Key Populations. 2006 Report on the Global AIDS Epidemic. Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from http://data.unaids.org/pub/GlobalReport/2006/2006_GR_CH05_en.pdf
HIV/AIDS Prevention, Care, and Treatment in Prison Settings: A Framework for an Effective National Response. Health Organization and Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from
http://data.unaids.org/pub/Report/2006/20060701_HIV-AIDS_prisons_en.pdf.
Kahn, Stanya. Fire in the belly: A model program stresses community involvement. AIDS Info NYC. January 2000. Retrieved Dec 2, 2006 from http://www.aidsinfonyc.org/hivplus/issue6/report/model.html.
Kantor, Elizabeth. HIV Transmission and Prevention in Prisons. HIV Insight. April 2006. Retrieved Dec 2, 2006 from http://hivinsite.ucsf.edu/InSite?page=kb-07-04-13
Friday, February 23, 2007
A Dual Epidemic: HIV/AIDS and Injection Drug Use in Russia
I'm Meredith Prasse.
Before 1995, the total number of HIV infections in the entire region of central and Eastern Europe, with over 450 million inhabitants, was less than 30,000. The World Health Organization reported an estimated 0.6-1.9% prevalence, between 420,000 and 1.4 million cases, of HIV/AIDS in Russia in 2003. Between 1996 and 1998 alone, Russia experienced a 100-fold increase in new HIV infections, demonstrating the rapid onset of the epidemic in this region. Well over 70% of all HIV cases in Russia occur in injection drug users (IDUs), demonstrating the widespread exercise of unsafe drug-using practices among the IDU population in Russia. Sadly, only 10% of HIV-infected Russian IDUs currently receive HIV combination therapy, and only 15% of HIV-positive Russians receiving therapy are IDUs.
An epidemic of drug use is occurring alongside the HIV/AIDS epidemic in Russia. While the epidemic of injection drug use in Russia cannot be attributed to a single factor, there was a significant rise in drug use following the collapse of the Soviet Union. WHO estimates that between 1.5 and 3.5 million Russians are IDUs, and the prevalence of HIV in the drug-using population approaches 65% in some Russian cities, further demonstrating the connection between drug use and HIV in Russia. Between 1990 and 2002, the number of first-time drug users referred to treatment centers increased 6.5-fold, while the number of drug-associated deaths increased 5-fold between 1999 and 2000.
The challenges facing the Russian HIV/AIDS epidemic are multifaceted. An estimated 30-40% of IDUs in Russia use non-sterile needles or share needles, demonstrating the widespread unsafe drug use in Russia. Many IDUs reportedly re-fill their syringes by front-loading from the dealers’ syringes, and many dealers are IDUs themselves who inject from that very supply. During the drug preparation process, dealers in several different Russian cities have also reported adding blood to the drug solution as a ‘cleansing’ process, believing that the blood neutralizes toxic substances used to produce the drugs.
There are also significant legal and political dilemmas which complicate the Russian HIV/AIDS epidemic in IDUs. A combination of harsh drug policies and regular harassment by the police force pushes IDUs underground and decreases their chances of accessing preventive resources or care in drug treatment facilities. The synonymously corrupt Russian police arrests IDUs for possession of minimal amounts of narcotics in order to fill quotas. As a result, drug users refrain from seeking treatment or accessing clean needles in fear of incarceration or simply being registered as a drug user. IDUs that access formal treatment centers are officially registered and monitored by that facility for five years, and this official registration can have further negative repercussions such as restrictions on employment, drivers’ licenses, and military service. While treatment for drug dependence is an effective way to both eliminate drug dependence and decrease the risk of contracting HIV, the distrust in drug treatment services has resulted in low utilization of these resources by IDUs. Another legal dilemma for IDUs is that methadone, a common substitution for heroine users and an important part of HIV prevention for heroine users elsewhere, is banned for treatment in Russia.
While IDUs comprise the majority of the at-risk population in Russia, the threat to non-IDUs is on the rise. A majority of IDUs in Russia are young heterosexual men. These men have the potential to spread HIV to their partners: commercial sex workers, girlfriends, wives, etc., many who do not have the power or awareness to demand condom usage. In addition, commercial sex work is on the rise in numerous Russian cities, and the overlap between injection drug use and commercial sex work is high. It is estimated that between 15 and 50% of female IDUs practice commercial sex work, and many of them do so as a means of obtaining drugs. HIV transmission from sex workers to their clients is high, and these male clients may subsequently infect their non-IDU sex partners. Thus, IDUs and sex workers act as a bridge for sexual HIV transmission between IDUs and non-IDUs in Russia, facilitating a more widespread epidemic.
In the face of the continually increasing rates of drug use and HIV infection, the Russian government needs to implement policy changes to slow these increasing rates. This dual epidemic can be fought on many different fronts. Primarily, the government must increase support for safe needle exchange programs to reduce the spread of HIV among the IDU population. In addition, the ban on methadone-substitution therapy for heroine users should be lifted to encourage treatment options and reduce needle use. More generally, the government needs to put more focus on drug prevention programs. Future HIV prevention strategies targeting IDUs should include sexual risk reduction to reduce the potential spread between the IDU and non-IDU populations. With such alarmingly high rates of HIV infection among the IDU population, this problem cannot be ignored. The longer it is disregarded, the more this epidemic will seep into the non-IDU sectors of Russian society, facilitating an epidemic with a wider scope and greater force.
Works Cited
Bobrova, Natalia, Tim Rhodes, Robert Power, Ron Alcorn, Elena Neifeld, Nikolai Krasiukov, Natalia Latyshevskaia, and Svetlana Maksimova. “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities.” Drug and Alcohol Dependence 82 (2006): S57-S63.
Dehne, Karl L., Lev Khodakevich, Francoise F. Hamers, and Bernhard Schwartlander. “The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.” AIDS 13 (1999): 741-749.
Human Rights Watch. “Russia: harsh drug policies fuel AIDS epidemic.” Available at http://hrw.org/english/docs/2004/04/27/russia8497_txt.htm. Accessed on 16 November 2006. Human Rights Watch: 28 April 2004.
Kalichman, Seth C., Jeffrey A. Kelly, Kathleen J. Koslov, P Andrei, Alla Shaboltas, and Juliana Granskaya. “The emerging AIDS crisis in Russia: review of enabling factors and prevention needs.” International Journal of STD & AIDS 11 (February 2000): 71-75.
Lowndes, Catherine M., Michel Alary, and Lucy Platt. “Injection drug use, commercial sex work, and the HIV/STI epidemic in the Russian Federation.” Sexually Transmitted Diseases 30 (January 2003): 46-8.
Luo, Robert F. and Joseph Cofrancesco Jr. “Injection drug use and HIV transmission in Russia.” AIDS 20 (2006): 935-936.
Rhodes, Tim, Lucy Platt, et. al. “Prevalence of HIV, hepatitis C, and syphilis among injecting drug users in Russia: a multi-city study.” Addiction 101 (February 2006): 252-266.
Shaboltas, Alla V., Olga V. Toussova, et. al. “HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia.” Journal of Acquired Immune Deficiency Syndrome 41 (15 April 2006): 657-662.
World Health Organization. “Summary Country Profile for HIV/AIDS Treatment Scale Up: Russian Federation.” Available at http://www.who.int/hiv/HIVCP_RUSSIA.pdf. Accessed on November 16, 2006. WHO 2005.
Before 1995, the total number of HIV infections in the entire region of central and Eastern Europe, with over 450 million inhabitants, was less than 30,000. The World Health Organization reported an estimated 0.6-1.9% prevalence, between 420,000 and 1.4 million cases, of HIV/AIDS in Russia in 2003. Between 1996 and 1998 alone, Russia experienced a 100-fold increase in new HIV infections, demonstrating the rapid onset of the epidemic in this region. Well over 70% of all HIV cases in Russia occur in injection drug users (IDUs), demonstrating the widespread exercise of unsafe drug-using practices among the IDU population in Russia. Sadly, only 10% of HIV-infected Russian IDUs currently receive HIV combination therapy, and only 15% of HIV-positive Russians receiving therapy are IDUs.
An epidemic of drug use is occurring alongside the HIV/AIDS epidemic in Russia. While the epidemic of injection drug use in Russia cannot be attributed to a single factor, there was a significant rise in drug use following the collapse of the Soviet Union. WHO estimates that between 1.5 and 3.5 million Russians are IDUs, and the prevalence of HIV in the drug-using population approaches 65% in some Russian cities, further demonstrating the connection between drug use and HIV in Russia. Between 1990 and 2002, the number of first-time drug users referred to treatment centers increased 6.5-fold, while the number of drug-associated deaths increased 5-fold between 1999 and 2000.
The challenges facing the Russian HIV/AIDS epidemic are multifaceted. An estimated 30-40% of IDUs in Russia use non-sterile needles or share needles, demonstrating the widespread unsafe drug use in Russia. Many IDUs reportedly re-fill their syringes by front-loading from the dealers’ syringes, and many dealers are IDUs themselves who inject from that very supply. During the drug preparation process, dealers in several different Russian cities have also reported adding blood to the drug solution as a ‘cleansing’ process, believing that the blood neutralizes toxic substances used to produce the drugs.
There are also significant legal and political dilemmas which complicate the Russian HIV/AIDS epidemic in IDUs. A combination of harsh drug policies and regular harassment by the police force pushes IDUs underground and decreases their chances of accessing preventive resources or care in drug treatment facilities. The synonymously corrupt Russian police arrests IDUs for possession of minimal amounts of narcotics in order to fill quotas. As a result, drug users refrain from seeking treatment or accessing clean needles in fear of incarceration or simply being registered as a drug user. IDUs that access formal treatment centers are officially registered and monitored by that facility for five years, and this official registration can have further negative repercussions such as restrictions on employment, drivers’ licenses, and military service. While treatment for drug dependence is an effective way to both eliminate drug dependence and decrease the risk of contracting HIV, the distrust in drug treatment services has resulted in low utilization of these resources by IDUs. Another legal dilemma for IDUs is that methadone, a common substitution for heroine users and an important part of HIV prevention for heroine users elsewhere, is banned for treatment in Russia.
While IDUs comprise the majority of the at-risk population in Russia, the threat to non-IDUs is on the rise. A majority of IDUs in Russia are young heterosexual men. These men have the potential to spread HIV to their partners: commercial sex workers, girlfriends, wives, etc., many who do not have the power or awareness to demand condom usage. In addition, commercial sex work is on the rise in numerous Russian cities, and the overlap between injection drug use and commercial sex work is high. It is estimated that between 15 and 50% of female IDUs practice commercial sex work, and many of them do so as a means of obtaining drugs. HIV transmission from sex workers to their clients is high, and these male clients may subsequently infect their non-IDU sex partners. Thus, IDUs and sex workers act as a bridge for sexual HIV transmission between IDUs and non-IDUs in Russia, facilitating a more widespread epidemic.
In the face of the continually increasing rates of drug use and HIV infection, the Russian government needs to implement policy changes to slow these increasing rates. This dual epidemic can be fought on many different fronts. Primarily, the government must increase support for safe needle exchange programs to reduce the spread of HIV among the IDU population. In addition, the ban on methadone-substitution therapy for heroine users should be lifted to encourage treatment options and reduce needle use. More generally, the government needs to put more focus on drug prevention programs. Future HIV prevention strategies targeting IDUs should include sexual risk reduction to reduce the potential spread between the IDU and non-IDU populations. With such alarmingly high rates of HIV infection among the IDU population, this problem cannot be ignored. The longer it is disregarded, the more this epidemic will seep into the non-IDU sectors of Russian society, facilitating an epidemic with a wider scope and greater force.
Works Cited
Bobrova, Natalia, Tim Rhodes, Robert Power, Ron Alcorn, Elena Neifeld, Nikolai Krasiukov, Natalia Latyshevskaia, and Svetlana Maksimova. “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities.” Drug and Alcohol Dependence 82 (2006): S57-S63.
Dehne, Karl L., Lev Khodakevich, Francoise F. Hamers, and Bernhard Schwartlander. “The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.” AIDS 13 (1999): 741-749.
Human Rights Watch. “Russia: harsh drug policies fuel AIDS epidemic.” Available at http://hrw.org/english/docs/2004/04/27/russia8497_txt.htm. Accessed on 16 November 2006. Human Rights Watch: 28 April 2004.
Kalichman, Seth C., Jeffrey A. Kelly, Kathleen J. Koslov, P Andrei, Alla Shaboltas, and Juliana Granskaya. “The emerging AIDS crisis in Russia: review of enabling factors and prevention needs.” International Journal of STD & AIDS 11 (February 2000): 71-75.
Lowndes, Catherine M., Michel Alary, and Lucy Platt. “Injection drug use, commercial sex work, and the HIV/STI epidemic in the Russian Federation.” Sexually Transmitted Diseases 30 (January 2003): 46-8.
Luo, Robert F. and Joseph Cofrancesco Jr. “Injection drug use and HIV transmission in Russia.” AIDS 20 (2006): 935-936.
Rhodes, Tim, Lucy Platt, et. al. “Prevalence of HIV, hepatitis C, and syphilis among injecting drug users in Russia: a multi-city study.” Addiction 101 (February 2006): 252-266.
Shaboltas, Alla V., Olga V. Toussova, et. al. “HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia.” Journal of Acquired Immune Deficiency Syndrome 41 (15 April 2006): 657-662.
World Health Organization. “Summary Country Profile for HIV/AIDS Treatment Scale Up: Russian Federation.” Available at http://www.who.int/hiv/HIVCP_RUSSIA.pdf. Accessed on November 16, 2006. WHO 2005.
Friday, February 16, 2007
Male Circumcision and HIV/AIDS
“When is it appropriate for public health practice to be on the side of an intervention that causes bodily injury?” (Franco)
I'm Erika Larson.
That is the question McGill’s Professor of Epidemiology, Eduardo Franco, asked when addressing circumcision as a possible method of reducing HIV prevalence. Circumcision has historically caused a polarizing debate across sectors of society including the pious, and the hygienic. Health workers have generally abstained from taking a side. However, new evidence that circumcision reduces infectivity of HIV may alter this precedent.
A recent study in the Journal of Infectious Diseases, Baeten et al. explore “Female to Male Infectivity of HIV-1 among Circumcised and Uncircumcised” in a cohort of Kenyan men. Unlike previous studies which did not isolate behavioral practices, this analysis designates per-sex act probabilities of HIV-1 transmission between circumcised and uncircumcised men.
