Introduction
HIV, or Human Immunodeficiency Virus, is a highly stigmatized disease that, if not treated for a significant period, can develop into AIDS (Acquired Immunodeficiency Syndrome). HIV is currently an incredibly prevalent disease and is classed as a ‘global epidemic’ by the World Health Organisation, due to the huge numbers of people affected: there are approximately 38 million people1 globally who are living with HIV now. In 2018 alone, around 770,000 individuals died from AIDS2. Many people with HIV, unfortunately, have minimal access to any form of prevention or treatment – and even if it is available, it may not be economically accessible or the severe prejudice against HIV and AIDS will prevent people with these conditions from seeking medical help. Additionally, there is still no cure for either HIV or AIDS. These issues are compacted with the fact that HIV disproportionately affects developing and emerging countries – for instance, eastern and southern Africa is most predominantly affected, where it is estimated that 54% of all people with HIV live. South Africa specifically has the highest prevalence of HIV cases, containing 7.5 million people who live with HIV. After eastern and southern Africa, the western and central regions of Africa are the most severely affected, where there are approximately 4.9 million people with HIV1.
The Origin of HIV
While the Human Immunodeficiency Virus was only first identified and diagnosed in people in the 1980s, it is suggested that it originated in the 1920s in the Democratic Republic of Congo3. HIV developed from SIV (Simian Immunodeficiency Virus), which is a virus that can be contracted by monkeys and apes, and like HIV, attacks the immune system in these primates. Both HIV and SIV are primate lentiviruses, and share neuropathological features including causing white matter lesions, subtle white matter astrocytosis and viral macrophages invading the brain4. The strain of SIV which can infect humans is known as SIVcpz, and it is not fully known how this viral strain was transferred from chimps to humans. One theory of how this may have occurred is humans hunting and eating the chimps, who were affected by SIV, or the infected blood of the chimps entering open wounds of the humans, while they hunted the chimps or otherwise5. The SIVcpz then mutated inside the human host cells to produce the new strain: HIV-1. There are multiple different strains of HIV-1, and the four main groups of such strains are M, N, O and P. HIV-1 Group M is the most studied and most widespread strain of HIV to date5.
Transmission
The most commonly known method of transmitting HIV is sexual transmission, though semen or vaginal secretions from the infected host to an unaffected individual – but this virus can also be transmitted through many other bodily fluids. Examples include blood, for instance during blood transfusions, and breast milk. An infected mother can also transmit HIV to her offspring throughout pregnancy across the placenta, and also during delivery. This is called a perinatal transmission and is the main way in which children are infected with HIV, but this method of transmission is decreasing in prevalence due to medical developments. If a pregnant mother takes HIV medicine daily throughout her pregnancy, and the child is given HIV medicine for 4 to 6 weeks following delivery, the risk of the child contracting HIV is below 1%6.
Furthermore, HIV can be transmitted via contaminated needles, predominantly through intravenous drug use but can also be through tattoo needles, for example. The latter, however, is very rare – and indeed there are no known cases of HIV being transmitted in this way6. It remains a possible method of spreading HIV though, as the unsterilized needles could be contaminated with the blood of an infected host with HIV.
Additionally, HIV is not spread through shaking hands, hugging, sweat, saliva nor through the air – these were and still are perceived as methods of transmitting HIV7. This exacerbates the stigma surrounding those living with HIV and AIDS as it can lead them to feel isolated if people purposefully avoid any close or physical contact with them.
Symptoms
8After an individual contracts HIV, they will likely experience a flu-like illness anytime between 2- and 6-weeks following infection, typically only lasting between 1 and 2 weeks. Approximately 80% of people who contract HIV experience this and are likely to have symptoms such as fever, sore throat, rash, muscle pain, joint pain, tiredness, and swollen glands. As these symptoms are not limited to HIV, it can mean that people may not realize they are infected – and afterwards, HIV often will not cause symptoms for many years. This is a key reason why HIV is so underdiagnosed, as the virus will be actively damaging the host’s immune system while they will still feel and appear healthy – and this process can last up to ten years. When the immune system has been significantly damaged, other symptoms can follow, such as weight loss, night sweats, chronic diarrhea, and recurrent infections. Improved diagnosis and earlier treatment of HIV can prevent the disease from causing greater damage and developing into AIDS.
