Human Immunodeficiency Virus (HIV)

Hopes are high that there will someday be an end to the HIV epidemic. Activism, research, and global commitment are paving the way. Today, the need is urgent to fill “the gap” of people infected with HIV who are being “left behind.” This UNAIDS infographic represents the gap, or the 12 populations that are being left behind. HIV infections have dropped by 38% since 2001. It is time to close the gap between people moving forward and people who are not accessing life-saving treatment. Section 12.4 addresses the 12 populations that have been left behind and the global epidemiology of HIV/AIDS.

Courtesy of UNAIDS.



“The AIDS epidemic is one of the greatest challenges to our society today. It is a fight that we cannot afford to lose.


—Anthony S. Fauci, director of the National Institute of Allergies and Infectious Diseases


The 2014 Gap Report, published by the Joint United Nations Programme on HIV/AIDS (UNAIDS), stated that we are at the beginning of the end of the AIDS epidemic. The HIV epidemic has halted and has begun to reverse, as the number of new HIV infections has fallen globally by 38% since 2001. As of 2013, however, 2.1 million people were newly infected with HIV, and 22 million people were unable to access lifesaving treatment. The goal of the UNAIDS was to close this “gap” between the people moving forward and the people left behind. The “gap” represents the HIV+ people who have access to antiretroviral therapy (ART) and those who don’t. UNAIDS provided data and information on those that remain vulnerable to HIV infection and the gap between the “haves” and “have nots” with regard to access to treatment. A world map representing the average number of people living with HIV at the end of 2013 is shown in FIGURE 12-1.


The “hope” in the Gap Report included the following scorecard updates:




  • As of 2013, the number of people newly infected with HIV was continuing to decline in most parts of the world.



  • Approximately 2.1 million new HIV infections occurred in 2013, a 38% decline from 2001, when there were approximately 3.4 million new infections.



  • Between 2011 and 2013 alone, new infections fell by 13%.



  • Among the 82 countries for which data trends are of sufficient quality, new infections declined by more than 75% in 10 countries and by more than 50% in 27 countries.



  • Progress in stopping new HIV infections in children has been dramatic. In 2013, approximately 240,000 children were newly infected with HIV. This represented a 58% decline from 2002, in which approximately 580,000 children became newly infected with HIV.



  • New HIV infections among children declined by more than 50% or more in eight countries: Botswana, Ethiopia, Ghana, Malawi, Mozambique, Namibia, South Africa, and Zimbabwe.



  • Providing access to antiretroviral medicines for pregnant women living with HIV has averted more than 900,000 new HIV infections among children since 2009.



  • Almost half of all adults living with HIV (48%) now know their status.



  • Some 86% of people living with HIV who know their status in sub-Saharan Africa are receiving antiretroviral therapy, and nearly 76% of them have achieved viral suppression.



  • The number of people living with HIV who were not receiving antiretroviral therapy fell from 90% in 2006 to 63% in 2013.



  • Fewer people are dying of AIDS-related illnesses. In 2013, there were 1.5 million AIDS-related deaths.



  • AIDS-related deaths have fallen by 35% since 2005, when the highest number of deaths was recorded.



  • From 2010 to 2013 alone, AIDS-related deaths fell by 19%, the largest decline in the past 10 years.



  • In sub-Saharan Africa, the number of AIDS-related deaths fell by 39% between 2005 and 2013.



  • The number of AIDS-related deaths decreased significantly between 2009 and 2013 in several countries, including South Africa (51%), the Dominican Republic (37%), Ukraine (32%), Kenya (32%), Ethiopia (37%), and Cambodia (45%).


FIGURE 12-1 Regional average estimates of all ages of people living with HIV as of the end of 2013. As of 2013, approximately 35 million people were living with HIV.




  • The number of men who opted for medical male circumcision in the priority countries tripled from 2012 to 2013.



  • From 2004 to 2012, tuberculosis-related deaths among people living with HIV declined by 36% worldwide.


Lifesaving ART has resulted in a gain of about 40.2 million life-years since the start of the epidemic.


The “gap” in the 2014 UNAIDS Gap Report includes the following scorecard updates:




  • In sub-Saharan Africa, sexually active individuals only have access to eight male condoms each year. Among young people, condom access was even lower.



  • Three out of five people, 22 million, who are living with HIV are not accessing antiretroviral therapy.



  • Three out of every four children living with HIV are not receiving treatment.



  • Globally, 15% of all women living with HIV aged 15 years and older are young women aged 15–24 years old. Of these, 80% live in sub-Saharan Africa. In this region, women acquire HIV infection at least 5–7 years earlier than men.



  • Of the 35 million people living with HIV, 2–4 million also have hepatitis B and 4–5 million have hepatitis C.



  • An estimated 12.7 million people inject drugs, and 13% of them are living with HIV.