Between 1993 and 1997, 745 Kenyan men, employed by six trucking companies around the Mombasa area, were recruited. After pre-counseling and informed consent, these men were examined for circumcision status, STD infection, and HIV-1 seropositivity using the ELISA antibody test. Follow-up visits included detailed accounts of sexual encounters and condom use. Each man attended a median of 4 follow-up visits over the span of 400 days. Risk reduction counseling and provision of free condoms accompanied follow-up visits.
Of the 95 uncircumcised men (13%), 11 experienced sercoconversion. Of the 650 circumcised men (87%), 32 seroconverted. Though the majority engaged in sexual activity with their wives, many were involved in extramarital sexual contact. The median number of sex acts per month (4.0) did not vary between circumcised and uncircumcised men. By using surveillance data to estimate prevalence for potential partners (wives, casual partners, and prostitutes), the researchers found an overall probability of acquiring HIV-1 through a single sex act was .0063. Female to male infectivity was higher for uncircumcised men than circumcised men (.0128 vs. .0051). Uncircumcised men were found to have over a 2-fold increased risk of HIV-1 infectivity per sex act.
Because the study could not trace the infection status or disease status of partners, some variants could not be isolated. However, ethnicity, occupation, and sexual risk behavior were statistically isolated. All results still revealed that uncircumcised men were at a higher risk for contracting HIV. The biological factors that cause this discrepancy could be the result of the thick skin that develops after circumcision which prevents HIV from targeting Langerhans cells.
Another study by French and South African researchers found results so dramatic that the control group was given the option to undergo the procedure. New research has created a wave of optimism in the scientific community. Dr. Seth Berkley, president of the International AIDS Vaccine Initiative, stated circumcision would be “an intervention that works over a person’s lifetime and could reduce HIV in a community setting.” Questions of acceptance as a risk-reduction policy were appeased in a recent South African study. In a survey of uncircumcised men, 70% stated they would undergo the procedure if it “proved to protect against sexually transmitted diseases.”
However optimism of community acceptance is marred by a false sense of security that circumcision could create. Increased risk behavior on the part of circumcised men could counter-act the benefits. For example 30% of uncircumcised men and 18% of circumcised men believed that the procedure would allow them to safely engage in sex with multiple partners.
Though we have already seen considerable risk-taking in prevention policy with needle exchange programs and safe injection facilities, circumcision continues to push the envelope on ethical approaches. Can we promote circumcision as a global policy to help weaken the horrifying forces of HIV? Is it feasible to pursue a worldwide circumcision effort especially in countries that rely on traditional practices (whose circumcision procedures may increase HIV-risk)? How can we prevent the unintentional consequences of viewing circumcision as a cure and the abandonment of safe-sex practices? Though circumcision does not affect HIV prevalence in men who have sex with men or IV drug users, it has huge possibilities on the African continent where heterosexual contact is the primary mode of transmission.
I'm Erika Larson.
That is the question McGill’s Professor of Epidemiology, Eduardo Franco, asked when addressing circumcision as a possible method of reducing HIV prevalence. Circumcision has historically caused a polarizing debate across sectors of society including the pious, and the hygienic. Health workers have generally abstained from taking a side. However, new evidence that circumcision reduces infectivity of HIV may alter this precedent.
A recent study in the Journal of Infectious Diseases, Baeten et al. explore “Female to Male Infectivity of HIV-1 among Circumcised and Uncircumcised” in a cohort of Kenyan men. Unlike previous studies which did not isolate behavioral practices, this analysis designates per-sex act probabilities of HIV-1 transmission between circumcised and uncircumcised men.
Between 1993 and 1997, 745 Kenyan men, employed by six trucking companies around the Mombasa area, were recruited. After pre-counseling and informed consent, these men were examined for circumcision status, STD infection, and HIV-1 seropositivity using the ELISA antibody test. Follow-up visits included detailed accounts of sexual encounters and condom use. Each man attended a median of 4 follow-up visits over the span of 400 days. Risk reduction counseling and provision of free condoms accompanied follow-up visits.
Of the 95 uncircumcised men (13%), 11 experienced sercoconversion. Of the 650 circumcised men (87%), 32 seroconverted. Though the majority engaged in sexual activity with their wives, many were involved in extramarital sexual contact. The median number of sex acts per month (4.0) did not vary between circumcised and uncircumcised men. By using surveillance data to estimate prevalence for potential partners (wives, casual partners, and prostitutes), the researchers found an overall probability of acquiring HIV-1 through a single sex act was .0063. Female to male infectivity was higher for uncircumcised men than circumcised men (.0128 vs. .0051). Uncircumcised men were found to have over a 2-fold increased risk of HIV-1 infectivity per sex act.
Because the study could not trace the infection status or disease status of partners, some variants could not be isolated. However, ethnicity, occupation, and sexual risk behavior were statistically isolated. All results still revealed that uncircumcised men were at a higher risk for contracting HIV. The biological factors that cause this discrepancy could be the result of the thick skin that develops after circumcision which prevents HIV from targeting Langerhans cells.
Another study by French and South African researchers found results so dramatic that the control group was given the option to undergo the procedure. New research has created a wave of optimism in the scientific community. Dr. Seth Berkley, president of the International AIDS Vaccine Initiative, stated circumcision would be “an intervention that works over a person’s lifetime and could reduce HIV in a community setting.” Questions of acceptance as a risk-reduction policy were appeased in a recent South African study. In a survey of uncircumcised men, 70% stated they would undergo the procedure if it “proved to protect against sexually transmitted diseases.”
However optimism of community acceptance is marred by a false sense of security that circumcision could create. Increased risk behavior on the part of circumcised men could counter-act the benefits. For example 30% of uncircumcised men and 18% of circumcised men believed that the procedure would allow them to safely engage in sex with multiple partners.
Though we have already seen considerable risk-taking in prevention policy with needle exchange programs and safe injection facilities, circumcision continues to push the envelope on ethical approaches. Can we promote circumcision as a global policy to help weaken the horrifying forces of HIV? Is it feasible to pursue a worldwide circumcision effort especially in countries that rely on traditional practices (whose circumcision procedures may increase HIV-risk)? How can we prevent the unintentional consequences of viewing circumcision as a cure and the abandonment of safe-sex practices? Though circumcision does not affect HIV prevalence in men who have sex with men or IV drug users, it has huge possibilities on the African continent where heterosexual contact is the primary mode of transmission.
Friday, February 09, 2007
The Links between HIV/AIDS and National Security
I'm Rebecca Jameson
In July of 2000, the UN Security Council passed Resolution 1308 stipulating that HIV poses a risk to the stability and security of the nations of the world. Since then, there has been considerable debate regarding the relationship between the AIDS pandemic and national security. According to expert analysts, the security implications of HIV’s rapid spread in Africa and other regions must be taken far more seriously by the industrialized West.
One concern expressed by security analysts has been the impact of HIV on individuals critical to the maintenance of state and international security: namely, soldiers and peacekeepers. AIDS is now the leading cause of death in military and police forces in some African countries, accounting for more than half of in-service mortality. The loss of highly trained, professional soldiers is not limited to Africa. Trained soldiers are difficult and expensive to replace, and their absence interrupts the training of younger recruits. Armed forces that rely wholly or partially on conscripts face a decreasing pool of healthy recruits as HIV continues to spread. The strategic impact of high HIV prevalence on the armed forces is complex and involves other country-specific factors as well.
There is growing evidence that the AIDS pandemic poses increasing challenges for the conduct of peacekeeping operations. These challenges include the spread of HIV by peacekeepers, the reduced ability of countries to contribute peacekeepers, and the decrease in willingness of some countries to accept peacekeepers who may pose a disease risk to them.
Security analysts also correlate high rates of HIV infection with state instability and failure, particularly in sub-Saharan African nations. The erosion of elite populations, political leadership and skilled labor forces undermines economic growth and exacerbates social tensions. Some argue that the growing number of children orphaned by AIDS is contributing to an impoverished orphan cohort that is vulnerable to exploitation and radicalization. Even though the involvement of HIV/AIDS in state failure remains unproven and is probably indirect, the perceived linkage has propelled regions once considered “peripheral” to Western security interests into national security agendas.
The impact of the HIV/AIDS pandemic on strategically important states is another major security concern. Analysts warn that a “second wave” of HIV could potentially destabilize powerful countries and regions that are critical to the US and, by extension, to global strategic interests. Particular emphasis has been placed on the effects of the worsening pandemic in Russia, India, and China, each of which has been declared a nuclear state. The security impact of HIV in these countries may not be immediate, but increased instability in any large and strategically significant state would have major economic, political and military consequences around the world.
Although arguments linking HIV/AIDS to national security have helped to elevate the disease to the highest levels of international politics, it is also important to recognize that there are a number of potential risks in adopting a national security approach to combat the pandemic. An inappropriate redirection of HIV/AIDS resources toward strategically important countries or those supportive of the “War on Terror” is one possible outcome of such a focus. Strengthening the evidence of linkages between the AIDS pandemic and national security is essential for successfully negotiating these risks and ensuring that the public health–national security nexus benefits the fight against HIV/AIDS.
In July of 2000, the UN Security Council passed Resolution 1308 stipulating that HIV poses a risk to the stability and security of the nations of the world. Since then, there has been considerable debate regarding the relationship between the AIDS pandemic and national security. According to expert analysts, the security implications of HIV’s rapid spread in Africa and other regions must be taken far more seriously by the industrialized West.
One concern expressed by security analysts has been the impact of HIV on individuals critical to the maintenance of state and international security: namely, soldiers and peacekeepers. AIDS is now the leading cause of death in military and police forces in some African countries, accounting for more than half of in-service mortality. The loss of highly trained, professional soldiers is not limited to Africa. Trained soldiers are difficult and expensive to replace, and their absence interrupts the training of younger recruits. Armed forces that rely wholly or partially on conscripts face a decreasing pool of healthy recruits as HIV continues to spread. The strategic impact of high HIV prevalence on the armed forces is complex and involves other country-specific factors as well.
There is growing evidence that the AIDS pandemic poses increasing challenges for the conduct of peacekeeping operations. These challenges include the spread of HIV by peacekeepers, the reduced ability of countries to contribute peacekeepers, and the decrease in willingness of some countries to accept peacekeepers who may pose a disease risk to them.
Security analysts also correlate high rates of HIV infection with state instability and failure, particularly in sub-Saharan African nations. The erosion of elite populations, political leadership and skilled labor forces undermines economic growth and exacerbates social tensions. Some argue that the growing number of children orphaned by AIDS is contributing to an impoverished orphan cohort that is vulnerable to exploitation and radicalization. Even though the involvement of HIV/AIDS in state failure remains unproven and is probably indirect, the perceived linkage has propelled regions once considered “peripheral” to Western security interests into national security agendas.
The impact of the HIV/AIDS pandemic on strategically important states is another major security concern. Analysts warn that a “second wave” of HIV could potentially destabilize powerful countries and regions that are critical to the US and, by extension, to global strategic interests. Particular emphasis has been placed on the effects of the worsening pandemic in Russia, India, and China, each of which has been declared a nuclear state. The security impact of HIV in these countries may not be immediate, but increased instability in any large and strategically significant state would have major economic, political and military consequences around the world.
Although arguments linking HIV/AIDS to national security have helped to elevate the disease to the highest levels of international politics, it is also important to recognize that there are a number of potential risks in adopting a national security approach to combat the pandemic. An inappropriate redirection of HIV/AIDS resources toward strategically important countries or those supportive of the “War on Terror” is one possible outcome of such a focus. Strengthening the evidence of linkages between the AIDS pandemic and national security is essential for successfully negotiating these risks and ensuring that the public health–national security nexus benefits the fight against HIV/AIDS.
Friday, February 02, 2007
History of HIV/AIDS in the United States
In a speech given on December 1, 2006, World AIDS Day, Kofi Annan declared HIV/AIDS to be the greatest challenge of our generation. This dreaded infectious disease has claimed the lives of over 25 million people worldwide and infected 40 million more. In the United States alone, 1.2 million are infected with the HIV virus and more than 500,000 have died. No virus has been as well studied or understood as the human immunodeficiency virus, yet we are far from controlling this pandemic.
When the first reference to AIDS was published in the CDC’s Morbidity and Mortality Weekly Report on June 5, 1981, physicians were taken aback by the presence of pneumocystis pneumonia in five previously healthy young men. As more and more cases of unusual opportunistic infections were identified, the medical community felt helpless in the face of this challenge. No one had any idea what was causing this disease, how it was transmitted, or how it could be treated.
Before long, pioneers in dealing with this disease discovered that it was transmitted through sexual contact, blood products, and needle sharing and could begin to discourage people from behavior that put them at risk. HIV was identified as the disease-causing agent in early 1984. The next year, the first test to detect antibodies to HIV was developed and the US blood supply was declared to be free of contamination. The numbers of new HIV infections in the US reached their height in the 1980’s at approximately 160,000. Since the 90’s, however, prevention and education efforts have stabilized infection rates around 40,000.
Doctors had nothing to offer their patients until AZT, a nucleoside analog, was approved by the FDA in 1987. By the end of the decade, the first candidate vaccine began testing, the first comprehensive needle exchange program was established, and the Americans with Disabilities Act was expanded to include people living with HIV/AIDS. The CDC announced measures that could be taken to prevent HIV infection and to avoid some of the opportunistic infections common among people with AIDS.
While they offered hope, none of these efforts really changed the reality for people living with the disease, and by 1994-1995, AIDS was the leading cause of death among Americans aged 25 to 44. The death sentence for AIDS patients was finally lifted in 1995 when highly active antiretroviral therapy was introduced with the first protease inhibitor, saquinavir. The following year, the FDA approved the first non-nucleoside reverse transcriptase inhibitor, nevirapine, and a viral load test to measure levels of HIV in the body. Since then, these developments have led to a 70% reduction in AIDS-related deaths.
While new treatments have revolutionized the face of the AIDS epidemic, drastic changes in epidemiology and populations infected have altered the way people view the disease. Originally seen as a highly stigmatized disease of the gay community and feared for its mystery and lethality, AIDS is now recognized as a controllable disease that preys on men, women, and children alike. Homosexual contact remains the highest mode of transmission in the US, but heterosexual contact has grown significantly as a mode of transmission. Women constituted 8% of new HIV cases in 1985, but rose to account for 27% of new cases in 2005. HIV is slowly becoming a plague of the minorities. Blacks disproportionately constitute over half of new HIV infections while the incidence among whites is decreasing.
