12.1 The History of HIV

1980–1983: Gay Cancer, GRID, and AIDS

During the early 1980s, physicians in New York and California observed a new infectious disease in young homosexual men. The disease was characterized by the appearance of a rare skin cancer and opportunistic infections associated with immune suppression. The rare skin cancer was kaposi’s sarcoma, which became referred to as the gay cancer. Previously, this cancer was only seen in elderly men of Mediterranean descent (FIGURE 12-2A). The men also often presented with the following infections:

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  Atypical pneumonia caused by Pneumocystis carinii (later renamed P. jiroveci)

  
  
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  Cytomegalovirus infection

  
  
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  Oral candidiasis (FIGURE 12-2B)

All of the observed opportunistic infections suggested that these individuals suffered from a type of cell-mediated immune suppression. In 1981, the CDC named the syndrome gay-related immune deficiency (gRId). In attempting to unravel the causes of the decline in gay men’s health, physicians noted that many of the patients were also being treated for hepatitis B, herpesvirus, and intestinal illnesses such as amebiasis and giardiasis. Common behaviors among GRID patients were the use of drugs to heighten sexual experiences and unprotected, anonymous sex at bathhouses. The number of known deaths from GRID in the United States in 1981 was 234, which then climbed to 853 in 1982. At the same time, physicians began to report that heterosexual individuals who received blood products or blood transfusions (e.g., hemophiliacs) were developing similar opportunistic infections. The latter cases were traced to blood donors who were homosexual men dying of GRID. In 1982, the CDC renamed GRID to acquired immune deficiency syndrome (AIds). In 1983, the CDC warned blood banks of a possible problem with the national blood supply. The number of known deaths from AIDS in the United States during 1983 was 2,304. In 1985, film star Rock Hudson died from the complications of AIDS. He was the first major American celebrity whose AIDS diagnosis became public knowledge. U.S. President Ronald Reagan mentioned the term “AIDS” in public for the first time that same year. TABLE 12-1 lists some of the famous people who were infected with HIV during the 1980s and early 1990s. Most of them died of HIV/AIDS.

The Origin of HIV-1 and the AIDS Pandemic

Where did HIV-1 originate? Has it been evolving for hundreds of years? Numerous myths and controversial theories have surfaced over the years to explain the origin of HIV. In the scientific community, the most widely accepted postulation is the hunter theory (or crossing the species barrier theory), or extensions of it. Other theories have been the subject of speculation as well, including the following:

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  The contaminated vaccine theory

  
  
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  The colonization theory (or “Heart of Darkness” theory)

  
  
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  The house cat theory

  
  
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  The conspiracy theory

The Hunter Theory

The hunter theory is the most commonly accepted hypothesis on the origins of HIV-1 in the scientific community. It is based on the premise that the HIV/ AIDS pandemic is a viral zoonosis. A retrovirus related to HIV-1 was isolated from the common chimpanzee (Pan troglodytes), which is native to Cameroon, Gabon, and the Democratic Republic of the Congo (FIGURE 12-3). The chimpanzee retrovirus is known as simian immuno-deficiency virus (SIV_cpz). The genome of SIV_cpz and the early strains of HIV-1 are nearly identical. The conclusion thus far is that the chimpanzee is the natural reservoir for HIV-1. The belief is that AIDS arose when chimpanzee-to-human transmission of SIV_cpz occurred.

The SIV_cpz infections in humans were likely acquired through the butchering and consumption of contaminated chimp, monkey, or ape meat. The meat of wild animals, or bushmeat, accounts for up to 80% of the dietary protein intake of people in the Congo basin area of Central Africa. The majority of bushmeat consists of porcupines, pouched rats, and duikers (small antelopes). Chimps and monkeys are hunted in large numbers in some areas, but they represent a small percentage of bushmeat consumed. It is thought that chimps infected with SIV_cpz were killed and eaten. The blood from the butchered infected chimp entered cuts or wounds on the hunter. Subsequently, the SIV_cpz strain adapted in the human host to become HIV-1. A 2004 study determined that retrovirus transmission from primates to hunters continues to occur today. Banning hunting, transport, sale, and consumption of bushmeat to prevent the transmission of simian viruses to humans has been difficult to enforce.

A serological study involving the analysis of plasma samples used for malarial studies in Africa between 1959 and 1982 was reported in Nature in 1998. Researchers stated that the oldest serum containing HIV-1 antibodies dated to 1959. The seropositive sample had viral RNA from HIV-1. It is currently the oldest known human case of HIV-1 infection. The sample is from an adult Bantu-speaking male who lived in Kinshasa, Democratic Republic of the Congo (Figure 12-3). It is hypothesized that the man was infected in rural Cameroon and then traveled by river to Kinshasa.