  • On average, only 90 needles are available per year per person who injects drugs, while the need is 200 per year.



  • Every year, almost 120,000 people aged 50 or older acquire HIV. People aged 50 and older need specialized care for HIV and other chronic conditions.


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:




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



  • Cytomegalovirus infection



  • 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.


FIGURE 12-2 (a) These brown nodules represent Kaposi’s sarcoma lesions commonly found in AIDS patients. (b) This AIDS patient has a chronic opportunistic oral candidiasis infection.


The Discovery of Human Immunodeficiency virus (HIv)


The discovery of the cause of AIDS was published in the journal Science by two different research teams: Luc Montagnier’s team at the Pasteur Institute in Paris (May 20, 1983) and Robert C. Gallo’s group at the National Cancer Institute at the National Institutes of Health (NIH) in Bethesda, Maryland (May 4, 1984). Both described a retrovirus isolated from cultured TH lymphocytes derived from a lymph node biopsy of an AIDS patient with lymphadenopathy (swollen lymph nodes). Lymphadenopathy was considered a precursor syndrome to AIDS. The virus Gallo identified originated from tissue samples sent to him by Montagnier, whose group suggested that the virus be named lymphadenopathy-associated virus (LAV). Gallo recommended the virus be named human T cell lymphotrophic virus type III (HTLV-III). In 1986, the name was changed from HTLV-III/LAV to human immunodeficiency virus (HIV).


Controversy emerged regarding which researcher discovered HIV first—Gallo or Montagnier. In 1990, the National Institutes of Health’s Office of Scientific Integrity began to investigate Gallo’s HIV research program. The HIV discovery dispute was finally resolved in Washington, D.C., in July 1994. At this time, it was acknowledged that the virus isolated at Gallo’s laboratory was one of the first viruses isolated in 1983 at the Pasteur Institute. This dispute is the focus of John Crewdson’s book, Science Fictions: A Scientific Mystery, a Massive Cover-up, and the Dark Legacy of Robert Gallo.


HIV-1 Versus HIV-2


The first HIV strain isolated by Montagnier’s and Gallo’s research teams was designated HIV-1. Shortly after the discovery of HIV-1, Montagnier’s group isolated another strain, which was designated HIV-2. HIV-2 is rare in the United States but is endemic in Western Africa. HIV-2 is significantly less infectious and progresses more slowly to AIDS than HIV-1.


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:




  • The contaminated vaccine theory



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



  • The house cat theory



  • 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 (SIVcpz). The genome of SIVcpz 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 SIVcpz occurred.


The SIVcpz 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 SIVcpz were killed and eaten. The blood from the butchered infected chimp entered cuts or wounds on the hunter. Subsequently, the SIVcpz 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.


Table 12-1 Famous HIV-Positive Individuals and Famous Individuals Who Have Died from AIDS-Related Causes




























































































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.

FIGURE 12-3 The oldest isolate of HIV-1 to date is from a blood sample collected from a male in 1959 in Kinshasa in the Democratic Republic of the Congo. HIV-1 isolates analyzed from human tissue, blood, or fecal samples collected from people in Kinshasa contain the greatest genomic diversity, suggesting that HIV-1 has been there longer than anywhere else. The initial HIV-2 epidemic is believed to have occurred during the war when Guinea-Bissau gained its independence from Portugal (1963–1974). Shaded areas on the map represent the geographical distribution of chimpanzees and sooty mangabeys in Africa.


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 SIVcpz 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 SIVcpz 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 SIVcpz.


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 SIVcpz and HIV-1 contamination. No HIV-1 or SIVcpz 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/SIVcpz 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 SIVcpz 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.


Table 12-2 Earliest Cases of AIDS







































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.

Where Did HIV-2 Originate?


Like HIV-1, HIV-2 entered the human population as the result of a zoonotic, or cross-species, transmission. It transferred from sooty mangabeys to humans during the first half of the 20th century in West Africa. The sooty mangabey (Cercocebus atys) is an Old World monkey that is native to Guinea-Bissau, Gabon, and Cameroon. Sooty mangabeys are naturally infected with SIVsm that is genetically similar to HIV-2. They are commonly hunted for food and kept as pets in West Africa. It is believed that the initial HIV-2 epidemic coincided with the independence war (1963–1974) in Guinea-Bissau, a former Portuguese colony. The war caused social disruption and a mass vaccination effort that may have brought forth a regional HIV-2 epidemic by increasing the number of people at the Canchungo clinic in Guinea-Bissau who were administered vaccine injections through unsterile, reused needles contaminated with HIV-2. HIV-tainted blood transfusions also occurred. Social disruption resulted in the increased movement of people and sexual activities such as rape and prostitution. The first reported cases of HIV-2 in Europe occurred among Portuguese soldiers who returned from the independence war. Today, up to 10% of the general population in Guinea-Bissau is HIV-2 seropositive.