Despite the many breakthroughs that have been made to alter the HIV epidemic, many challenges remain. Stigma still persists as a major debilitating factor of this illness. Over a quarter of a million people are living with HIV but do not know they are infected. While it is no longer the leading killer, AIDS remains the sixth leading cause of death in this country. There are currently 29 drugs on the FDA’s list of drugs approved for the treatment of HIV/AIDS, but a cure or an effective preventative vaccine remain elusive. The American public finally realized that this disease could not be ignored and has recently embraced it more than ever before. Billions of dollars have been allocated towards HIV programs in the US and abroad. Nonetheless, HIV/AIDS will continue to pose the greatest challenge to our generation as we strive to halt transmission, provide diagnosis and treatment to those in need, and develop a cure to this deadly virus.
Thanks for listening,
Lauren Finley
When the first reference to AIDS was published in the CDC’s Morbidity and Mortality Weekly Report on June 5, 1981, physicians were taken aback by the presence of pneumocystis pneumonia in five previously healthy young men. As more and more cases of unusual opportunistic infections were identified, the medical community felt helpless in the face of this challenge. No one had any idea what was causing this disease, how it was transmitted, or how it could be treated.
Before long, pioneers in dealing with this disease discovered that it was transmitted through sexual contact, blood products, and needle sharing and could begin to discourage people from behavior that put them at risk. HIV was identified as the disease-causing agent in early 1984. The next year, the first test to detect antibodies to HIV was developed and the US blood supply was declared to be free of contamination. The numbers of new HIV infections in the US reached their height in the 1980’s at approximately 160,000. Since the 90’s, however, prevention and education efforts have stabilized infection rates around 40,000.
Doctors had nothing to offer their patients until AZT, a nucleoside analog, was approved by the FDA in 1987. By the end of the decade, the first candidate vaccine began testing, the first comprehensive needle exchange program was established, and the Americans with Disabilities Act was expanded to include people living with HIV/AIDS. The CDC announced measures that could be taken to prevent HIV infection and to avoid some of the opportunistic infections common among people with AIDS.
While they offered hope, none of these efforts really changed the reality for people living with the disease, and by 1994-1995, AIDS was the leading cause of death among Americans aged 25 to 44. The death sentence for AIDS patients was finally lifted in 1995 when highly active antiretroviral therapy was introduced with the first protease inhibitor, saquinavir. The following year, the FDA approved the first non-nucleoside reverse transcriptase inhibitor, nevirapine, and a viral load test to measure levels of HIV in the body. Since then, these developments have led to a 70% reduction in AIDS-related deaths.
While new treatments have revolutionized the face of the AIDS epidemic, drastic changes in epidemiology and populations infected have altered the way people view the disease. Originally seen as a highly stigmatized disease of the gay community and feared for its mystery and lethality, AIDS is now recognized as a controllable disease that preys on men, women, and children alike. Homosexual contact remains the highest mode of transmission in the US, but heterosexual contact has grown significantly as a mode of transmission. Women constituted 8% of new HIV cases in 1985, but rose to account for 27% of new cases in 2005. HIV is slowly becoming a plague of the minorities. Blacks disproportionately constitute over half of new HIV infections while the incidence among whites is decreasing.
Despite the many breakthroughs that have been made to alter the HIV epidemic, many challenges remain. Stigma still persists as a major debilitating factor of this illness. Over a quarter of a million people are living with HIV but do not know they are infected. While it is no longer the leading killer, AIDS remains the sixth leading cause of death in this country. There are currently 29 drugs on the FDA’s list of drugs approved for the treatment of HIV/AIDS, but a cure or an effective preventative vaccine remain elusive. The American public finally realized that this disease could not be ignored and has recently embraced it more than ever before. Billions of dollars have been allocated towards HIV programs in the US and abroad. Nonetheless, HIV/AIDS will continue to pose the greatest challenge to our generation as we strive to halt transmission, provide diagnosis and treatment to those in need, and develop a cure to this deadly virus.
Thanks for listening,
Lauren Finley
Friday, January 26, 2007
Pre-exposure Chemoprophylaxis
Leaders from around the world in AIDS research and health policy gathered in Toronto in August 2006 for the XVI International AIDS Conference. A key theme of the conference was HIV prevention, including assessment of old standards as well as new strategies. Leigh Peterson of Family Health International presented preliminary data from a current AIDS prevention study of women in Ghana (2006). This new prevention strategy is called pre-exposure chemoprophylaxis, or PrEP. In the PrEP strategy, HIV-negative individuals with high risk behavior take a single daily dose of tenofovir, a widely prescribed anti-retroviral. Tenofovir is a nucleotide reverse transcriptase inhibitor, meaning tenofovir’s unique shape blocks the reverse transcriptase protein in HIV from making new copies of the virus. The FDA approved tenofovir in 2001 and was a good drug candidate for this study because it has few side effects and showed low levels of resistance. The idea of prophylaxis is not new. It is most commonly used to prevent malaria; but it has not been tested as a valid strategy for preventing HIV until now.
According to the Family Health International study, 936 HIV-negative women in Ghana, Cameroon, and Nigeria were enrolled into a double-blind, 1:1 randomized trial. Half of the women received a daily 300 mg dose of tenofovir and the other half received a placebo. Between June 2004 and March 2005, participants were evaluated monthly for adverse events, abnormal serum creatinine and phosphorus levels, were HIV tested, and were re-supplied with drugs. Before the study was completed, the Nigerian trial was stopped due to faulty laboratory monitoring; and the Cameroon site prematurely closed due to ethical concerns about the study. The preliminary results presented at the AIDS conference showed that only two out of 363 women in the tenofovir group contracted HIV compared with six out of 368 in the placebo control group. While those in the PrEP group were 65% less likely to become infected, the difference was not statistically significant due to a small population size. There were no significant differences in adverse events or laboratory abnormalities between the two groups. Gilead, the maker of tenofovir, has committed to making the drug available at no profit cost to the areas where the need for prevention is greatest (Kresge 2003).
The Centers for Disease Control and Prevention is currently sponsoring three clinical trials of PrEP in homosexual men in San Francisco and Atlanta, men and women in Botswana, and intravenous drug users in Thailand (2006). These trials divide each subpopulation into two experimental groups: one taking tenofovir and the other taking truvada, a combination of tenofovir and emtricitabine. The results from these trials will not be available for at least another year.
Both of these PrEP trials attempt to answer the same questions: will prophylaxis reduce the risk of HIV transmission, is tenofovir a safe drug for uninfected individuals to take daily, and how will PrEP affect HIV risk behavior? PrEP is intended to be a part of an integrated approach to HIV prevention and should be used in concert with condoms, AIDS education and counseling, rather than by itself. If the PrEP strategy proves to be effective, then it could result in millions of averted AIDS deaths globally. One reason PrEP studies target women in Africa is because they are currently the most vulnerable and unprotected victims of AIDS. Specifically, PrEP would offer protection for women who are unable to negotiate condom use during sex and represents a big step toward empowerment of women in the third world. Important obstacles under consideration with PrEP are: the development of tenofovir-resistant HIV, increased risk behavior of people taking PrEP, and the cost effectiveness of using medication as a prevention strategy. Nonetheless, the discussion of an HIV prophylaxis at the international AIDS conference represents an expansion of HIV prevention strategies and the potential to avert future AIDS deaths.
Thanks for listening, I’m Wes Fiser
Bibliography
Centers for Disease Control and Prevention. CDC Trials of Pre-Exposure Prophylaxis for HIV Prevention: Clinical Trials in Botswana, Thailand, and the United States. August 2006.
Kresge, Kristen. Tenofovir as Pre-Exposure Prophylaxis. American Foundation for AIDS Research. February 2003.
Peterson, L et al. Findings from a double-blind, randomized, placebo-controlled trial of tenofovir disoproxil fumarate (TDF) for prevention of HIV infection in women. XVI International AIDS Conference, Toronto. August 13-18, 2006. Abstract THLB0103.
According to the Family Health International study, 936 HIV-negative women in Ghana, Cameroon, and Nigeria were enrolled into a double-blind, 1:1 randomized trial. Half of the women received a daily 300 mg dose of tenofovir and the other half received a placebo. Between June 2004 and March 2005, participants were evaluated monthly for adverse events, abnormal serum creatinine and phosphorus levels, were HIV tested, and were re-supplied with drugs. Before the study was completed, the Nigerian trial was stopped due to faulty laboratory monitoring; and the Cameroon site prematurely closed due to ethical concerns about the study. The preliminary results presented at the AIDS conference showed that only two out of 363 women in the tenofovir group contracted HIV compared with six out of 368 in the placebo control group. While those in the PrEP group were 65% less likely to become infected, the difference was not statistically significant due to a small population size. There were no significant differences in adverse events or laboratory abnormalities between the two groups. Gilead, the maker of tenofovir, has committed to making the drug available at no profit cost to the areas where the need for prevention is greatest (Kresge 2003).
The Centers for Disease Control and Prevention is currently sponsoring three clinical trials of PrEP in homosexual men in San Francisco and Atlanta, men and women in Botswana, and intravenous drug users in Thailand (2006). These trials divide each subpopulation into two experimental groups: one taking tenofovir and the other taking truvada, a combination of tenofovir and emtricitabine. The results from these trials will not be available for at least another year.
Both of these PrEP trials attempt to answer the same questions: will prophylaxis reduce the risk of HIV transmission, is tenofovir a safe drug for uninfected individuals to take daily, and how will PrEP affect HIV risk behavior? PrEP is intended to be a part of an integrated approach to HIV prevention and should be used in concert with condoms, AIDS education and counseling, rather than by itself. If the PrEP strategy proves to be effective, then it could result in millions of averted AIDS deaths globally. One reason PrEP studies target women in Africa is because they are currently the most vulnerable and unprotected victims of AIDS. Specifically, PrEP would offer protection for women who are unable to negotiate condom use during sex and represents a big step toward empowerment of women in the third world. Important obstacles under consideration with PrEP are: the development of tenofovir-resistant HIV, increased risk behavior of people taking PrEP, and the cost effectiveness of using medication as a prevention strategy. Nonetheless, the discussion of an HIV prophylaxis at the international AIDS conference represents an expansion of HIV prevention strategies and the potential to avert future AIDS deaths.
Thanks for listening, I’m Wes Fiser
Bibliography
Centers for Disease Control and Prevention. CDC Trials of Pre-Exposure Prophylaxis for HIV Prevention: Clinical Trials in Botswana, Thailand, and the United States. August 2006.
Kresge, Kristen. Tenofovir as Pre-Exposure Prophylaxis. American Foundation for AIDS Research. February 2003.
Peterson, L et al. Findings from a double-blind, randomized, placebo-controlled trial of tenofovir disoproxil fumarate (TDF) for prevention of HIV infection in women. XVI International AIDS Conference, Toronto. August 13-18, 2006. Abstract THLB0103.
Friday, January 19, 2007
Considerations for Real-World Use of Microbicides
For more than ten years, the scientific community has been touting microbicides as the next big breakthrough in HIV/AIDS prevention. Microbicides are compounds that protect against sexually transmitted infections such as HIV and can be applied inside the vagina or rectum as a gel, cream, film, or suppository. Numerous strategies for microbicides are currently in development, including disruption of HIV’s viral envelope, maintenance of the normally acidic environment of the vagina, nonspecific inhibition of viral entry or fusion by creating a film over vaginal cells, and specific entry inhibition by providing competing ligands for receptors on CD4 cells. Despite the promise of various microbicides, results from efficacy trials will not be available for several more years. There are several areas of consideration when deciding which of the numerous microbicides in development will be realistic for real-world applications.
The first important factor to consider is the microbicide’s safety. Recent studies of nonoxynol-9 showed that the hopeful microbicide actually increased the risk of HIV infection. In vitro, N-9 disrupted the HIV envelope and prevented fusion. In vivo with prolonged use, however, the drug disrupted the vaginal epithelium, resulting in inflammation and a gathering of the immune cells. This aided HIV in overcoming the body’s natural defenses. This example shows that possible interactions with the body must be considered. Other safety issues should include complications from other sexually transmitted infections, drug resistance development in unknowingly infected women, and carcinogenicity of a compound continually applied to the vagina or rectum.
The next important real-world consideration is the acceptability of the microbicide. Many women will refuse to use something if it inhibits fertility. Thus, an effective microbicide should not also be a spermicide. In addition, the microbicide should be able to be applied well in advance of sex, in order to aid in secrecy of use if necessary. The microbicide should not be difficult to use or have an unusual consistency or smell. Finally, some countries in the world may not like microbicides based on genetically modified microorganisms.
One of the most important concerns is the efficacy of the microbicide. At the 2006 Microbicide Conference in South Africa, scientists began to push for drugs with higher potency towards HIV instead of drugs that are less effective but might prevent multiple sexually transmitted infections. In order to be truly effective, the microbicide would combine multiple methods of HIV prevention. A 2006 study by Robert Neurath found that some microbicides are extremely effective in vitro. However, development of these drugs did not take into account the nature of seminal plasma, a compound certain to be present in heterosexual intercourse. Neurath found that the plasma changed the pH environment significantly enough to alter the efficacy of the drug. This demonstrates just one of many possible interactions unaccounted for in current research and development.
The final factor in real-world use of microbicides is affordability. It is estimated that for microbicides to be available to donate to developing countries, each application must cost less than a dollar. Currently, only large pharmaceutical companies can afford the high cost of development of microbicides, which can cost up to tens of millions of dollars. Companies have little financial reason to develop these drugs when they are aimed primarily at poor women in developing countries. However, in 2003, the Bill and Melinda Gates Foundation pledged $60 million to aid with microbicide research aimed at HIV/AIDS, aiding the small laboratories struggling to develop these drugs. Ultimately, the investment will pay off. The World Health Organization estimates that a microbicide which only reduced the risk of infection by 40% and was only used in 30% of women in low-income countries would prevent approximately 6 million HIV infections in 3 years. This would reduce health care costs, not including the cost of antiretroviral drugs, by 3.2 billion US dollars.
More than 60 different microbicides are in development or testing currently. Not all of these, however, will meet the important criteria for real-world use. Even for those that do, data will not be available for several more years. The time and cost of development, however, is far outweighed by the hope that such a drug would give to the at-risk female population of the world.
This has been Cara Maguire.
The first important factor to consider is the microbicide’s safety. Recent studies of nonoxynol-9 showed that the hopeful microbicide actually increased the risk of HIV infection. In vitro, N-9 disrupted the HIV envelope and prevented fusion. In vivo with prolonged use, however, the drug disrupted the vaginal epithelium, resulting in inflammation and a gathering of the immune cells. This aided HIV in overcoming the body’s natural defenses. This example shows that possible interactions with the body must be considered. Other safety issues should include complications from other sexually transmitted infections, drug resistance development in unknowingly infected women, and carcinogenicity of a compound continually applied to the vagina or rectum.