Individual	Occupation	HIV Status
Arthur Ashe	Tennis player and social activist	Infected in 1983 via blood transfusion during heart surgery; died in 1993.
John Curry	Figure skating champion	Died of AIDS-related illness in 1994.
Earvin “Magic” Johnson	Former Los Angeles Lakers point guard	Announced his HIV-positive status on November 7, 1991.
Greg Louganis	Olympic diver	HIV positive in 1988; announced it in 1995.
Tommy Morrison	Former world boxing champion	Tested HIV positive in 1996, automatically retiring him from boxing.
Michael Bennett	Choreographer of the Broadway show A Chorus Line	Died in 1987.
Rock Hudson	Movie star	First major American celebrity whose AIDS diagnosis became public knowledge; died in 1985.
Liberace	Pianist	Died in 1987 of cytomegalovirus pneumonia due to AIDS.
Freddie Mercury	Lead singer of the band Queen	Died from AIDS-related causes in 1991.
Anthony Perkins	Actor; famous for playing Norman Bates in the movie Psycho	Died of AIDS-related causes in 1992.
Isaac Asimov	Science fiction author	Infected by a blood transfusion during heart surgery. Died in 1992.
Randy Shilts	American journalist and author of And the Band Played On	Died in 1994.
Ryan White	Teenager with hemophilia; AIDS activist	Contracted AIDS via blood products; died in 1990 at the age of 18.
Elizabeth Glazer	Wife of Starsky and Hutch actor Paul Michael Glazer	Infected via a blood transfusion. Her son and daughter were also infected. She started the Pediatric AIDS Foundation. She died in 1994; her daughter died in 1988. Her son, now a young adult, remains healthy.
Robert Reed	American actor; played Mike Brady in The Brady Bunch	Died of AIDS-related complications in 1992.
Tom Fogerty	American musician; played rhythm guitar in Creedence Clearwater Revival (CCR); elder brother of John Fogerty, the lead singer and guitar player in CCR	Died of AIDS-related complications in 1990.
Tommy Sexton	Canadian comedian	Died of AIDS-related complications in 1993.
John Holmes	American adult film star; one of the most famous male porn stars of all time	Died of AIDS-related complications in 1988.
Bill Goldsworthy	Canadian-born player in the National Hockey League	Died of AIDS-related complications in 1996.
Kurt Raab	West German stage and film actor, screenwriter, and playwright	Died of AIDS-related complications in 1988.
Charlie Sheen	American actor, known for roles on shows such as Two and a Half Men and Anger Management	Publically announced HIV-positive status in November 2015, about 4 years after being diagnosed.

The Contaminated Polio Vaccine Theory

The contaminated polio vaccine theory is an extension of the hunter theory proposed by virologist Preston A. Marx. Marx posits that the initial spread of HIV-1 occurred in Africa during large-scale poliovirus vaccination campaigns that began in the early 1950s. Disposable plastic syringes were introduced in the 1950s and used to administer vaccines and medicines. This was a big change in healthcare practice; up until then, using huge quantities of traditional, metal syringes was too expensive in Africa. Multiple patients were inoculated with the same syringe containing poliovirus vaccine without sterilization between patients. The practice allowed the rapid transmission and spread of viruses from one individual to another, creating the potential for SIV_cpz to mutate and replicate in each new individual it entered.

Others believe in a slightly modified extension of the theory, suggesting that the oral poliovirus vaccines were contaminated with SIV_cpz virus. Edward Hooper, author of The River, suggested that HIV could be traced to the oral poliovirus vaccine referred to as Chat. The Chat vaccine was manufactured at the Wistar Institute in Philadelphia and tested in Africa. It was administered to a million people in the Democratic Republic of the Congo and surrounding areas during the late 1950s. Hooper believed the Chat poliovirus vaccine was produced in kidney cells taken from chimpanzees that were infected with SIV_cpz.

Vaccinees received the contaminated poliovirus vaccine and subsequently became infected with HIV-1. The Chat poliovirus vaccines have since been exonerated. Original stocks prepared by the Wistar Institute were tested for the presence of SIV_cpz and HIV-1 contamination. No HIV-1 or SIV_cpz or chimpanzee nucleic acids were detected in the Chat poliovirus vaccine. Furthermore, the vaccines made by the Wistar Institute were created using the kidney cells of rhesus monkeys.