The HIV/AIDS Pandemic: Patient Zero Versus the Earliest AIDS Cases


The HIV/AIDS epidemic appeared suddenly and nearly simultaneously in several metropolitan areas of the United States. The greatest number of cases were homosexual men living in Los Angeles, San Francisco, and New York City. In 1981, the CDC began an investigation of the epidemic, led by Dr. William Darrow and colleagues, to determine the risk factors for AIDS. The term patient zero refers to the first infected patient in an epidemiological investigation who is likely responsible for the spread of a particular infectious agent.


Randy Shilts, author of And the Band Played On, chronicled Darrow’s investigation. It was Shilts who proposed that a homosexual Canadian flight attendant was likely patient zero. The flight attendant admitted to anonymous, unprotected sex with as many as 2,500 partners, even after he developed Kaposi’s sarcoma. As research continued, though, earlier cases of AIDS were reported (TABLE 12-2), disproving the patient zero theory.


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:




  • Anal or vaginal intercourse



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



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



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



  • Congenital AIDS (before or during birth or through breastfeeding)



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


Rare Routes of HIV Transmission: Organ Transplants and Premastication


Donated organs are routinely screened for HIV infection in the United States. From 1994 to 2007, nearly 300,000 transplants were performed without any reported cases of HIV transmission. However, HIV transmission through an organ transplant has always been theoretically possible. The window between the time of HIV infection and the time of detectable HIV-specific antibodies by enzyme-linked immunosorbent assay (ElIsA) ranges from 3 to 8 weeks. An 8- to 10-day window exists during the early period of infection in which HIV nucleic acid-amplification tests (nAATs) do not detect HIV RNA. ELISA is less sensitive than NAATs. NAATs detect HIV before the body produces antibodies. HIV NAATs are not consistently used for screening donated organs. The chance of an organ recipient being infected during that small window is remote, but the risk of dying while on the waiting list is not incredibly small. Deceased donors and/or their organs to be donated are screened for HIV infection at the time of the donor’s cardiac or brain death. Typically, the organ is transplanted within 3–4 hours into the recipient. No national policy exists for the type or timing of HIV screening tests used for living donors.


In 2009, the first documented case of HIV transmission through organ transplantation of an organ from a living donor occurred in a New York City hospital. A living donor is someone who willingly volunteers to give his or her kidney or part of the liver to another person for transplantation. Living donors undergo comprehensive physicals and a thorough psychological evaluation. In this case, the living donor was evaluated and tested HIV negative 10 weeks before surgery. The recipient tested negative for HIV 12 days before transplant surgery by an ELISA test. The recipient had no history of sexually transmitted diseases and had not engaged in injection drug use or other high-risk activities. Upon an extensive investigation, it was determined that the donor contracted HIV sexually during the 10-week period before the surgery. This was a rare case. This incident spurred new testing recommendations for living donors and the development of questions for living donors about risky behaviors (e.g., sexual history, injection drug use). The CDC recommends that living donors be rescreened by ELISA and NAATs as close to the time of organ recovery as possible, but no more than 7 days before organ donation. Living donors should also be advised to avoid behaviors that put them at risk for contracting HIV before organ donation.


Three unusual cases of HIV transmission in Florida in children aged 9–39 months were reported in Pediatrics in 2009 (see Gaur in the Resources). Researchers found compelling evidence to determine that the three children were infected with HIV from mothers or caregivers primarily through premastication. Premastication is the transfer of prechewed food into the mouth of an infant or young child. Premastication practices occur in developing countries because dental care is lacking and commercial baby foods and blenders are not available. Over the course of human history, premastication has been practiced on all continents and in all types of societies with the purpose of providing food for babies. It was a complementary practice to breastfeeding. In humans, breastfeeding does not offer enough nutrition to the infant after 6 months of age. Teeth develop late, especially molars, which erupt at about 18–24 months. Premastication of adult diets was a solution that made up for the shortfall in breast milk. It was a fundamental health practice, providing nutritional support, including iron; promoting resistance to infections in infancy and later life; and preventing immuno-logical hypersensitivity (e.g., asthma). The most common premasticated plant foods were nuts, legumes, maize, rice, tubers, potatoes, noodles, millet, bread, fruit, and roots. The most common animal foods premasticated were eggs, wild game, domesticated meat, and fish.


The practice of premastication disappeared in populations that had access to modern food-processing techniques (e.g., blender) and/or prepackaged foods or that abandoned the practice because it was viewed as being “unhygienic.” Premastication has been linked with the potential for the transmission of pathogens, such as group A streptococci, Helicobacter pylori, Epstein-Barr virus, cytomegalovirus, human herpesvirus 8 (Kaposi’s sarcoma–associated virus), hepatitis B virus, and, most recently, HIV.