The next important real-world consideration is the acceptability of the microbicide. Many women will refuse to use something if it inhibits fertility. Thus, an effective microbicide should not also be a spermicide. In addition, the microbicide should be able to be applied well in advance of sex, in order to aid in secrecy of use if necessary. The microbicide should not be difficult to use or have an unusual consistency or smell. Finally, some countries in the world may not like microbicides based on genetically modified microorganisms.
One of the most important concerns is the efficacy of the microbicide. At the 2006 Microbicide Conference in South Africa, scientists began to push for drugs with higher potency towards HIV instead of drugs that are less effective but might prevent multiple sexually transmitted infections. In order to be truly effective, the microbicide would combine multiple methods of HIV prevention. A 2006 study by Robert Neurath found that some microbicides are extremely effective in vitro. However, development of these drugs did not take into account the nature of seminal plasma, a compound certain to be present in heterosexual intercourse. Neurath found that the plasma changed the pH environment significantly enough to alter the efficacy of the drug. This demonstrates just one of many possible interactions unaccounted for in current research and development.
The final factor in real-world use of microbicides is affordability. It is estimated that for microbicides to be available to donate to developing countries, each application must cost less than a dollar. Currently, only large pharmaceutical companies can afford the high cost of development of microbicides, which can cost up to tens of millions of dollars. Companies have little financial reason to develop these drugs when they are aimed primarily at poor women in developing countries. However, in 2003, the Bill and Melinda Gates Foundation pledged $60 million to aid with microbicide research aimed at HIV/AIDS, aiding the small laboratories struggling to develop these drugs. Ultimately, the investment will pay off. The World Health Organization estimates that a microbicide which only reduced the risk of infection by 40% and was only used in 30% of women in low-income countries would prevent approximately 6 million HIV infections in 3 years. This would reduce health care costs, not including the cost of antiretroviral drugs, by 3.2 billion US dollars.
More than 60 different microbicides are in development or testing currently. Not all of these, however, will meet the important criteria for real-world use. Even for those that do, data will not be available for several more years. The time and cost of development, however, is far outweighed by the hope that such a drug would give to the at-risk female population of the world.
This has been Cara Maguire.
Thursday, January 11, 2007
The AIDS Pandemic: A note to our listeners
Our podcast is now 6 months old. During this time, we have addressed many topics related to HIV/AIDS, including recent advances in treatment, the South African disability grant program, HIV in the Southeastern United States, and Bono’s Product (RED) campaign.
If you are a regular listener, you probably know that many of the episodes have been conceived, developed, and produced by Davidson College undergraduate students. Rebecca Jameson, a senior at Davidson, discussed violence toward women and the spread of HIV. Wes Fiser, another senior, talked about his personal experiences in Mwandi, Zambia.
Over the next several months, we will be posting additional episodes by these students on a weekly basis. I hope you stay tuned. If you have any questions about this podcast, please email me at dawessner@davidson.edu. If you would like to see other HIV/AIDS projects ongoing at Davidson College, please check my web site at www.bio.davidson.edu/people/dawessner.
Thanks.
If you are a regular listener, you probably know that many of the episodes have been conceived, developed, and produced by Davidson College undergraduate students. Rebecca Jameson, a senior at Davidson, discussed violence toward women and the spread of HIV. Wes Fiser, another senior, talked about his personal experiences in Mwandi, Zambia.
Over the next several months, we will be posting additional episodes by these students on a weekly basis. I hope you stay tuned. If you have any questions about this podcast, please email me at dawessner@davidson.edu. If you would like to see other HIV/AIDS projects ongoing at Davidson College, please check my web site at www.bio.davidson.edu/people/dawessner.
Thanks.
Tuesday, December 26, 2006
HIV/AIDS Stigma in Rural America
One of the largest obstacles to proper care of patients early in the AIDS epidemic was and may still be stigma associated with the disease. A common question throughout any major crisis and especially the AIDS epidemic is how the reaction in urbanized America differs from the more rural parts of the United States. To gain some insight into these issues, I have asked my parents to share their first experiences with AIDS patients and their thoughts on these issues. My father, Dr. James Raver, is a respiratory and intensive care specialist in the private sector of health care and my mother, Dr. Sue Raver, is a pediatrician in public health. Both of them live and work in rural western Maryland. I'm Charles Raver. To listen to the interview, please listen to the podcast at: http://www.bio.davidson.edu/people/dawessner/361HIV/podcast/AIDS_Pandemic_23.m4a
Wednesday, December 13, 2006
Side effects of HAART
Welcome to this installment of the AIDS Pandemic, a podcast hosted by Dave Wessner of the Department of Biology at Davidson College. I am Justin Fried.
A study recently published in the Journal of Infectious Diseases credited AIDS treatment for saving 3,000,000 years of life in the United States (Walensky et al 2006). While effective treatment of common AIDS-related opportunistic infections has indeed benefited AIDS patients, the study cites treatments that decrease the virulence of the HIV virus as having the greatest impact on mortality rates of AIDS patients (Walensky et al. 2006). In the United States and countries that can afford it, the standard treatment for HIV is highly active antiretroviral treatment, HAART for short. HAART is composed of a combination of three or four drugs that fit into as many as three categories: reverse transcriptase inhibitors, protease inhibitors, and fusion inhibitors. Each of these categories of drugs attempts to interrupt the viral life cycle at a different point. Reverse transcriptase inhibitors block the activity of reverse transcriptase, an enzyme the virus uses to build new DNA from its RNA. Protease inhibitors inhibit the activity of viral enzymes used by HIV to cleave new proteins for final assembly into new HIV virons. Fusion inhibitors, the newest addition to the HAART treatment, block entry of HIV into the cell membrane, preventing infection of uninfected cells. The medications of HAART complement each other and are taken together to give an additive effect.
While the HAART treatment has had a profound impact on the AIDS epidemic in America, it should be understood that the HAART treatment is not a cure for HIV and carries its own drawbacks. Until recently, the only HAART treatments available were complicated regimens that required patients to take a series of pills at varying times of the day. Atripla, a new once a day HAART treatment, has greatly simplified the HIV treatment regimen but it is not for everyone. Aside from its expense, it is likely that the HIV virus in some people will eventually evolve to become resistant to one or more drugs in Atripla, and those patients will have to revert to more complicated treatment regimens.
While side effects of HAART treatment vary considerably between individuals and the particular medicines making up their therapy, the most common side effects include diarrhea, nausea, and vomiting ("Side effects"). Lipodystrophy is another common side effect of HAART treatment in which fat is redistributed to other parts of the body (Ammassari 2001). Often in this condition, face and limbs become thin while one's breasts, stomach and/or neck enlarge. Hyperglycemia and onset of diabetes have also occurred in a significant number of HAART patients. Liver toxicity including liver failure, pancreatitis and neuropathy are other unpleasant and potentially life threatening side effects experienced by some patients. These side effects can amount to such a physical and psychological burden that patients skip doses or stop taking their medications all together which increases the likelihood of drug resistance developing. In fact, about 25 % of patients stop therapy within the first year on HAART because of side effects (d'Arminio Monforte 2000). Reconstitution of the immune system, a major goal of HAART treatment, may even carry risks in some patients. A debilitating inflammatory syndrome has recently been linked to HAART treatment (Stoll and Reinhold 2004).
This podcast installation was not meant to scare anyone away from seeking HAART therapy; indeed as I stated earlier, it is very effective in combating infection and allows many HIV positive patients to live longer healthier lives. My goal was to simply alert people to the fact that there are frequently side effects and complications associated with HAART treatment. Prevention is still the best treatment for HIV that carries no side effects.
Until next time this is Justin Fried....
References:
Ammassari, A., Murri, R., Pezzotti, P., Trotta, M., Ravasio, L., De Longis, P., Caputo, S. Narciso, P., Pauluzzi, S., Carosi, G., Nappa, S., Piano, P., Izzo, C., Lichtner, M., Rezza, G., Monforte, A., Ippolito, G., Moroni, M., Wu, A., and A. Antinori. 2001. Journal of Acquired Immune Deficiency Syndromes, 28(5): 445-449.
d'Arminio Monforte, A., Lepri, A., Rezza, G. 2000. Insights into the reasons for discontinuation of the first highly active antiretroviral therapy (HAART) regimen in a cohort of antiretroviral naïve patients. AIDS, 14:499-507.
"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.
Stoll, Mathias, and Reinhold Schmidt. 2004. Adverse events of desirable gain in immunocompetence: the Immune Restoration Inflammatory Syndromes. Autoimmunity Reviews, 3: 243-249.
"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.
Walensky, R., Paltiel, A., Losina, E., Mercincavage, L., Schackman, B., Sax, P., Weinstein, M., and K. Freedberg. 2006. The survival benefits of AIDS Treatment in the United States. Journal of Infectious Diseases, 194: 11-19.
A study recently published in the Journal of Infectious Diseases credited AIDS treatment for saving 3,000,000 years of life in the United States (Walensky et al 2006). While effective treatment of common AIDS-related opportunistic infections has indeed benefited AIDS patients, the study cites treatments that decrease the virulence of the HIV virus as having the greatest impact on mortality rates of AIDS patients (Walensky et al. 2006). In the United States and countries that can afford it, the standard treatment for HIV is highly active antiretroviral treatment, HAART for short. HAART is composed of a combination of three or four drugs that fit into as many as three categories: reverse transcriptase inhibitors, protease inhibitors, and fusion inhibitors. Each of these categories of drugs attempts to interrupt the viral life cycle at a different point. Reverse transcriptase inhibitors block the activity of reverse transcriptase, an enzyme the virus uses to build new DNA from its RNA. Protease inhibitors inhibit the activity of viral enzymes used by HIV to cleave new proteins for final assembly into new HIV virons. Fusion inhibitors, the newest addition to the HAART treatment, block entry of HIV into the cell membrane, preventing infection of uninfected cells. The medications of HAART complement each other and are taken together to give an additive effect.
While the HAART treatment has had a profound impact on the AIDS epidemic in America, it should be understood that the HAART treatment is not a cure for HIV and carries its own drawbacks. Until recently, the only HAART treatments available were complicated regimens that required patients to take a series of pills at varying times of the day. Atripla, a new once a day HAART treatment, has greatly simplified the HIV treatment regimen but it is not for everyone. Aside from its expense, it is likely that the HIV virus in some people will eventually evolve to become resistant to one or more drugs in Atripla, and those patients will have to revert to more complicated treatment regimens.
While side effects of HAART treatment vary considerably between individuals and the particular medicines making up their therapy, the most common side effects include diarrhea, nausea, and vomiting ("Side effects"). Lipodystrophy is another common side effect of HAART treatment in which fat is redistributed to other parts of the body (Ammassari 2001). Often in this condition, face and limbs become thin while one's breasts, stomach and/or neck enlarge. Hyperglycemia and onset of diabetes have also occurred in a significant number of HAART patients. Liver toxicity including liver failure, pancreatitis and neuropathy are other unpleasant and potentially life threatening side effects experienced by some patients. These side effects can amount to such a physical and psychological burden that patients skip doses or stop taking their medications all together which increases the likelihood of drug resistance developing. In fact, about 25 % of patients stop therapy within the first year on HAART because of side effects (d'Arminio Monforte 2000). Reconstitution of the immune system, a major goal of HAART treatment, may even carry risks in some patients. A debilitating inflammatory syndrome has recently been linked to HAART treatment (Stoll and Reinhold 2004).
This podcast installation was not meant to scare anyone away from seeking HAART therapy; indeed as I stated earlier, it is very effective in combating infection and allows many HIV positive patients to live longer healthier lives. My goal was to simply alert people to the fact that there are frequently side effects and complications associated with HAART treatment. Prevention is still the best treatment for HIV that carries no side effects.
Until next time this is Justin Fried....
References:
Ammassari, A., Murri, R., Pezzotti, P., Trotta, M., Ravasio, L., De Longis, P., Caputo, S. Narciso, P., Pauluzzi, S., Carosi, G., Nappa, S., Piano, P., Izzo, C., Lichtner, M., Rezza, G., Monforte, A., Ippolito, G., Moroni, M., Wu, A., and A. Antinori. 2001. Journal of Acquired Immune Deficiency Syndromes, 28(5): 445-449.
d'Arminio Monforte, A., Lepri, A., Rezza, G. 2000. Insights into the reasons for discontinuation of the first highly active antiretroviral therapy (HAART) regimen in a cohort of antiretroviral naïve patients. AIDS, 14:499-507.
"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.
Stoll, Mathias, and Reinhold Schmidt. 2004. Adverse events of desirable gain in immunocompetence: the Immune Restoration Inflammatory Syndromes. Autoimmunity Reviews, 3: 243-249.
"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.
Walensky, R., Paltiel, A., Losina, E., Mercincavage, L., Schackman, B., Sax, P., Weinstein, M., and K. Freedberg. 2006. The survival benefits of AIDS Treatment in the United States. Journal of Infectious Diseases, 194: 11-19.
Monday, December 11, 2006
Selective Pressures on CCR5-Δ32 in the European Population
I'm Pete Levandoski
Recent research into the HIV pandemic has focused on the presence of individuals who do not become infected by HIV when exposed to the virus. So-called co receptors, which are essential for viral docking and infection, are thought to play a role in this immunity. One such co receptor is the protein CCR5, a chemokine receptor on the surface of T4 cells (Galvani et al.). Individuals who lack functional CCR5 protein do not become infected when exposed to HIV-1. A gene mutation, CCR5-Δ32, which causes a deletion of the allele for making CCR5, is present in about 10% of the European population (Galvani et al.). Homozygous individuals are completely immune to HIV-1 and heterozygotes while still susceptible to viral transmission, show slower progression of infection (Galvani et al.). A study done by Doctors Alison P. Galvani and. Montgomery Slatkin published in the December 9th, 2003 Proceedings of the National Academy of The Sciences in the United States, suggests that the higher rate of CCR5-Δ32 in European populations is the direct result of selection pressure caused by Small Pox epidemics.