The Colonization (or “Heart of Darkness”) Theory

In 2000, Jim Moore, a specialist in primate behavior, proposed another variation of the hunter theory. He pointed out that between 1880 and 1915 colonial rule of French Equatorial Africa, also referred to as the “Heart of Africa” or the “Heart of Darkness,” was very harsh. Colonial authorities required people to construct railroads or other projects. Many Africans were forced into labor camps and sent into the forest in search of valuable rubber for weeks at a time, year after year, and women were held hostage in unsanitary conditions and nearly starved. The physical demands were extreme. There was little time or energy left devoted to agriculture, leading to the increased reliance on bushmeat for food. These factors would have been sufficient to create poor health, including weakened immune systems. A stray and perhaps infected chimpanzee was likely a welcome source of bushmeat for laborers.

Moore believed that well-intentioned but undersup-plied doctors routinely vaccinated the workers against variola virus to prevent smallpox with unsterile/contaminated needles to keep them alive and working. A half a dozen syringes were used to draw blood to identify carriers and intravenously treat approximately 90,000 workers for sleeping sickness from 1917 to 1919. About 100,000 arm-to-arm passage inoculations to prevent smallpox were carried out prior to 1914. The inoculation material with pox vesicles likely contained a high concentration of lymphocytes, the primary host cell of HIV-1. Many of the camps actively employed sex workers (prostitutes), creating additional means of HIV/SIV_cpz transmission.

The transmission of pathogens was inevitable in the camps and disease was rampant. Anyone sick would not have stood out as being different because the laborers were present in an already disease-ridden population. It was speculated that half of the labor workers died in the camps, and many of them would have died before the first symptoms of AIDS. No medical records for these camps exist.

The House Cat Theory

Feline immunodeficiency virus (FIV) is a retrovirus that was discovered in 1987. It causes an infection of domestic cats that leads to an immunodeficiency syndrome resembling HIV-1 infection in humans, referred to as feline AIDS. In some cases it may cause feline leukemia. FIV does not cause disease in humans; however, HIV-1 and FIV are related retroviruses. A 2005 study published in the journal AIDS demonstrated that cats vaccinated with the HIV-1 p24 protein appeared to be at least as well protected against FIV as those immunized with the FIV p24 protein currently used by veterinarians. This surprising finding suggested that the p24 protein of the two retroviruses is an important immunogen that has been evolutionarily conserved.

The Conspiracy Theory

A significant number of individuals believe that HIV is a genetically engineered or man-made virus. During the 1980s, the Soviet press reported that HIV was manufactured as part of an American biological warfare research program. Third World newspapers and publications run by Soviet front organizations picked up this false information. The Soviet reports were stopped in 1987.

Others believe that HIV was genetically engineered to wipe out large numbers of black and homosexual people. The evidence these speculations are based on is tenuous at best, as it ignores the clear link between SIV_cpz and HIV. It also ignores the fact that HIV antibodies were detected in serum samples collected from people as far back as 1959—a time when genetic engineering technology was not available to “create” HIV. Genetic engineering did not become a reality until 1977, when a man-made gene was used to manufacture human somatostatin in the bacterium Escherichia coli.

Year of Death	Case	Location	Evidence
1959	Preserved blood sample from a male	Kinshasa, Democratic Republic of the Congo, Africa	HIV and antibodies in blood sample of this individual who died in 1959.
1959	25-year-old male, former naval seaman	Manchester, England, UK	Unexplained immunodeficiency, Pneumocystis pneumonia, cytomegalovirus infection. PCR detected HIV proviral DNA. Findings were controversial.
1969	15-year-old male prostitute	St. Louis, Missouri, USA	Frozen tissue and serum samples contained HIV antibodies. Patient died of aggressive Kaposi’s sarcoma.
1976	30-year-old Norwegian sailor and long-haul truck driver throughout Europe (mainly Germany)	Oslo, Norway	Had sex with African women, including prostitutes in Cameroon during the early 1960s. His wife and daughter both died from AIDS in 1977.
1977	47-year-old female Danish surgeon who had worked in a primitive hospital in Zaire from 1972 to 1975	Europe/Denmark	Died of AIDS-like illness; no obvious risk factors.
1984	31-year-old homosexual French-Canadian flight attendant	Quebec City, Canada	Kaposi’s sarcoma; died of kidney failure caused by AIDS-related infections.