In all three cases reported in Pediatrics, the African American children tested HIV negative after birth. The fathers of the children were also HIV negative. Two of the mothers were HIV positive. In one case, the mother was HIV negative, but the child spent a lot of time with a great aunt who was infected with HIV. The mothers and aunt fed the children prechewed food. In all three cases, it was suggested that a factor aiding HIV transmission was mouth bleeding in the HIV-positive aunt or mothers as well as the infants due to teething or infection. The aunt and mothers were not adhering to antiretroviral therapy (ART) regimens, increasing their blood HIV levels and the likelihood of HIV transmission.


This was the first report of HIV transmission by premastication of food. Albeit rare, HIV-infected caregivers or parents are advised against this practice. Other traditional African practices exist where children are exposed to adult saliva that may increase the risk of HIV transmission. For example, traditional healers rub premasticated medicinal herbs mixed with “spit” (saliva) and blood onto a child’s face, head, and/or body to wipe away bad spirits and nightmares. Some caregivers apply saliva to treat cuts and soothe itchy insect bites. Another practice is to insert a finger lubricated with saliva into a constipated child’s rectum to stimulate the rectum mildly. Given the continuing and unacceptably high rate of pediatric HIV infection in Africa, it is important that mechanisms of caregiver–child transmission be identified and addressed.


Can HIV be Transmitted by Kissing or Oral Sex?


Social kissing is not a high-risk behavior. The risk increases, though, with open-mouthed, or “French,” kissing because considerable amounts of saliva are exchanged. The risk increases if the uninfected person has canker sores or other lesions in his or her mouth. Oral sex also poses a similar risk to uninfected individuals, because HIV-infected TH lymphocytes from semen may enter abrasions or lesions in the mouth.


Ways That HIV Is Not Transmitted: The Fragility of HIV in the Environment


HIV is an enveloped virus. Soap easily disrupts or inactivates infectious virions so that they no longer cause infection. HIV is highly susceptible to disruption through drying in the environment. It is important to understand that finding a low viral load in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. For example, HIV has not been recovered from the sweat of HIV-infected individuals. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV. HIV cannot be acquired by sharing a toilet seat used by an AIDS patient, nor can it be transmitted by hugging, shaking hands with, or coming into contact with the sweat or mucus (e.g., coughing and sneezing) of an infected individual.


Mosquitoes or other insects cannot transmit HIV, and it is not expected that an HIV–mosquito connection will occur. Pathogens that are transmitted by mosquitoes multiply in high numbers in the mosquito or other blood-sucking host and then concentrate in its salivary glands. When the mosquito takes a blood meal, it passes the pathogen into the victim’s blood through its saliva. HIV cannot replicate in mosquito cells, nor can it concentrate in any part of the mosquito so that it could leave the mosquito.


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:




  • Abstinence from sex



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



  • Microbicides



  • Pre-exposure prophylaxis (PREP)



  • 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:




  • 35 million people worldwide were living with HIV.



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



  • 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:




  • 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.



  • 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.



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



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



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



  • 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.



  • 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.



  • 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.



  • 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.



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



  • 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.



  • 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:




  • Human rights violations, stigma, and discrimination



  • Inequalities in access to treatment and services



  • Gender-based inequalities



  • 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.


FIGURE 12-4 (a) Issues faced by people living with HIV today. (b) Infographic representing the global burden of the HIV/AIDS epidemic at the end of 2013 by country. About 75% of people living with HIV are located in 15 countries. South Africa and Nigeria are the top two countries with the most number of people living with HIV.


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.


FIGURE 12-5 Infographic representing the percentage of adults living with HIV by country in sub-Saharan Africa at the end of 2013 with access to antiretroviral therapy. Note that many of the countries with less than 25% access were also hit by the recent Ebola outbreak.


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 12-6 (a) HIV subtype A followed homemade heroin drug trafficking routes into Eastern Europe. HIV subtype B predominates Western Europe. (b) Map designating the percentage of people living with HIV in Eastern Europe and Central Asia at the end of 2013. The blue region represents locations where Needle and Syringe Programs (NSPs) exist. The green regions have NSPs and opioid substitution therapy (OST).


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).


FIGURE 12-7 (a) Infographic representing the number of people living with HIV in Asia and the Pacific at the end of 2013. The countries with the highest percentage of people who are HIV positive are India, China, Indonesia, and Thailand. (b) Infographic representing the incidence of new HIV infections in Asia and the Pacific at the end of 2013. India, China, Pakistan, and Indonesia had the highest number of new HIV infections in this region. Indonesia increased by 48%, which raised cause for concern.


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:




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



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


Table 12-3 Registered Drug Users in China











































































































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.

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Jul 29, 2017 | Posted by in MICROBIOLOGY | Comments Off on Human Immunodeficiency Virus (HIV)

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