Previous studies have tried to correlate the augmented prevalence of CCR5-Δ32 in Europe with the intense selection pressure caused by Bubonic Plague. Galvani et al. propose that a correlation between CCR5-Δ32 and Small Pox is a more likely scenario (Galvani et al.). To back this up, a population genetics model was set up using derivations of Hardy-Weinberg equations. These models assume that the CCR5-Δ32 is at least 700 years old and measure selection pressure caused by both diseases on CCR5-Δ32 since 1300 (Galvani et al.). Derivations of the Hardy-Weinberg equation, which factor in the frequency of outbreaks, percentage of mortality and age of the victims, were used to calculate the selection pressure of each disease on CCR5-Δ32. These models were used to determine whether or not each disease exerted enough selection pressure to cause 10% prevalence of CCR5-Δ32 in the European population over a 700 year period (Galvani et al.). This model shows conclusively that the Bubonic Plague did not exert enough selection pressure over 700 years to cause 10% prevalence of CCR5-Δ32 in the population while Small Pox did (Galvani et al.)..
Small Pox exerted higher selection pressure than Plague for a variety of reasons. Small Pox appeared in the population as early as 1,300 years before the first outbreak of Plague. Small Pox outbreak cycles were more frequent than Plague, correlating to a greater mortality (Galvani et al.). Finally, children, who had the greatest reproductive potential, were most susceptible to death by Small Pox while Bubonic Plague tended to eliminate people indiscriminately (Galvani et al.). All of these factors were included in the mathematical model, which showed that Small Pox was enough of a selecting force in Europe to cause the prevalence of CCR5-Δ32 to increase from 0-10% over 700 years.
There were two other pieces of evidence used by the authors to support their claim. The first came from noting that CCR5-Δ32 was present in a higher percentage of the population (14%) in Scandinavia, where Small Pox epidemics were most severe (Galvani et al.). When examined at the molecular level, the mechanism for infection by Small Pox virus involves the use of chemokine receptors, like CCR5, while Y. pestis infection in Plague is independent of these receptors (Galvani et al.).
The implications of this study on the future the HIV-1 pandemic are alarming. At least 700 years of fairly high selective pressure on a population by Small Pox conferred only 10% immunity (Galvani et al.). Since jumping species, HIV has already evolved into two subtypes, three groups and nine clades. In addition, co-infection with different clades is producing recombinant viruses, which are resistant to drug treatments and have stronger binding affinities for immune cells (Avert). HIV is evolving faster than the human race, which from a Darwinian perspective, does not bode well for our species. An interesting application of this data would be to run the same sort of population models in Africa. The selection pressure there on CCR5-Δ32 and other genes, which confer immunity to HIV, theoretically will be high. A measurement of the evolution of HIV immunity would be a helpful tool in determining the prospects for this embattled continent.
Sources
Avert. “Introduction to HIV types, groups and subtypes”.. Avert International Aids Charity: 13 July 2006. (21 October 2006).
Galvani, A.P. et al.. “Evaluating plague and smallpox as historical selectivepressures for the CCR5-Δ32 HIV-resistance allele”. Proceedings of the National Academy of The Sciences in the United States. Vol. 100, no. 25. 9 December 2003. pp. 15276-15279.
Recent research into the HIV pandemic has focused on the presence of individuals who do not become infected by HIV when exposed to the virus. So-called co receptors, which are essential for viral docking and infection, are thought to play a role in this immunity. One such co receptor is the protein CCR5, a chemokine receptor on the surface of T4 cells (Galvani et al.). Individuals who lack functional CCR5 protein do not become infected when exposed to HIV-1. A gene mutation, CCR5-Δ32, which causes a deletion of the allele for making CCR5, is present in about 10% of the European population (Galvani et al.). Homozygous individuals are completely immune to HIV-1 and heterozygotes while still susceptible to viral transmission, show slower progression of infection (Galvani et al.). A study done by Doctors Alison P. Galvani and. Montgomery Slatkin published in the December 9th, 2003 Proceedings of the National Academy of The Sciences in the United States, suggests that the higher rate of CCR5-Δ32 in European populations is the direct result of selection pressure caused by Small Pox epidemics.
Previous studies have tried to correlate the augmented prevalence of CCR5-Δ32 in Europe with the intense selection pressure caused by Bubonic Plague. Galvani et al. propose that a correlation between CCR5-Δ32 and Small Pox is a more likely scenario (Galvani et al.). To back this up, a population genetics model was set up using derivations of Hardy-Weinberg equations. These models assume that the CCR5-Δ32 is at least 700 years old and measure selection pressure caused by both diseases on CCR5-Δ32 since 1300 (Galvani et al.). Derivations of the Hardy-Weinberg equation, which factor in the frequency of outbreaks, percentage of mortality and age of the victims, were used to calculate the selection pressure of each disease on CCR5-Δ32. These models were used to determine whether or not each disease exerted enough selection pressure to cause 10% prevalence of CCR5-Δ32 in the European population over a 700 year period (Galvani et al.). This model shows conclusively that the Bubonic Plague did not exert enough selection pressure over 700 years to cause 10% prevalence of CCR5-Δ32 in the population while Small Pox did (Galvani et al.)..
Small Pox exerted higher selection pressure than Plague for a variety of reasons. Small Pox appeared in the population as early as 1,300 years before the first outbreak of Plague. Small Pox outbreak cycles were more frequent than Plague, correlating to a greater mortality (Galvani et al.). Finally, children, who had the greatest reproductive potential, were most susceptible to death by Small Pox while Bubonic Plague tended to eliminate people indiscriminately (Galvani et al.). All of these factors were included in the mathematical model, which showed that Small Pox was enough of a selecting force in Europe to cause the prevalence of CCR5-Δ32 to increase from 0-10% over 700 years.
There were two other pieces of evidence used by the authors to support their claim. The first came from noting that CCR5-Δ32 was present in a higher percentage of the population (14%) in Scandinavia, where Small Pox epidemics were most severe (Galvani et al.). When examined at the molecular level, the mechanism for infection by Small Pox virus involves the use of chemokine receptors, like CCR5, while Y. pestis infection in Plague is independent of these receptors (Galvani et al.).
The implications of this study on the future the HIV-1 pandemic are alarming. At least 700 years of fairly high selective pressure on a population by Small Pox conferred only 10% immunity (Galvani et al.). Since jumping species, HIV has already evolved into two subtypes, three groups and nine clades. In addition, co-infection with different clades is producing recombinant viruses, which are resistant to drug treatments and have stronger binding affinities for immune cells (Avert). HIV is evolving faster than the human race, which from a Darwinian perspective, does not bode well for our species. An interesting application of this data would be to run the same sort of population models in Africa. The selection pressure there on CCR5-Δ32 and other genes, which confer immunity to HIV, theoretically will be high. A measurement of the evolution of HIV immunity would be a helpful tool in determining the prospects for this embattled continent.
Sources
Avert. “Introduction to HIV types, groups and subtypes”.
Galvani, A.P. et al.. “Evaluating plague and smallpox as historical selectivepressures for the CCR5-Δ32 HIV-resistance allele”. Proceedings of the National Academy of The Sciences in the United States. Vol. 100, no. 25. 9 December 2003. pp. 15276-15279.
Monday, December 04, 2006
Mother to Child Transmission of HIV
When the AIDS epidemic commenced in the early 1980s, the high risk groups were identified as the 4 H’s: homosexuals, hemophiliacs, Haitians, and heroine users. Today, the face of the AIDS epidemic has transformed and women have the highest rates of infection. As more women become infected, the potential for vertical transmission from mother to child increases. Of the nearly seven million children newly infected with HIV in 2003, it is estimated that over ninety percent acquired the disease from mother-to-child-transmission. Similarly, it is estimated that over 90% of the HIV-infected children in sub-Saharan Africa acquired the infection vertically. While a combination of intervention methods can reduce the risk of vertical transmission to less than 2%, mother-to-child HIV transmission still persists worldwide, especially in developing countries which account for 95% of the vertically transmitted HIV cases.
Vertical HIV transmission is the cause of most cases of HIV in children below age 15, so it is important to understand how HIV passes from mother to child. Without intervention or treatment, the possibility of HIV transmission from mother to child is 15-30% in developed countries and 30-45% in developing countries. While 50-80% of infants are vertically infected during delivery, HIV transmission can also occur during pregnancy and after birth. During pregnancy, the fetus can become infected by contacting maternal blood through a placental hemorrhage or by swallowing infected amniotic fluid. Maternal factors which increase the chance of mother-to-fetus transmission include: maternal seroconversion during pregnancy, high viral load, malnutrition, other sexually transmitted diseases, and lack of or poor compliance with antiretroviral drug therapy.
During birth, factors that increase the risk of mother-to-child HIV transmission include: vaginal delivery, rupture of vaginal tissue, contact with maternal blood and vaginal secretions, and chorioamnitis. Pregnant women with chorioamnitis have a potentially increased white blood cell count that acts as a target for the HIV virus. Higher maternal viral load is positively correlated with vertical HIV transmission. Posnatally, the most significant risk factor is breastfeeding. The HIV virus has been isolated from breast milk, demonstrating the risk of long-term breastfeeding in infants. Transmission of HIV through breastfeeding occurs in 16-29% of cases. Specific risk factors during breastfeeding include: cracked nipples, mastitis (breast inflammation), breastfeeding for extended time periods, postnatal maternal seroconversion, high viral load, and low CD4 cell count. Mixed feeding of breast milk and other food sources has been shown to increase the risk of HIV transmission. Scientists hypothesize that an infant’s immune response is triggered by the introduction of new foods, attracting white blood cells to the gastrointestinal tract and increasing targets for the HIV viruses to spread infection.
The most successful methods of intervention to prevent mother-to-child HIV transmission include: antiretroviral medication for mother and child, caesarian section, and refraining from breastfeeding. While the recommended type and regimen of antiretroviral drugs for mothers varies, mothers on antiretroviral drugs have less than a 2% chance of transmitting HIV to their babies. The Pediatric AIDS Group Protocol 076 (PACTG 076) was an important study that demonstrated the effectiveness of using zidovudine in reducing vertical HIV transmission. This study showed that zidovudine given during pregnancy and labor and given to the baby during the first six weeks of life decreased the risk of vertical transmission by 66%. Another drug called nevirapine, a nonnucleoside reverse transcriptase inhibitor, is also effective in reducing vertical HIV transmission when given during pregnancy and after birth to the child. Aside from drug therapy, pregnant HIV positive women are also advised to have a cesarean section at 38 weeks to further reduce the risk of vertical transmission. Cesarean delivery reduces exposure of the infant to maternal fluids and tissues which is high during vaginal delivery. Finally, HIV positive women are encouraged to refrain from breastfeeding to reduce the risk of spreading HIV to their babies postnatally.
While the methods of preventing vertical HIV transmission are fairly effective, implementing these interventions in sub-Saharan Africa and other developing areas of the world is difficult due to cultural and economic barriers. While encouraging HIV-positive mothers to refrain from breastfeeding is a logical preventive measure against vertical HIV transmission, most women in poverty-stricken areas cannot afford to pay for formula or do not have access to clean drinking water to prepare the formula. Also, women who stop breastfeeding to protect their children from HIV risk the stigma of being labeled as HIV positive. These obstacles, combined with the lower level of access to antiretroviral drugs in developing countries, create obvious barriers to decreasing vertical HIV transmission worldwide.
I'm Meredith Prasse. Thanks for listening.
Vertical HIV transmission is the cause of most cases of HIV in children below age 15, so it is important to understand how HIV passes from mother to child. Without intervention or treatment, the possibility of HIV transmission from mother to child is 15-30% in developed countries and 30-45% in developing countries. While 50-80% of infants are vertically infected during delivery, HIV transmission can also occur during pregnancy and after birth. During pregnancy, the fetus can become infected by contacting maternal blood through a placental hemorrhage or by swallowing infected amniotic fluid. Maternal factors which increase the chance of mother-to-fetus transmission include: maternal seroconversion during pregnancy, high viral load, malnutrition, other sexually transmitted diseases, and lack of or poor compliance with antiretroviral drug therapy.
During birth, factors that increase the risk of mother-to-child HIV transmission include: vaginal delivery, rupture of vaginal tissue, contact with maternal blood and vaginal secretions, and chorioamnitis. Pregnant women with chorioamnitis have a potentially increased white blood cell count that acts as a target for the HIV virus. Higher maternal viral load is positively correlated with vertical HIV transmission. Posnatally, the most significant risk factor is breastfeeding. The HIV virus has been isolated from breast milk, demonstrating the risk of long-term breastfeeding in infants. Transmission of HIV through breastfeeding occurs in 16-29% of cases. Specific risk factors during breastfeeding include: cracked nipples, mastitis (breast inflammation), breastfeeding for extended time periods, postnatal maternal seroconversion, high viral load, and low CD4 cell count. Mixed feeding of breast milk and other food sources has been shown to increase the risk of HIV transmission. Scientists hypothesize that an infant’s immune response is triggered by the introduction of new foods, attracting white blood cells to the gastrointestinal tract and increasing targets for the HIV viruses to spread infection.
The most successful methods of intervention to prevent mother-to-child HIV transmission include: antiretroviral medication for mother and child, caesarian section, and refraining from breastfeeding. While the recommended type and regimen of antiretroviral drugs for mothers varies, mothers on antiretroviral drugs have less than a 2% chance of transmitting HIV to their babies. The Pediatric AIDS Group Protocol 076 (PACTG 076) was an important study that demonstrated the effectiveness of using zidovudine in reducing vertical HIV transmission. This study showed that zidovudine given during pregnancy and labor and given to the baby during the first six weeks of life decreased the risk of vertical transmission by 66%. Another drug called nevirapine, a nonnucleoside reverse transcriptase inhibitor, is also effective in reducing vertical HIV transmission when given during pregnancy and after birth to the child. Aside from drug therapy, pregnant HIV positive women are also advised to have a cesarean section at 38 weeks to further reduce the risk of vertical transmission. Cesarean delivery reduces exposure of the infant to maternal fluids and tissues which is high during vaginal delivery. Finally, HIV positive women are encouraged to refrain from breastfeeding to reduce the risk of spreading HIV to their babies postnatally.
While the methods of preventing vertical HIV transmission are fairly effective, implementing these interventions in sub-Saharan Africa and other developing areas of the world is difficult due to cultural and economic barriers. While encouraging HIV-positive mothers to refrain from breastfeeding is a logical preventive measure against vertical HIV transmission, most women in poverty-stricken areas cannot afford to pay for formula or do not have access to clean drinking water to prepare the formula. Also, women who stop breastfeeding to protect their children from HIV risk the stigma of being labeled as HIV positive. These obstacles, combined with the lower level of access to antiretroviral drugs in developing countries, create obvious barriers to decreasing vertical HIV transmission worldwide.