12.2 HIV Transmission

HIV is present in blood; semen; vaginal fluids; breast milk; and, in very low levels, saliva and tears. The most common ways that HIV is transmitted are by the following modes of transmission:

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  Anal or vaginal intercourse

  
  
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  Sharing of HIV-contaminated needles (e.g., by injection drug users)

  
  
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  Blood transfusions using infected blood or blood-clotting factors (this is now rare in the United States)

  
  
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  Accidental needlestick injuries (healthcare workers are at risk while working with HIV-positive patients)

  
  
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  Congenital AIDS (before or during birth or through breastfeeding)

  
  
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  Sharing of HIV-contaminated tattoo needles, razors, acupuncture needles, or ear-piercing implements

12.3 Prevention of HIV Infection

No “silver bullet” method has been found to prevent HIV infection; however, a variety of practices and methods are in development that have the potential to stem HIV epidemics (note that preventative HIV vaccines are discussed later in this chapter). The following practices can be used to prevent HIV transmission:

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  Abstinence from sex

  
  
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  Use of barrier methods (e.g., condoms) during sexual activity

  
  
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  Microbicides

  
  
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  Pre-exposure prophylaxis (PREP)

  
  
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  Postexposure prophylaxis (PEP)

Abstinence from sexual activity eliminates the risk of acquiring HIV. The use of male and female condoms effectively reduces the risk of HIV transmission. The Roman Catholic Church, which bans the use of contraceptives, has been considering the issue of using condoms as a barrier to infection among married couples when one of the partners is infected with HIV. Some priests hold the view that it would be a sin for an HIV-seropositive person to engage in sex without the use of a condom because the act would ultimately kill the partner. Driving this debate is the fact that 165 million Roman Catholics live in Africa, the continent most affected by HIV and AIDS. If the use of condoms is approved by the Roman Catholic Church, it would be a sign of hope for those suffering from AIDS, especially in Africa, where about 6,600 people die every day of the disease.

Microbicides are being developed to reduce sexual transmission of HIV to women. Formulations may be a gel, cream, suppository, or slow-release vaginal sponge that would be applied prior to sexual intercourse. Microbicides could prevent HIV transmission through several different mechanisms of action. Some microbicides are surfactants that disrupt the envelope of HIV. Others are fusion inhibitors that block attachment of HIV to the host cell receptors and coreceptors or replication inhibitors that inhibit HIV reverse transcriptase.

Microbicides with only one mechanism of action will likely not offer complete protection against HIV infection. As a result, a combination of microbicides will increase their efficacy. Nearly 60 microbicide candidate products are undergoing preclinical or early-phase clinical trials. The microbicide that has advanced the farthest in clinical trials to date is a 1% tenofovir gel that is used intravaginally both before and after sex. Tenofovir is an HIV reverse transcriptase inhibitor.

An intriguing approach is the use of genetically engineered probiotic bacterial strains of Lactobacillus. Lactobacillus strains are involved in the production of yogurt, kefir, and cheese. L. lactis has been engineered to produce the antiviral agent cyanovirin. Cyanovirin is an HIV cell fusion inhibitor that was isolated from cultures of cyanobacteria. L. jensenii was engineered to secrete CD4 proteins that bind to HIV gp120 that could inhibit viral entry. The idea is to use the bacteria to prevent vaginal and oral transmission of HIV. Will anti-HIV yogurt be a future microbicide?

Pre-exposure prophylaxis (PREP) is the use of antiretroviral drugs by high-risk individuals prior to HIV exposure to reduce the risk of becoming infected. For this method to be desirable, the antiviral drugs must be effective and nontoxic and prevent the development of resistant strains of HIV. PREP trials testing tenofovir were conducted with prostitutes in Cambodia, Cameroon, Malawi, and Nigeria, but local governments stopped the studies due to protests from activists. In PREP, tenofovir is used as an oral, once-daily, single-tablet regimen. New trials using Truvada are under way in Peru, Thailand, Ghana, Botswana, and the United States. Truvada is a single-pill therapy that combines tenofovir and emtricitabine reverse transcriptase inhibitors.

Postexposure prophylaxis (PEP) involves providing antiretroviral drugs to lower the risk of HIV infection after an individual has had a possible exposure to HIV (e.g., through occupational, accidental needlestick injuries). PEP should be administered within 48 hours (not to exceed 72 hours) of a high-risk exposure to HIV. The sooner PEP is administered, the more effective it is. It is a 4-week program in which two or three antiviral medications are provided several times per day. Some individuals may not be able to adhere to the regimen due to serious side effects of the drugs.