AS HIV is a virus, when it is transmitted to an individual it will bind to their host cells, as viruses are unable to replicate outside of living cells. HIV specifically binds to T-helper cells, which are a type of white blood cell and can also be referred to as CD4 cells, and fuse with the DNA inside the cell9. 10The HIV life cycle has seven stages, the first stage being the binding of the HIV to the receptors on the cell surface membrane of a CD4 cell. The second stage is fusion, where the HIV envelope fuses with the cell membrane of the CD4 cell as the HIV particle permeates the cell. Reverse transcription is the next stage and involves an HIV enzyme called reverse transcriptase. This converts HIV RNA into HIV DNA, which then allows the HIV DNA to bind with the genetic material of the CD4 cell. Integration is the fourth stage, involving integrase (another HIV enzyme) being released within the nucleus of the CD4 cell so that the HIV DNA can fuse with the cell’s DNA. Replication is the following stage, and this consists of HIV utilizing the CD4 cell’s machinery to synthesize HIV proteins. During the sixth stage (assembly), new viral proteins and HIV RNA move further away from the nucleus and towards the surface of the cell. It is at this point in the cycle where immature HIV is assembled. In the final stage (budding), the assembled viral particles leave the CD4 cell and release protease (an additional HIV enzyme). This enzyme breaks up the immature viral particles to form mature viral particles, which are infectious.
A person is considered to have AIDS when the CD4 cell count drops below 200 cells per cubic millimetre of blood. In a healthy person, a CD4 cell count is between 500 and 1600 cells per cubic millimetre of blood. A person can also be considered to have AIDS when they develop one or more opportunistic infections – due to their severely weakened immune systems11. Common opportunistic infections include a salmonella infection, where bacteria affect the intestines, and toxoplasmosis, which is a parasitic infection of the brain12.
Stigma and Global Crisis
HIV and AIDS are shrouded in stigma, especially due to common methods of contracting HIV being sexual intercourse or intravenous drug use. It was during the AIDS epidemic in the 1980s in the United States, where cases were reported on a large scale as they had not been before. The AIDS crisis in the 1980s was the first large-scale instance of HIV and AIDS being recognized, and there was an arduous struggle to quickly determine the causes, risk factors and modes of transmission for these conditions. One of the groups of people where there was the highest prevalence of HIV and AIDS was gay men. In 1983, the most ‘at-risk’ groups of contracting HIV were colloquially referred to as the ‘4H Club’13, consisting of gay males, hemophiliacs, heroin users (as well as other intravenous drug users) and those of Haitian origin.
Heroin and other intravenous drug users were at risk of being infected with HIV as blood from an infected host could be transmitted to them via a contaminated needle. People with hemophilia also could easily become infected when they received the clotting factors they lacked from donated blood – which was not screened for HIV and thus could be infectious. In 1985, blood screening for donated blood was introduced and greatly decreased the transmission of HIV via this treatment method for haemophilia14.
13Since 1982, the prevalence of AIDS in Haiti has been higher than in any other country in the Caribbean. Being Haitian or of Haitian descent does not increase the risk of becoming infected with HIV – as there is no genetic risk factor – and the modes of transmission for this virus are the same for Haitians as for all other people. It is suggested that HIV and AIDS was, and is, widespread in Haiti due to migrants arriving there from the Democratic Republic of Congo, where HIV is thought to have originated from.
Gay men were considered to be the most at-risk group of HIV and AIDS during the 1980s AIDS epidemic in the United States, but that has not yet disappeared. In June 1982, there were several cases of severe immune deficiency amongst the gay male population of Southern California, which led to the disease being called ‘gay-related immune deficiency’ or GRID15. There were approximately 1.2 million people in America living with HIV in 2018, and 740,400 of them were gay or bisexual men. A key reason why this is apparent is that anal sex is considered to be the form of sexual intercourse where there is the highest risk of transmitting HIV, due to the thin rectal lining making it easier for HIV to enter the body6.
Treatment
While there remains no cure for either HIV or AIDS, the former can be treated using antiretroviral therapy (ART)16. The key purpose of this treatment is reducing the individual’s viral load to an undetectable level – and if this can be maintained, the individual will have an almost zero risk of transmitting HIV to their partners (who do not have HIV) via sexual intercourse. ART consists of a combination of HIV medications that must be taken daily, and these medications work by preventing HIV particles from multiplying. This will reduce the number of HIV particles in the body, thus reducing the viral load. ART should preferably begin as soon as possible after infection, but this can be difficult if the affected person is unaware they have HIV. Combivir is a combination of two antiretroviral drugs taken as part of ART by those with HIV, and this treatment was approved by the FDA in September 199715.