I'm Meredith Prasse. Thanks for listening.
Tuesday, November 21, 2006
HIV/AIDS and the South African Disability Grant Program
I’m Erika Larson.
I want to get sick so the doctor will give me a grant, and my children will have healthy food. Even if I die, my children will be better taken care of.
These words were spoken by Zolile, one of over 4.8 million HIV-infected South Africans. Her story illustrates the perverse incentives of the South African disability grant program that offers $130 per month to those with a CD4 count of 200 or below. Because grants expire after six months, patients have stopped taking medicine to remain sick in order to receive the grant and feed their families. Selwyn Jehoma, Deputy Director-General of South Africa’s Social Security Department is investigating yet another possible problem the program has created. “There’s another area that we’ve investigated: we’re asking ourselves ‘Are people leaving children with family members for the provisions for a foster care grant. And why are they doing this? Given there is a lack of income and they can’t support their own children, and obviously one would like to look at support systems.” In a country where unemployment soars to nearly 40%, HIV patients are confronted with a desperate choice: a choice between personal health and the well-being of their family.
Decisions like those of Zolile suggest not only inadvertent problems with the welfare program, but consequences of South Africa’s poverty. Destitution increases vulnerability to HIV. Migrant laborers, sex workers, disempowered women, and low education have augmented the spread of the epidemic. In turn, HIV compounds impoverishment. Affected households earn only 50-60% of the income earned by non-affected families. Low incomes, further drained by medical bills and funerals, do not adequately finance nutritional food, thereby increasing the chances for opportunistic infections. South Africa’s dilemma demonstrates that the vicious cycle between poverty and HIV has yet to be broken.
Though solving the problem seems unfathomable, there are alternatives to the disability grant program. When asked about other options, Dr. Peter Hess, Professor of Economic Development at Davidson College, drew from the success of Mexico’s educational conditional cash transfer program. For South Africa, a program would mobilize community health workers to test patients’ CD4 counts before and after medication, measuring their regime adherence and rewarding them for continuing drug therapy. Conditional cash transfers not only lighten the heavy bureaucracy, but also provide a space for positive incentives and community involvement, both essential components to sustainable development.
These South African songs are reminders not only of a profound culture, but also resilient religious and civil societies. Like Brazil, South Africa can draw on both churches and NGOs to create a comprehensive approach, fusing both top-down epidemiology and bottom-up development.
Though President Mbeki’s denial of HIV as the cause of AIDS has created an unredeemable lag in tackling the HIV issue, South Africa can find hope in policies that address HIV, poverty, and malnutrition. By engaging the expansive, young population through education and open dialogue, South Africa can harness one of its most important assets, its people.
Though it may be easy to criticize South Africa, we should ultimately examine our own choices. Have we, as an international community, failed to recognize the link between HIV and poverty? The moral imperative to address AIDS lies beyond science—it can be found in stories like that of Zolile, narratives that are reminders of what it means to be a part of global community.
I want to get sick so the doctor will give me a grant, and my children will have healthy food. Even if I die, my children will be better taken care of.
These words were spoken by Zolile, one of over 4.8 million HIV-infected South Africans. Her story illustrates the perverse incentives of the South African disability grant program that offers $130 per month to those with a CD4 count of 200 or below. Because grants expire after six months, patients have stopped taking medicine to remain sick in order to receive the grant and feed their families. Selwyn Jehoma, Deputy Director-General of South Africa’s Social Security Department is investigating yet another possible problem the program has created. “There’s another area that we’ve investigated: we’re asking ourselves ‘Are people leaving children with family members for the provisions for a foster care grant. And why are they doing this? Given there is a lack of income and they can’t support their own children, and obviously one would like to look at support systems.” In a country where unemployment soars to nearly 40%, HIV patients are confronted with a desperate choice: a choice between personal health and the well-being of their family.
Decisions like those of Zolile suggest not only inadvertent problems with the welfare program, but consequences of South Africa’s poverty. Destitution increases vulnerability to HIV. Migrant laborers, sex workers, disempowered women, and low education have augmented the spread of the epidemic. In turn, HIV compounds impoverishment. Affected households earn only 50-60% of the income earned by non-affected families. Low incomes, further drained by medical bills and funerals, do not adequately finance nutritional food, thereby increasing the chances for opportunistic infections. South Africa’s dilemma demonstrates that the vicious cycle between poverty and HIV has yet to be broken.
Though solving the problem seems unfathomable, there are alternatives to the disability grant program. When asked about other options, Dr. Peter Hess, Professor of Economic Development at Davidson College, drew from the success of Mexico’s educational conditional cash transfer program. For South Africa, a program would mobilize community health workers to test patients’ CD4 counts before and after medication, measuring their regime adherence and rewarding them for continuing drug therapy. Conditional cash transfers not only lighten the heavy bureaucracy, but also provide a space for positive incentives and community involvement, both essential components to sustainable development.
These South African songs are reminders not only of a profound culture, but also resilient religious and civil societies. Like Brazil, South Africa can draw on both churches and NGOs to create a comprehensive approach, fusing both top-down epidemiology and bottom-up development.
Though President Mbeki’s denial of HIV as the cause of AIDS has created an unredeemable lag in tackling the HIV issue, South Africa can find hope in policies that address HIV, poverty, and malnutrition. By engaging the expansive, young population through education and open dialogue, South Africa can harness one of its most important assets, its people.
Though it may be easy to criticize South Africa, we should ultimately examine our own choices. Have we, as an international community, failed to recognize the link between HIV and poverty? The moral imperative to address AIDS lies beyond science—it can be found in stories like that of Zolile, narratives that are reminders of what it means to be a part of global community.
Monday, November 20, 2006
Perspectives on Condom use in Zambia and the U.S.
I’m Steve Halliday.
During the month of July, 2006 I had the opportunity, along with several other Davidson students, to travel to Mwandi, Zambia with the Davidson Biology department. As a part of this trip I had to research and write a paper on the effectiveness of education in preventing HIV/AIDS. Through my experience in the local classrooms, and interviews with hospital workers and community members I realized that the level of HIV awareness and the general knowledge of the disease was very high, but for some reason seemed to have relatively little effect in preventing HIV transmission.
While there are obviously many factors that contribute to this problem, such as abject poverty and lack of access to healthcare, I found that one factor that may play a very large role are the adverse attitudes towards condom use in the community.
The town of Mwandi, which is largely centered around a mission compound, is very Christian. Most everyone in town attends religious services at least once a week, and the mission hospital is the only Western medical institution in the area. While the mission is affiliated with a protestant church, it is still a quite conservative Christian faith, and officially the church does not advocate condom use, except between monogamous married couples. As a result of this the hospital is not supposed to distribute condoms to patients, and it presents a major conflict of interest in the counseling they can offer.
The actual opinions on condom use vary substantially from person to person, based on personal views as well as what they’ve seen in their line of work. For example, the head clinical officer openly advocates condom use, and distributes them as often as he can receive shipments from the ministry of health. But at the same time, he does not believe that condoms should be talked about or distributed to children because he believes it will increase promiscuity.
Condom use is taught in school, but with the caveat that they are not very effective, and the only real way to protect yourself is through abstinence and monogamy. This creates an attitude where condom use is not thought of seriously, and when a child becomes sexually active they are less likely to use a condom.
These attitudes toward condom use are detrimental to public health, and severely decrease the effectiveness of HIV prevention. These attitudes aren’t limited to Mwandi, to Zambia, or even to Africa, but are common throughout the world. The main scapegoat for spreading this sentiment is the Catholic church, which is opposed to condom use on the grounds that premarital and extramarital sex are sins, and the now less common belief
that married couples should only have sex for the purpose of procreating. The Catholic church is certainly not the only organization at fault though, as even the current administration of the United States supports abstinence only education.
This idea of abstinence only education is destructive to sexual education, and contributes to the spread of STDs and unwanted pregnancies, and needs to be abolished worldwide. Condom use should be taught in all schools as a viable means of protection from HIV and STDs should a person decide to have sex, because it has been shown time and time again that simply telling people not to have sex doesn’t work. With the lack of a cure for HIV in the foreseeable future prevention is clearly the most important action that must
be taken, and education centered around safe sex needs to play a central role in prevention policy, along with social welfare programs and the empowerment of women.
During the month of July, 2006 I had the opportunity, along with several other Davidson students, to travel to Mwandi, Zambia with the Davidson Biology department. As a part of this trip I had to research and write a paper on the effectiveness of education in preventing HIV/AIDS. Through my experience in the local classrooms, and interviews with hospital workers and community members I realized that the level of HIV awareness and the general knowledge of the disease was very high, but for some reason seemed to have relatively little effect in preventing HIV transmission.
While there are obviously many factors that contribute to this problem, such as abject poverty and lack of access to healthcare, I found that one factor that may play a very large role are the adverse attitudes towards condom use in the community.
The town of Mwandi, which is largely centered around a mission compound, is very Christian. Most everyone in town attends religious services at least once a week, and the mission hospital is the only Western medical institution in the area. While the mission is affiliated with a protestant church, it is still a quite conservative Christian faith, and officially the church does not advocate condom use, except between monogamous married couples. As a result of this the hospital is not supposed to distribute condoms to patients, and it presents a major conflict of interest in the counseling they can offer.
The actual opinions on condom use vary substantially from person to person, based on personal views as well as what they’ve seen in their line of work. For example, the head clinical officer openly advocates condom use, and distributes them as often as he can receive shipments from the ministry of health. But at the same time, he does not believe that condoms should be talked about or distributed to children because he believes it will increase promiscuity.
Condom use is taught in school, but with the caveat that they are not very effective, and the only real way to protect yourself is through abstinence and monogamy. This creates an attitude where condom use is not thought of seriously, and when a child becomes sexually active they are less likely to use a condom.
These attitudes toward condom use are detrimental to public health, and severely decrease the effectiveness of HIV prevention. These attitudes aren’t limited to Mwandi, to Zambia, or even to Africa, but are common throughout the world. The main scapegoat for spreading this sentiment is the Catholic church, which is opposed to condom use on the grounds that premarital and extramarital sex are sins, and the now less common belief
that married couples should only have sex for the purpose of procreating. The Catholic church is certainly not the only organization at fault though, as even the current administration of the United States supports abstinence only education.
This idea of abstinence only education is destructive to sexual education, and contributes to the spread of STDs and unwanted pregnancies, and needs to be abolished worldwide. Condom use should be taught in all schools as a viable means of protection from HIV and STDs should a person decide to have sex, because it has been shown time and time again that simply telling people not to have sex doesn’t work. With the lack of a cure for HIV in the foreseeable future prevention is clearly the most important action that must
be taken, and education centered around safe sex needs to play a central role in prevention policy, along with social welfare programs and the empowerment of women.
Wednesday, November 15, 2006
Evidence that HIV-2 can infect CD4-negative cells
Human Immunodeficiency Virus Type 2, also known as HIV-2, is prevalent in West Africa and has spread recently to the western coastal region of India and to Europe. Compared to HIV-1 HIV-2’s mortality rate is thought to be a third lower and appears to be closer to the Simian Immunodeficiency Virus or SIV. As of 1999 it is known that all three types of immunodeficiency virus interact in some fashion with the CD4 cell surface and a co-receptor triggered by contact with the viral protein gp120. It is known that HIV-1 uses CCR5 and CXCR4 as its major co-receptors, but SIV and HIV-2 can use other co-receptors besides CCR5 and CXCR4 for infection in CD4+ cells.
Clapham, McKnight, and Weiss in 1992 showed that one strain of HIV-2 was able to successfully fuse cell to cell and have an efficient infection in CD4- human cells, while other strains were still dependent on CD4 or sCD4 (soluble CD4) for fusion. Reeves et al. in June of 1999 wanted to see if primary HIV-2 strains could infect CD4- cells that expressed either CCR5 or CXCR4 receptors.
They began by characterizing the co-receptors used by HIV-1, HIV-2, and SIV strains in CD4+ cells and found that compared to HIV-1, HIV-2 did use a variety of co-receptors for infection in almost all the viral strains but predominately CCR5 and CXCR4. They then tested for CD4-independent infection for the different HIV-2 strains using CD4- cells. The researchers concluded that certain strains could produce an effective infection in the cells using only CCR5 or CXCR4 receptors. To verify this, Reeves et al. used specific ligands of CCR5, CXCR4, and CD4 and confirmed that infection could occur independent of CD4 with CCR5 or CXCR4.
Overall, they found that there were 7 HIV-2 strains that used CCR5 and/or CXCR4 to infect CD4+ cells, but in CD4- cells 2 strains used only CXCR4, 2 strains used only CCR5, and 3 used neither CCR5 nor CXCR4 efficiently.
In comparing HIV-1, HIV-2, and SIV, they showed that HIV-2 and SIV are less reliant on CD4 for infection and that certain strains using CCR5 to infect CD4- cells levels were very similar to SIV strains in CD4 independent infection.
It is unknown why, but astrocytes although not expressing CD4, in vivo can be infected with HIV-1. Reeves et al. then determined whether astrocytes, CD4- cells, were susceptible to infection. Results showed that infection occurred via the CXCR4 receptor and that the concentration of the receptor might play a role in the efficiency of infection.
Thus the ability of HIV-2 to infect a cell independent of CD4 depends on the cell type and the concentration of co-receptors on the cell surface. The researchers note that there could be other receptors or factors that have yet to be identified. Co-receptors could have different conformational changes in different cells or could exist as oligomers, which would influence their activity and identification.
It is theorized that the original SIV and HIV strains used only one receptor and then evolved to the two co-receptor mechanism. This explains the difference between the different types of immunodeficiency viruses and variation of the strains within the sub-types. It is unknown why HIV needs 2 co-receptors to infect a cell, but it does seem selective pressures to gain immune resistance have evolved to make it harder for the body to inhibit viral infection. The fact that there are differences between types and strains make HIV mechanism difficult to understand and makes HIV treatment even more difficult to design.
Jessica Lahre
Reeves, J. et al. (1999). Primary Human Immunodeficiency Virus Type 2 (HIV-2)
Isolates Infect CD4-Negative Cells via CCR5 and CXCR4: Comparison with
HIV-1 and Simian Immunodeficiency Virus and Relevance to Cell Tropism In
Vivo. Journal of Virology. 73 (9): 7795-7804.
Clapham, McKnight, and Weiss in 1992 showed that one strain of HIV-2 was able to successfully fuse cell to cell and have an efficient infection in CD4- human cells, while other strains were still dependent on CD4 or sCD4 (soluble CD4) for fusion. Reeves et al. in June of 1999 wanted to see if primary HIV-2 strains could infect CD4- cells that expressed either CCR5 or CXCR4 receptors.