12.4 Global Epidemiology of HIV/AIDS: Closing the Gap

There are people living with HIV in all parts of the world, from all walks of life and cultures, all ages and all genders. Some are more affected than others, and some have better services than others. Consider the following statistics on the global burden of HIV at the end of 2013:

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  35 million people worldwide were living with HIV.

  
  
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  3.2 million children and 2.1 million adolescents worldwide were living with HIV.

  
  
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  4.2 million people 50 years and older were living with HIV globally.

Since the start of the HIV/AIDS epidemic, more than 78 million people have been infected with HIV, and 39 million have died. On a positive note, HIV infections have dropped by 38% since 2001. However, in 2013 approximately 2.1 million people were newly infected with HIV.

HIV infection is no longer a death sentence. A person who has access to HIV treatment in a high-income setting has nearly the same life expectancy as a person who is not infected with HIV. However, about 22 million people or only two out of five people infected with HIV have access to HIV treatment. One of the major reasons why this is the case is because children and adults in lowand middle-income countries cannot afford treatment or cannot afford second-line drug combinations needed after first-line medicines have stopped working. Affordable and accessible treatment for all—irrespective of age, sexual orientation, gender, religion, socioeconomic status, or ethnicity—is an absolute necessity for the survival of people living with HIV. According to the 2014 UNAIDS Gap Report, 12 populations, or “gaps,” of HIV-infected people are being left behind:

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  People living with HIV in all parts of the world, from all walks of life and cultures, all ages and gender who are not benefiting from health care, employment, or education or social protection. Some are more affected than others and some have better access to services than others.

  
  
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  Almost 60% of new HIV infections occur among adolescent girls and women aged 15–24 years (of whom 80% live in sub-Saharan Africa) who are in relationships with older male partners and are unable to protect themselves from HIV infection. This group engages in unsafe sex behavior and low condom use because of gender inequalities and gender-based violence. Punitive and age-restrictive laws and policies present barriers to young women accessing health services.

  
  
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  HIV-infected inmates leave prison with a suppressed viral load but become disconnected from care and nonadherent to ART during reentry into community life.

  
  
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  Undocumented HIV+ migrants face complex obstacles, such as lack of access to health care.

  
  
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  HIV+ individuals who inject drugs face punitive legal environments and poor access to services.

  
  
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  HIV prevalence among sex workers is 12 times higher than among the general population. They face stigma, violence, and punitive legal environments that limit the availability, access, and uptake of HIV prevention, treatment, care, and support.

  
  
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  Gay men and other men who have sex with men are 19 times more likely to be living with HIV than the general population. They face stigma, discrimination, and violence based on sexual orientation and gender identity, which contributes to the lack of access to HIV treatment and services, HIV prevention, and diagnostics.

  
  
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  Transgender people do not identify with the gender assigned at birth. They experience social exclusion. Globally, an estimated 19% of transgender women are living with HIV. They face discrimination and lack of access to appropriate health care.

  
  
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  About half of the children and pregnant women living with HIV in low- and middle-income countries do not receive an HIV test and access to HIV prevention and treatment.

  
  
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  Displaced persons living with HIV relocated through conflict or disaster can experience a disruption of access to HIV treatment.

  
  
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  In South Africa, there is an HIV prevalence of 17% among people with disabilities. People with disabilities represent one of the largest and most under-served populations.

  
  
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  The needs of people aged 50 years and older living with HIV are often overlooked, neglected, or ignored.

Overall, people living with HIV are being left behind because they are not benefiting from health care, employment, education, or social protection. This is usually due to stigma, discrimination, prohibitive laws and policies, or a lack of services. The issues faced by people living with HIV are illustrated in FIGURE 12-4A. The following are the top four reasons why people are being left behind:

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  Human rights violations, stigma, and discrimination

  
  
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  Inequalities in access to treatment and services

  
  
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  Gender-based inequalities

  
  
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  Criminalization and exclusion

The 2014 International AIDS Conference put the eradication of AIDS and discrimination against those who are HIV positive on its agenda with the slogan “no one left behind,” ensuring that nondiscrimination is adhered to in the HIV response.

12.5 HIV/AIDS in Sub-Saharan Africa

At the end of 2013, 75% of people living with HIV lived in just 15 countries. An infographic representing where the majority of people living with HIV live by country at the end of 2013 is shown in FIGURE 12-4B. Sub-Saharan Africa has been hit harder by HIV/AIDS than any other region. AIDS erased much of the progress that had been made in extending life expectancy. In the most heavily affected countries, life expectancy is now less than 49 years. This decrease can be linked directly to HIV/ AIDS. However, new HIV infections have fallen. A significant decline (39%) of AIDS-related deaths in subSaharan countries occurred between 2005 and 2013. At the end of 2013, the largest numbers of people living with HIV in sub-Saharan Africa were located in South Africa (25%), Nigeria (13%), Kenya (6%), Mozambique (6%), Uganda (6%), the United Republic of Tanzania (6%), and Zimbabwe (6%).