Targets and Future Development
The significant social stigma surrounding HIV and AIDS undoubtedly persists, yet there is an increasingly global movement to tackle this and advocate for improved treatment – possibly even a cure in the future. The Joint United Nations Program on AIDS, known as UNAIDS was established in 1996 to coordinate responses to HIV and AIDS across the UN15. There are currently global targets in place to work towards the eventual goal of ending HIV and AIDS. These form part of the Sustainable Development Goals (SDGs), where target 3.3 is to ‘end AIDS as a public health threat by2030’17. Target 16 is ‘Peace, justice and strong institutions, including reduced violence against key populations and people living with HIV’18. The Millennium Development Goals were outlined by the United Nations in 2000, and within these goals, targets are addressing HIV and AIDS – for instance, goal 6 is to ‘combat HIV/AIDS, malaria and other diseases”19. Perhaps the most challenging targets outlined by the UN concerning HIV and AIDS are within the ‘Getting to Zero Strategy’ between 2011 and 2015; the objective was to achieve: zero new HIV infections, zero AIDS-related deaths, and zero discrimination against sufferers of HIV or AIDS20.
Conclusion
Arguably the stigma surrounding HIV and AIDs, in addition to limited access to healthcare in less economically developed regions of the world where HIV and AIDS tend to be more prevalent, is one of the main limiting factors of the global fight against HIV and AIDS. Prominent societal figures such as Freddie Mercury and Princess Diana of Wales have been instrumental in addressing this societal prejudice. Freddie Mercury was the lead singer of the British Band ‘Queen’, and he died from AIDS. Princess Diana opened an AIDS ward in Middlesex Hospital, London, in 1987, and she was photographed shaking hands with a person who had AIDS21. This was to break down the idea that HIV or AIDS was spread through skin contact, and work towards reducing the social isolation that many people living with HIV or AIDS are often forced to endure. The connections between intravenous drug use and sexual intercourse between men and HIV/AIDS has worsened the public view of these conditions due to homophobia and general discrimination. These global issues need to be confronted simultaneously with research into further treatment for HIV and AIDS, and potentially a cure.
Samara Macrae, Youth Medical Journal 2022
References
1. KFF: “the Global HIV/AIDS Epidemic” – https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
2. Wikipedia: “Epidemiology of HIV/AIDS” –https://en.wikipedia.org/wiki/Epidemiology_of_HIV/AIDS
4. National Library of Medicine: “Comparison of simian immunodeficiency virus and human immunodeficiency virus encephalitides in the immature host” –https://pubmed.ncbi.nlm.nih.gov/2831797/
5. Avert: “Origin of HIV & AIDS” – https://www.avert.org/professionals/history-hiv-aids/origin#footnote4_c7a0f2h
6. Centers for Disease Control and Prevention: “Ways HIV Can Be Transmitted” – https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html
7. Centres for Disease Prevention and Control: “Ways HIV is Not Transmitted” –https://www.cdc.gov/hiv/basics/hiv-transmission/not-transmitted.html
8. NHS: “Symptoms: HIV and AIDS” – https://www.nhs.uk/conditions/hiv-and-aids/symptoms/
9. Avert: “How HIV Infects the Body and the Lifecycle of HIV” –https://www.avert.org/about-hiv-aids/how-infects-body
10. National Institute of Health: National Institute of Allergy and Infectious Diseases: “HIV Replication Cycle” – https://www.niaid.nih.gov/diseases-conditions/hiv-replication-cycle
11. HIV gov: “What are HIV and AIDS” – https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids
12. HIV gov: “Opportunistic infections” – https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/opportunistic-infections
13. Microbiology Book: “Microbiology and Immunology On-Line” – http://www.microbiologybook.org/lecture/4hclub.htm
14. The New York Times: “Hemophilia and AIDS: Silent Suffering” – https://www.nytimes.com/1988/05/16/us/hemophilia-and-aids-silent-suffering.html
15. Avert: “History of HIV and AIDS Overview” – https://www.avert.org/professionals/history-hiv-aids/overview
16. HIV info/NIH.gov: “HIV Treatment: The Basics” – https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-treatment-basics
17. United Nations: “Sustainable Development Goals” – https://www.un.org/sustainabledevelopment/sustainable-development-goals/
18. UNAIDS: “HIV Preventions 2020 Road Map” – https://www.unaids.org/sites/default/files/media_asset/hiv-prevention-2020-road-map_en.pdf
19. United Nations: “Millennium Development Goals” – https://www.un.org/sustainabledevelopment/sustainable-development-goals/
20. UNAIDS: “2011-2015 Strategy/ Getting to Zero” – https://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/20101221_JC2034E_UNAIDS-Strategy_en.pdf
21. Tatler: “How Diana, Princess of Wales was instrumental in trying to stop the stigma against HIV/AIDS” – https://www.tatler.com/article/princess-diana-hiv-aids-awareness
Youth Medical Journal 