They began by characterizing the co-receptors used by HIV-1, HIV-2, and SIV strains in CD4+ cells and found that compared to HIV-1, HIV-2 did use a variety of co-receptors for infection in almost all the viral strains but predominately CCR5 and CXCR4. They then tested for CD4-independent infection for the different HIV-2 strains using CD4- cells. The researchers concluded that certain strains could produce an effective infection in the cells using only CCR5 or CXCR4 receptors. To verify this, Reeves et al. used specific ligands of CCR5, CXCR4, and CD4 and confirmed that infection could occur independent of CD4 with CCR5 or CXCR4.
Overall, they found that there were 7 HIV-2 strains that used CCR5 and/or CXCR4 to infect CD4+ cells, but in CD4- cells 2 strains used only CXCR4, 2 strains used only CCR5, and 3 used neither CCR5 nor CXCR4 efficiently.
In comparing HIV-1, HIV-2, and SIV, they showed that HIV-2 and SIV are less reliant on CD4 for infection and that certain strains using CCR5 to infect CD4- cells levels were very similar to SIV strains in CD4 independent infection.
It is unknown why, but astrocytes although not expressing CD4, in vivo can be infected with HIV-1. Reeves et al. then determined whether astrocytes, CD4- cells, were susceptible to infection. Results showed that infection occurred via the CXCR4 receptor and that the concentration of the receptor might play a role in the efficiency of infection.
Thus the ability of HIV-2 to infect a cell independent of CD4 depends on the cell type and the concentration of co-receptors on the cell surface. The researchers note that there could be other receptors or factors that have yet to be identified. Co-receptors could have different conformational changes in different cells or could exist as oligomers, which would influence their activity and identification.
It is theorized that the original SIV and HIV strains used only one receptor and then evolved to the two co-receptor mechanism. This explains the difference between the different types of immunodeficiency viruses and variation of the strains within the sub-types. It is unknown why HIV needs 2 co-receptors to infect a cell, but it does seem selective pressures to gain immune resistance have evolved to make it harder for the body to inhibit viral infection. The fact that there are differences between types and strains make HIV mechanism difficult to understand and makes HIV treatment even more difficult to design.
Jessica Lahre
Reeves, J. et al. (1999). Primary Human Immunodeficiency Virus Type 2 (HIV-2)
Isolates Infect CD4-Negative Cells via CCR5 and CXCR4: Comparison with
HIV-1 and Simian Immunodeficiency Virus and Relevance to Cell Tropism In
Vivo. Journal of Virology. 73 (9): 7795-7804.
Tuesday, November 14, 2006
HIV/AIDS in China
Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. This is Cara Maguire.
With a population of 1.3 billion people, many of them poor and in heavily concentrated cities, China appears to be a country ripe for the easy spread of HIV/AIDS. In 2000, the estimated HIV-positive population exceeded 500,000, with a growth rate that could peak at 10 million people by 2010. However, today in 2006, the current estimate is 650,000 infected. In comparison, the United States has approximately 1 billion fewer people overall, but has 850,000 infected. How has the Chinese government managed to maintain such low numbers and prevent a healthcare disaster?
Traditionally, China has avoided widespread STD epidemics because of strict policies and conservative morals towards prostitution. For China, the twentieth century was basically drug- and prostitution-free. A theory explaining the recent surge in venereal disease is China’s increasing acceptance of a free market. With the economic reforms instituted in the 1980s came a growing wealthy population and the money to support the drug and sex trades. Although estimates in 2000 put intravenous drug users as 72% of the HIV positive population, more recent numbers suggest this group only makes up 42% of infections. It is difficult to assess the percentage of infections due to the sex trade; however, the two trades are often linked due to women offering sex for drugs.
For many years, the Chinese government was slow to recognize the threat of AIDS. Although drug abuse remained illegal, the penalties were relaxed. These penalties involved a variety of rehabilitation programs ranging from voluntary 10-day treatments to up to three years in a reeducation through labor center. In recent years, the Chinese government has taken several steps to address the growing epidemic more decisively. In 2004, guidelines were published for methadone maintenance treatment and needle exchange programs. Exchange programs provide intravenous drug users with clean needles, while methadone, an oral drug, is used to replace the intravenous drugs altogether. Although these programs are socially liberal (and not condoned in the United States), they were primarily confined to large urban centers.
On March 1st, 2006, the most recent governmental guidelines went into effect. By specifying the responsibilities of all levels of government, the guidelines force local governments to take action against the spread of HIV/AIDS. Governments must now provide free anti-HIV/AIDS drugs for rural and underprivileged patients and free testing and information. In addition, the guidelines protect the rights of patients by forbidding the release of any personal information. Finally, local governments must provide free tuition and fee exemption to AIDS orphans.
Overall, the measures taken by the government have done a good job in helping victims and limiting the spread of HIV in this large country.
With a population of 1.3 billion people, many of them poor and in heavily concentrated cities, China appears to be a country ripe for the easy spread of HIV/AIDS. In 2000, the estimated HIV-positive population exceeded 500,000, with a growth rate that could peak at 10 million people by 2010. However, today in 2006, the current estimate is 650,000 infected. In comparison, the United States has approximately 1 billion fewer people overall, but has 850,000 infected. How has the Chinese government managed to maintain such low numbers and prevent a healthcare disaster?
Traditionally, China has avoided widespread STD epidemics because of strict policies and conservative morals towards prostitution. For China, the twentieth century was basically drug- and prostitution-free. A theory explaining the recent surge in venereal disease is China’s increasing acceptance of a free market. With the economic reforms instituted in the 1980s came a growing wealthy population and the money to support the drug and sex trades. Although estimates in 2000 put intravenous drug users as 72% of the HIV positive population, more recent numbers suggest this group only makes up 42% of infections. It is difficult to assess the percentage of infections due to the sex trade; however, the two trades are often linked due to women offering sex for drugs.
For many years, the Chinese government was slow to recognize the threat of AIDS. Although drug abuse remained illegal, the penalties were relaxed. These penalties involved a variety of rehabilitation programs ranging from voluntary 10-day treatments to up to three years in a reeducation through labor center. In recent years, the Chinese government has taken several steps to address the growing epidemic more decisively. In 2004, guidelines were published for methadone maintenance treatment and needle exchange programs. Exchange programs provide intravenous drug users with clean needles, while methadone, an oral drug, is used to replace the intravenous drugs altogether. Although these programs are socially liberal (and not condoned in the United States), they were primarily confined to large urban centers.
On March 1st, 2006, the most recent governmental guidelines went into effect. By specifying the responsibilities of all levels of government, the guidelines force local governments to take action against the spread of HIV/AIDS. Governments must now provide free anti-HIV/AIDS drugs for rural and underprivileged patients and free testing and information. In addition, the guidelines protect the rights of patients by forbidding the release of any personal information. Finally, local governments must provide free tuition and fee exemption to AIDS orphans.
Overall, the measures taken by the government have done a good job in helping victims and limiting the spread of HIV in this large country.
Tuesday, November 07, 2006
WOMEN AND HIV/AIDS IN AFRICA
Globally, women now constitute 48% of the HIV positive population. 76% of these HIV positive women live in Sub-Saharan Africa, where women account for 59% of adults living with HIV. The rising rates of HIV infection in women and young girls is directly related to their inferior social, economic, and legal status in this region of the world. Women’s autonomy relating to sexual decisions is rarely respected. Men tend to dominate women’s sexuality in Africa’s dramatic context of poverty.
While women are account for half of the HIV burden, many responses to the epidemic have failed to address the social, economic, and cultural factors that put women at an increased risk for HIV infection. The ABC program, which emphasizes Abstinence, Be faithful, and Condom use, has been adopted by many African governments but is simply not feasible for women. They are not given the choice to abstain from sex, but are often raped or coerced into having sex as a means of survival. While they may remain faithful to their husbands, they are powerless to ensure that their husbands remain faithful to them. In addition, women are not given sufficient control over sexual situations to ensure that their partners, particularly their husbands, always wear a condom. Such programs fail to address the social factors limiting women and girl’s sexual autonomy and placing them at an increased risk for HIV.
Violence against women, whether in the context of rape or sexual abuse, is a significant factor in the propagation of HIV in women. Women who have been subjected to violence are three times as likely to be infected with HIV as women who have not. Girls in Africa are also pressured into marrying at a young age. Most of these girls are married to older men who are more likely to have had exposure to sexually transmitted diseases and are less likely to use a condom.
Education efforts need to be extended to women and heavy investments should be made in methods that would allow women to control HIV prevention. Female condoms are very effective in blocking the passage of microorganisms, including HIV. However, these condoms cost on average $0.70, making them ten times more expensive than male condoms. In addition, they are not widely available and most women don’t even know about their existence. Microbicides are a very promising new method of HIV prevention that are able to block or disable the virus as soon as it enters the body and before it spreads. Even the first generation microbicides are expected to reduce HIV transmission by 40 to 60%. A 60% effective microbicide is projected to prevent 2.5 million new HIV infections over a period of three years.
Antiretroviral treatment is now available to 1.3 million people, representing a significant increase in just a few years. Still, ARVs are only available to 17% of the people in Sub-Saharan Africa who need them. Data has not shown that there are significant gender discrepancies in access to treatment, but women do encounter more difficulties in adhering to the regimens. Because women are confronted with more intense stigma and marginalization than men when infected with HIV, many chose not to return to clinics for their test results. They are also afraid that their serostatus will be disclosed without their consent, which in many cases leads to women being kicked out of their homes and losing all economic support. One study in Zambia revealed that 66% of women did not disclose their status to their partner for fear of blame, violence, and abandonment. 76% did not adhere to their treatment regimen because they were trying to hide their pills.
To design more effective AIDS programs, it is essential that more women, especially those living with HIV, be included in international AIDS conferences and meetings where programs are designed. An effective program needs to focus on education, economic empowerment, improved access to health services, and better prevention options for married women. Laws need to be developed to protect women’s rights and allow them to have a reliable legal recourse when those rights are violated. Pressure needs to be brought against social and cultural norms that legitimize child marriage and domestic violence. Programs need to be implemented that recognize the specific challenges faced by HIV positive women and improve their access to reproductive health services. Access to testing and treatment should be facilitated and promises of confidentiality respected. Thankfully, there are feasible steps that can be taken to empower women and address the issues that make them vulnerable to HIV infection.
Lauren Finley
While women are account for half of the HIV burden, many responses to the epidemic have failed to address the social, economic, and cultural factors that put women at an increased risk for HIV infection. The ABC program, which emphasizes Abstinence, Be faithful, and Condom use, has been adopted by many African governments but is simply not feasible for women. They are not given the choice to abstain from sex, but are often raped or coerced into having sex as a means of survival. While they may remain faithful to their husbands, they are powerless to ensure that their husbands remain faithful to them. In addition, women are not given sufficient control over sexual situations to ensure that their partners, particularly their husbands, always wear a condom. Such programs fail to address the social factors limiting women and girl’s sexual autonomy and placing them at an increased risk for HIV.
Violence against women, whether in the context of rape or sexual abuse, is a significant factor in the propagation of HIV in women. Women who have been subjected to violence are three times as likely to be infected with HIV as women who have not. Girls in Africa are also pressured into marrying at a young age. Most of these girls are married to older men who are more likely to have had exposure to sexually transmitted diseases and are less likely to use a condom.
Education efforts need to be extended to women and heavy investments should be made in methods that would allow women to control HIV prevention. Female condoms are very effective in blocking the passage of microorganisms, including HIV. However, these condoms cost on average $0.70, making them ten times more expensive than male condoms. In addition, they are not widely available and most women don’t even know about their existence. Microbicides are a very promising new method of HIV prevention that are able to block or disable the virus as soon as it enters the body and before it spreads. Even the first generation microbicides are expected to reduce HIV transmission by 40 to 60%. A 60% effective microbicide is projected to prevent 2.5 million new HIV infections over a period of three years.
Antiretroviral treatment is now available to 1.3 million people, representing a significant increase in just a few years. Still, ARVs are only available to 17% of the people in Sub-Saharan Africa who need them. Data has not shown that there are significant gender discrepancies in access to treatment, but women do encounter more difficulties in adhering to the regimens. Because women are confronted with more intense stigma and marginalization than men when infected with HIV, many chose not to return to clinics for their test results. They are also afraid that their serostatus will be disclosed without their consent, which in many cases leads to women being kicked out of their homes and losing all economic support. One study in Zambia revealed that 66% of women did not disclose their status to their partner for fear of blame, violence, and abandonment. 76% did not adhere to their treatment regimen because they were trying to hide their pills.
To design more effective AIDS programs, it is essential that more women, especially those living with HIV, be included in international AIDS conferences and meetings where programs are designed. An effective program needs to focus on education, economic empowerment, improved access to health services, and better prevention options for married women. Laws need to be developed to protect women’s rights and allow them to have a reliable legal recourse when those rights are violated. Pressure needs to be brought against social and cultural norms that legitimize child marriage and domestic violence. Programs need to be implemented that recognize the specific challenges faced by HIV positive women and improve their access to reproductive health services. Access to testing and treatment should be facilitated and promises of confidentiality respected. Thankfully, there are feasible steps that can be taken to empower women and address the issues that make them vulnerable to HIV infection.
Lauren Finley
Monday, November 06, 2006
The Influence of Viral Factors on Long-term Nonprogressing HIV
The progression of HIV infection varies from one individual to another. Although “the median time from infection to development of AIDS is 8 to 10 years,” some individuals, known as long-term nonprogressors, fail to develop AIDS after infection with HIV (Hogan and Hammer, 2001). These individuals have been identified on various continents, and include persons with various types of exposure, such as commercial sex workers, hemophiliacs who have received HIV positive blood during transfusions, infants born to seropositive mothers, health care professionals accidentally infected by needlestick, intravenous drug users, and sexual partners of known HIV positive individuals (Zhu et al., 2002). Despite prolonged periods of HIV infection, long-term nonprogressors “remain asymptomatic and have normal CD4 cell counts and low or undetectable viral loads,” (Hogan and Hammer, 2001). The existence of long-term nonprogressors indicates the possibility of a natural immunity to HIV (Haynes et al., 1996). Though current research suggests a broad range of potential viral and host factors that may influence progression rates, further investigation is necessary to clarify the roles of each of these factors and elucidate how this knowledge can be applied to the therapeutic development of vaccines (Hogan and Hammer, 2001). This podcast will focus solely on the influence of viral factors.