The future of Africa is threatened by a combination of ongoing crises that keep its people poor and its nations weak. The countries of Africa suffer from unpayable foreign debt, the AIDS epidemic, the largest Ebola epidemic in history (2014–2015), and trade policies that limit Africans from being able to sell their products at world prices in order to reduce their poverty status. SubSaharan Africa is the world’s poorest region: 70% of its population lives on less than $2.00 per day. Millions of the people in this region go hungry every day.

At least 12 million African children have lost one or both parents to AIDS. AIDS prevention campaigns can help to stop the spread of HIV, but access to antiretroviral drugs has been a significant problem in Africa. This is because the drugs are expensive and a sufficient number of trained healthcare workers to monitor and administer treatment are not available. The epidemic is putting strain on the healthcare sector and schools. Those living with HIV require medical care, and many countries do not have the healthcare resources to meet the demand.

AIDS heavily affects schools, and education is vital. Many children are affected by HIV in a number of ways. They live with parents and relatives living with HIV in households drained of resources. Orphaned children, particularly girls, are either pulled out of school or are not enrolled due to the financial constraints of their affected families, and have to assume responsibilities of caring for sick household members and/or providing for households. Interruption of girls education especially in their formative years bears life-long repercussions. Teachers are exposed to the reality of HIV and AIDS on a daily basis, in their personal lives, and also through interactions with students.

Teachers are expected to respond to the special needs of students who are AIDS orphans, students who are HIV positive, as well as students whose families are struggling with AIDS-related illness or socioeconomic circumstances. Many teachers are living with HIV but are afraid to be tested and/or afraid to seek treatment for fear of losing their jobs and stigmatization. An estimated 122,000 teachers in subSaharan Africa are living with HIV, most of whom have not sought testing and do not know their status. There is no quality education without qualified teachers. Teachers are at the front lines of HIV and AIDS information and knowledge dissemination to safeguard future generations. Yet, there is an estimated shortage of 1 million qualified teachers in sub-Saharan Africa. There is an urgent need to provide training for the millions of teachers who have little education themselves.

HIV/AIDS has dramatically affected labor and productivity, decimating the economy and social progress of Africa. The vast majority of HIV-infected people in Africa are between the ages of 15 and 49 years—the prime of their working lives. Factories, employers, schools, and hospitals have to train their staff to replace a workforce that has become too ill to work. Domestic and international support is needed for treatment and educational programs (including testing and support for those who are infected with the HIV virus) to further stop this global pandemic.

That being said, access to antiretroviral therapy is improving. Three out of four people on ART live in subSaharan Africa. In 2013, about 12.9 million people living with HIV in sub-Saharan Africa had access to antiretroviral therapy. This represents 37% of people living with HIV. Of those who have access, 38% are adults living with HIV. However, just 24% of all children living with HIV have access to lifesaving antiretroviral therapy in sub-Saharan Africa. Inequalities are present in where treatment is accessible. For example, in Nigeria, 80% of people infected with HIV do not have access to treatment (FIGURE 12-5). In contrast, between 1995 and 2009, 54% of life years were saved in North America and Western Europe, where access to HIV treatment has long been available. Gender inequalities exist with regard to access to ART. Overall, 67% of men and 57% of women were not receiving ART at the end of 2013 in sub-Saharan Africa.

Tuberculosis, which is caused by the bacterial pathogen Mycobacterium tuberculosis, is the most common opportunistic infection in HIV-positive people. Since 2004, tuberculosis-related deaths in people living with HIV have fallen 36% worldwide at the end of 2012. However, tuberculosis remains the leading cause of death among people living with HIV in Africa. In 2013, the percentage of people infected with HIV who also had tuberculosis who started antiretroviral therapy reached 70% in 2013 (up from 60% in 2012).

Women separated from their spouses for long periods because of financial challenges, food security, and social reasons find themselves in vulnerable situations. They may exchange sex for food or money. They may also be at risk if their spouse returns home having become HIV positive. Migrant men aged 18–49 spend 11 months of the year working in mines in southern Africa and return home for a month each year. The mines are located in communities surrounded by brothels. Miners separated from family have an increased likelihood of engaging in risky sexual behavior. Once infected, miners returning home may risk transmitting HIV to their partners. Non-migrant workers don’t have this added comparative risk of HIV infection. Policies that enhance the awareness of HIV/AIDS among all groups of people living with HIV in sub-Saharan Africa, reducing the vulnerability of women to HIV infection, and improving food security must be prioritized in order to end the HIV epidemic in this region.

12.6 Central Asia and Eastern Europe: Hot Spots in the Worldwide HIV Epidemic

Several regions and countries do not fit the overall trend of HIV epidemic decline or stabilization. HIV incidence increased by more than 25% in five countries in Eastern Europe and Central Asia between 2001 and 2009. The HIV epidemic in this region continues to worsen. Two countries, the Russian Federation and Ukraine, account for over 85% of the people living with HIV in the region. Eight out of 10 new HIV infections occur in people living in the Russian Federation. The primary route of transmission in the Russian Federation is injection drug use; however, sexual contact and mother-to-child transmissions have begun to increase.

Eastern Europe and Central Asia have an estimated 2.9 million injection drug users. More than 1.8 million of these live in the Russian Federation. At the end of 2013, HIV infection among injection drug users in the Russian Federation ranged from 18% to 31%. Detailed molecular analysis has revealed that HIV strains isolated in Belarus, the Russian Federation, Kazakhstan, and other former countries of the Soviet Union came from HIV isolates found in southern Ukraine. The spread of HIV subtype A followed heroin trading routes into Eastern Europe. Subtype B is predominantly found in Western Europe (FIGURE 12-6A). Section 12.10: Laboratory Diagnosis of HIV discusses HIV subtypes.

The Ukraine became an important transit country for heroin trafficking in the mid-1990s. It is located at a strategic crossroads between Southwest Asia, the primary heroin producing region, and markets in Western Europe. The Ukraine has transparent borders with its neighboring states of Russia, Moldova, and Belarus. Of the 1,500 roads connecting Ukraine with its contiguous states in the north, east, and southwest, only 98 have customs facilities (State Customs Service of Ukraine). Smugglers can travel virtually unfettered into and out of the Ukraine.

In the Russian Federation and other parts of Eastern Europe, people were injecting chernaya (a homemade heroin or opiate), methamphetamine (vindt), and methcathinone (jeff). Chernaya is made by adding water to ground poppies and then adding sodium bicarbonate as an alkalizing agent. The mixture is boiled, and the opiate alkaloids are extracted with solvents. Among the opiate alkaloids is morphine, which can be chemically converted into a heroin mixture that is reduced, boiled, and filtered. According to interview-based research, many dealers who prepared the chernaya sold prefilled used syringes picked off the street that were contaminated with blood (the blood may be from an HIV-infected injector).

Heavy alcohol consumption is prevalent among injection drug users in the Russian Federation. Alcohol consumption is associated with sexual risk-taking and drug injection practices that facilitate HIV transmission. Alcohol use also increases the prevalence of sexual risk behaviors among noninjection drug users engaging in sex with injection drug users, spreading HIV beyond the injection drug user population.

Fighting the HIV epidemic in this region will require governments to address heroin addiction. Methadone is a drug used to treat heroin addiction. It reduces cravings for heroin and blocks the high associated with heroin use. The Russian Federation outlaws methadone. The Ukraine recently legalized it but struggles to meet the demand for it. Intervention to reduce HIV transmission will also need to address alcohol consumption among noninjection drug users who engage in sexual activity with injection drug users and the propensity of having sex while high on chernaya or methamphetamine.

FIGURE 12-6B is a map of Eastern Europe and Central Asia that shows the percentage of people living with HIV in this region. The blue region represents locations where needle and syringe exchange programs exist. The green regions have both Needle and Syringe Programs (NSPs) and Opioid Substitution Therapy (OST). According to a World Bank study, only 4% of people who inject drugs living with HIV are currently receiving antiretroviral therapy. Because higher numbers of HIV infections are prevalent among people who inject drugs, HIV prevention strategies must be tailored to effectively reach this population.

12.7 HIV/AIDS in India and China

After sub-Saharan Africa, the region with the largest number of people living with HIV is Asia and the Pacific. At the end of 2013, an estimated 4.8 million people were living with HIV across the region. Six countries—India, China, Indonesia, Myanmar, Thailand, and Vietnam— account for more than 90% of people living with HIV in this region (FIGURE 12-7A). India has the third largest number of people in the world living with HIV after Nigeria and South Africa. At the end of 2013, India had 2.1 million people living with HIV. This accounts for about 4 out of every 10 people living with HIV in the region. Overall, new HIV infections declined by 8% in South and Southeast Asia and by 16% in the Pacific region by the end of 2013. The breakdown by country shows a mixed picture. New infections in India decreased by 19%, but new infections in Indonesia increased by 48%, which is an alarming increase (FIGURE 12-7B).