Research has indicated that certain characteristics of the HIV-1 virus may affect transmission and progression rates. These factors include viral tropism, viral escape, viral attenuation, and viral subtype. Two variants of viral tropism have been identified for the HIV-1 virus, which are macrophage-tropic (M tropic) and T-cell-tropic (T-tropic). Early HIV infection usually results from M-tropic strains. As the virus mutates, its phenotype may change, resulting in a T-tropic strain, which is known to increase the rate of T-cell depletion. The progression from one tropism to the other has been associated with increased pathogenicity and progressive disease (Connor and Ho, 1994).
Another factor that has been linked to disease progression is viral escape from immune response. Viral escape may result from mutations that arise in the gag, pol, and env genes, allowing the virus to elude intense cell-mediated and humoral immune response (Hogan and Hammer, 2001). Additionally, attenuated HIV-1 viruses have been linked with slowed progression of AIDS infection. More specifically, a group of individuals infected with a strain of HIV-1 with a deletion in the nef gene have been identified. When discovered, all eight individuals infected with this strand of HIV-1 appeared to have nonprogressive infection. Upon tracking these individuals, however, the disease reflects slowed progression (Learmont et al., 1992). Further investigation into attenuated strains may present methods that can be used to delay progression of HIV-1 and prolong the lives of infected individuals.
Finally, individuals with different viral subtypes may experience slowed or enhanced disease progression. Epidemiologic studies seeking differences between subtypes are difficult and often inconclusive. However, there is evidence suggesting that HIV-2, a related human retrovirus, is less virulent and less infective, supporting the notion that HIV subtypes may have differential risks associated with transmission and pathogenicity (Marlink et al., 1994).
Although the role of viral factors has not led to conclusive evidence that slows the progression HIV infection to the development of AIDS, continued research of the virus and host may clarify key features of the disease that may aid in the development of vaccines or treatments that induce individuals to acquire the mutations that long-term nonprogressors have obtained naturally (Hammer and Hogan, 2001).
Thanks for listening. I'm Christie Brough.
References
Connor, R.I. and Ho, D.D. (1994). Human immunodeficiency virus type 1 variants with increased replicative capacity develop during the asymptomatic stage before disease progression. Journal of Virology 68:4400-4408.
Haynes, B.F., Pantaleo, G., and Fauci, A.S. (1996). Toward and understanding of the correlates of protective immunity to HIV infection. Science 271:324-328.
Hogan, C.M. and Hammer, S.M. (2001). Host determinants in HIV infection and disease (Part 1: Cellular and humoral immune responses). Annals of Internal Medicine 134:761-776.
Learmont, J., Tindall, B., Evans, L., Cunningham, A., Cunningham, P., Wells, J., et al. (1992). Long-term symptomless HIV-1 infection in recipients of blood products from a single donor. Lancet 340:863-867.
Marlink, R., Kanki, P., Thior, I., Travers, K., Eisen, G., Siby, T., et al. (1992). Reduced rate of disease development after HIV-2 infection as compared to HIV-1. Science 265:1587-1590.
Zhu, T., Corey, L., Hwangbo, Y., Lee, J.M., Learn, G.H., Mullins, J.I., and McElrath, M.J. (2003). Persistence of extraordinarily low levels of genetically homogeneous human immunodeficiency virus type 1 in exposed seronegative individuals. Journal of Virology 77:6108-6116.
Research has indicated that certain characteristics of the HIV-1 virus may affect transmission and progression rates. These factors include viral tropism, viral escape, viral attenuation, and viral subtype. Two variants of viral tropism have been identified for the HIV-1 virus, which are macrophage-tropic (M tropic) and T-cell-tropic (T-tropic). Early HIV infection usually results from M-tropic strains. As the virus mutates, its phenotype may change, resulting in a T-tropic strain, which is known to increase the rate of T-cell depletion. The progression from one tropism to the other has been associated with increased pathogenicity and progressive disease (Connor and Ho, 1994).
Another factor that has been linked to disease progression is viral escape from immune response. Viral escape may result from mutations that arise in the gag, pol, and env genes, allowing the virus to elude intense cell-mediated and humoral immune response (Hogan and Hammer, 2001). Additionally, attenuated HIV-1 viruses have been linked with slowed progression of AIDS infection. More specifically, a group of individuals infected with a strain of HIV-1 with a deletion in the nef gene have been identified. When discovered, all eight individuals infected with this strand of HIV-1 appeared to have nonprogressive infection. Upon tracking these individuals, however, the disease reflects slowed progression (Learmont et al., 1992). Further investigation into attenuated strains may present methods that can be used to delay progression of HIV-1 and prolong the lives of infected individuals.
Finally, individuals with different viral subtypes may experience slowed or enhanced disease progression. Epidemiologic studies seeking differences between subtypes are difficult and often inconclusive. However, there is evidence suggesting that HIV-2, a related human retrovirus, is less virulent and less infective, supporting the notion that HIV subtypes may have differential risks associated with transmission and pathogenicity (Marlink et al., 1994).
Although the role of viral factors has not led to conclusive evidence that slows the progression HIV infection to the development of AIDS, continued research of the virus and host may clarify key features of the disease that may aid in the development of vaccines or treatments that induce individuals to acquire the mutations that long-term nonprogressors have obtained naturally (Hammer and Hogan, 2001).
Thanks for listening. I'm Christie Brough.
References
Connor, R.I. and Ho, D.D. (1994). Human immunodeficiency virus type 1 variants with increased replicative capacity develop during the asymptomatic stage before disease progression. Journal of Virology 68:4400-4408.
Haynes, B.F., Pantaleo, G., and Fauci, A.S. (1996). Toward and understanding of the correlates of protective immunity to HIV infection. Science 271:324-328.
Hogan, C.M. and Hammer, S.M. (2001). Host determinants in HIV infection and disease (Part 1: Cellular and humoral immune responses). Annals of Internal Medicine 134:761-776.
Learmont, J., Tindall, B., Evans, L., Cunningham, A., Cunningham, P., Wells, J., et al. (1992). Long-term symptomless HIV-1 infection in recipients of blood products from a single donor. Lancet 340:863-867.
Marlink, R., Kanki, P., Thior, I., Travers, K., Eisen, G., Siby, T., et al. (1992). Reduced rate of disease development after HIV-2 infection as compared to HIV-1. Science 265:1587-1590.
Zhu, T., Corey, L., Hwangbo, Y., Lee, J.M., Learn, G.H., Mullins, J.I., and McElrath, M.J. (2003). Persistence of extraordinarily low levels of genetically homogeneous human immunodeficiency virus type 1 in exposed seronegative individuals. Journal of Virology 77:6108-6116.
Thursday, November 02, 2006
HIV/AIDS in the Southeastern U.S.
The southern United States is a region both famous for fried chicken, sweet tea, and a slow pace of life, yet notorious for its religious conservatism and a history of slavery and segregation. The South has gained another reputation in the past few years, however, that is not so widely known: it is quickly becoming the center of the HIV/AIDS epidemic in the United States.
One reason why AIDS prevalence in the south has gone unnoticed for so long is that the average southerner doesn’t think the epidemic can affect them. Most associate HIV with large urban cities, like New York City, San Francisco, and Los Angeles, places that don’t have much in common with small southern towns. They also still see AIDS as a “gay disease” and are generally uneducated about HIV and what it means to be HIV+.
The southern region of the United States, as defined by the US Census Bureau, includes 16 states and the District of Columbia. The Deep South represents a group of six southern states (Alabama, Georgia, Louisiana, Mississippi, South Carolina, and North Carolina) that are disproportionately affected by the AIDS epidemic. From 2000-2003, CDC estimates show a 35% increase in new reported AIDS cases in the Deep South, but only a 5.2% increase nationally. The Deep South also has some of the highest AIDS death rates in the country.
Other health indicators, such as measures of diabetes prevalence, stroke rate, heart disease deaths, infant mortality and preterm births also show high mortality rates in the Deep South. Furthermore, the Deep South also has very high levels of STD infection. The Kaiser Family Foundation reported that in 2002, the five states with the highest rates of gonorrhea were all in the Deep South; these states also had high rates of chlamydia and syphilis. STD prevalence is of particular importance because the presence of an STD facilitates HIV transmission.
Since its discovery, HIV has disproportionately attacked socially marginalized groups, starting with the gay community and spreading to the poor and disenfranchised. Deep South states generally have higher poverty rates than other regions. Poverty contributes HIV/AIDS rates because individuals do not have access to health education or preventative services and cannot afford treatment. Poverty has also been associated with drug use, which can lead to HIV transmission through the sharing of needles.
The south also experiences a large number of rural HIV/AIDS cases. The 1995 US Census estimated that 43% of people living in the south live in rural areas. In rural areas it is often hard to find nearby healthcare, and many patients won’t or can’t get to services. This leads to late diagnosis and unintentional infection of others.
Nearly 80% of new AIDS cases in the South are among African Americans. The HIV/AIDS epidemic is concentrated in poor communities, where African Americans are disproportionately represented. This is particularly true in the Deep South, where populations are approximately 30% Black, compared to the 18.5% in other southern states. Overall, 25% of African Americans live in poverty and are 1.5 times more likely than Whites to lack health insurance. Medical and social service barriers for African Americans are not uncommon in the rural South, and access to HIV medication and care is no exception. Many African Americans feel distrust and anger towards the healthcare system due to historical oppression and enduring medical inequalities. This has led to conspiracy theories that are believed by even the most educated and has created barriers for HIV prevention.
HIV prevalence in the Deep South cannot be studied without a look at historical and cultural factors as well. Many people often blame the lack of medical professionals and poor access to healthcare for the South’s high HIV rates, yet the South is just as rural as the Midwest and does not have fewer health providers than other rural areas. The southern “culture of politeness” prevents discussion of topics that are deemed offensive, such as sex and homosexuality. Religious conservatism also contributes to the spread of HIV by affecting education. Many schools teach abstinence-only curriculums and don’t provide information about other forms of protection, putting youth at risk for infection. Religious conservatism is also associated with close-mindedness, which increases the perceived HIV stigma.
In the end it is important to consider all possible causes of AIDS prevalence in the Deep South states in order to provide more effective preventative and treatment services to everyone who is afflicted by HIV.
Sources:
Adams B. Polite to a Fault? HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=49&categoryid=1.
Adams B. The South Has Risen. HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=48&categoryid=1.
CDC. Fact Sheet: HIV/AIDS Among African Americans. Feb 2006. http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm.
Reif S, Geonnotti KL, Whetten K. HIV Infection and AIDS in the Deep South. Am J Public Health 2006; 96: 970-973.
Whetten, K, Nguyen, T. You’re the first one I’ve told: new faces of HIV in the South. New Brunswick: Rutgers University Press.
One reason why AIDS prevalence in the south has gone unnoticed for so long is that the average southerner doesn’t think the epidemic can affect them. Most associate HIV with large urban cities, like New York City, San Francisco, and Los Angeles, places that don’t have much in common with small southern towns. They also still see AIDS as a “gay disease” and are generally uneducated about HIV and what it means to be HIV+.
The southern region of the United States, as defined by the US Census Bureau, includes 16 states and the District of Columbia. The Deep South represents a group of six southern states (Alabama, Georgia, Louisiana, Mississippi, South Carolina, and North Carolina) that are disproportionately affected by the AIDS epidemic. From 2000-2003, CDC estimates show a 35% increase in new reported AIDS cases in the Deep South, but only a 5.2% increase nationally. The Deep South also has some of the highest AIDS death rates in the country.
Other health indicators, such as measures of diabetes prevalence, stroke rate, heart disease deaths, infant mortality and preterm births also show high mortality rates in the Deep South. Furthermore, the Deep South also has very high levels of STD infection. The Kaiser Family Foundation reported that in 2002, the five states with the highest rates of gonorrhea were all in the Deep South; these states also had high rates of chlamydia and syphilis. STD prevalence is of particular importance because the presence of an STD facilitates HIV transmission.
Since its discovery, HIV has disproportionately attacked socially marginalized groups, starting with the gay community and spreading to the poor and disenfranchised. Deep South states generally have higher poverty rates than other regions. Poverty contributes HIV/AIDS rates because individuals do not have access to health education or preventative services and cannot afford treatment. Poverty has also been associated with drug use, which can lead to HIV transmission through the sharing of needles.
The south also experiences a large number of rural HIV/AIDS cases. The 1995 US Census estimated that 43% of people living in the south live in rural areas. In rural areas it is often hard to find nearby healthcare, and many patients won’t or can’t get to services. This leads to late diagnosis and unintentional infection of others.
Nearly 80% of new AIDS cases in the South are among African Americans. The HIV/AIDS epidemic is concentrated in poor communities, where African Americans are disproportionately represented. This is particularly true in the Deep South, where populations are approximately 30% Black, compared to the 18.5% in other southern states. Overall, 25% of African Americans live in poverty and are 1.5 times more likely than Whites to lack health insurance. Medical and social service barriers for African Americans are not uncommon in the rural South, and access to HIV medication and care is no exception. Many African Americans feel distrust and anger towards the healthcare system due to historical oppression and enduring medical inequalities. This has led to conspiracy theories that are believed by even the most educated and has created barriers for HIV prevention.
HIV prevalence in the Deep South cannot be studied without a look at historical and cultural factors as well. Many people often blame the lack of medical professionals and poor access to healthcare for the South’s high HIV rates, yet the South is just as rural as the Midwest and does not have fewer health providers than other rural areas. The southern “culture of politeness” prevents discussion of topics that are deemed offensive, such as sex and homosexuality. Religious conservatism also contributes to the spread of HIV by affecting education. Many schools teach abstinence-only curriculums and don’t provide information about other forms of protection, putting youth at risk for infection. Religious conservatism is also associated with close-mindedness, which increases the perceived HIV stigma.
In the end it is important to consider all possible causes of AIDS prevalence in the Deep South states in order to provide more effective preventative and treatment services to everyone who is afflicted by HIV.
Sources:
Adams B. Polite to a Fault? HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=49&categoryid=1.
Adams B. The South Has Risen. HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=48&categoryid=1.
CDC. Fact Sheet: HIV/AIDS Among African Americans. Feb 2006. http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm.
Reif S, Geonnotti KL, Whetten K. HIV Infection and AIDS in the Deep South. Am J Public Health 2006; 96: 970-973.
Whetten, K, Nguyen, T. You’re the first one I’ve told: new faces of HIV in the South. New Brunswick: Rutgers University Press.
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