The spread of HIV in India has been uneven. In certain parts of India, more people are living with HIV than in other parts of the country. The HIV epidemic is severe in southern and northeastern India. In the southern states, HIV is primarily spread by heterosexual transmission. Infections in the northeast are mainly found among drug users using dirty needles and sex workers (prostitutes). Low literacy and widespread migration are major contributors toward the large HIV population in India.

On a global scale, 2% of people living with HIV are located in China (Figure 12-4). By the end of 2011, 780,000 adults and children were estimated to be living with HIV in China, and about 48,000 new HIV infections are diagnosed each year. Of those people diagnosed with HIV, 46.5% were infected through sexual transmission, 28.4% through injection drug use, and 13.7% through homosexual transmission. Other modes of transmission, albeit at very low rates, include commercial plasma donation and transfusion of infected blood and blood products and mother-to-child transmission. ART increased from 62% in 2009 to 73.5% in 2011.

The HIV/AIDS epidemic is driven by various entertainment venues that provide sex services in highly populated urban areas. Preventing initiation of or continuation of high-risk sexual behaviors associated with drug use also is needed to stem the Chinese HIV/AIDS epidemic. China is home to one of the largest injection drug user populations in the world. In just 10 years, China has evolved from a transit country for illegal drugs to a large drug consumption market (TABLE 12-3). In 2011, China had approximately 1.79 million registered drug users, of which 1 million were using heroin. The syringe-sharing rate was 69.5%. East and Southeast Asia and Eastern Europe (representing 35 countries out of 151 that identify injection drug users) have the lowest ratio of injection drug users accessing ART (1–4 per 100 injection drug users, of which 78–95% are HIV positive). In comparison, Western Europe (27 of the 151 countries that identify injection drug users) has a ratio of 89 per 100 injection drug users accessing ART (46% are HIV positive).

In China, widespread discrimination and prejudice is practiced toward people living with HIV/AIDS. Many people stigmatize those living with HIV. A UNAIDS survey of 6,000 people living in eight Chinese cities in 2008 revealed the following views toward those who have tested positive for HIV:

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  64.9% were unwilling or strongly unwilling to live in the same room as an HIV-positive person.

  
  
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  41.3% were unwilling or strongly unwilling to work in the same place as an HIV-positive person.

Year	Number of Registered Drug Users	Amphetamine-Type Stimulant Users	Comments/Implementation of Prevention Strategies
1988			Chinese government declared drug use a problem in the border area of the southwestern part of China.
1990	70,000
1991	148,000
1992	250,000		Number of registered drug users doubled in 2 years.
1994	380,000
1995	520,000
1997	540,000
1998	596,000		First clean needle and syringe exchange pilot program.
1999	681,000
2000	860,000
2001	901,000
2002	1,000,000		National Free Antiretroviral Treatment Program launched.
2003	1,050,000
2004	1,140,000		Methadone Maintenance Treatment (MMT) program launched with eight pilot clinics in five provinces.
2005	1,160,000
2008	1,132,000	216,526	By July 2007, 775 clean needle and syringe exchange sites had been established in 405 counties, covering 45,000 drug users. Asia Regional HIV/AIDS Project implemented in Yunnan distributed over 22,000 clean needles/syringes, collected over 324,000 used needles (65% collection rate), distributed more than 12,000 condoms. More than 100 MMT clinics serve 21 provinces.
2009	1,335,900	314,072
2010	1,545,000	423,000
2011	1,794,000	587,000	72.5% of registered users dependent on heroin; syringe-sharing rate increased 69.5%; average of 1,052 needle-exchange sites across the country, with an average of 52,600 drug users participating monthly.
Information from Li, J., and Xinyue, L. 2013. “Current status of drug use and HIV/AIDS prevention in drug users in China.” J Food Drug Anal 21:S37–S41. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Like this: Like Loading... Related Related posts: Rabies Poxviruses Epidemiology Host Resistance to Viral Infections Stay updated, free articles. Join our Telegram channel Join Tags: Understanding Viruses_gate Jul 29, 2017 | Posted by admin in MICROBIOLOGY | Comments Off on Human Immunodeficiency Virus (HIV) Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access %d