Overview of the HIV/AIDS epidemic and responses to it

How to stay on top of AIDS

The situation regarding HIV/AIDS changes all the time. It's important to have an overview of the epidemic and responses to it.

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The information in this article is drawn from UNAIDS, WHO, MSMGF, AIDS Alliance and HelpAge International. Their web pages give the following picture:

The HIV/AIDS pandemic is huge, but in the last two years the rate of new infections has probably began to decrease slightly. One big reason is the arrival of cheap, effective medication, antiretroviral medicines. Today, if people who are HIV positive get the correct dose and take the medication continuously, they can expect a normal life span. And as the viral load in people becomes less, they become less infectious and, it is hoped, they also learn to use condoms. But there are major barriers to this happening with enough people: getting drugs etc. to every corner of every country, every day, is a huge logistics problem; then people seeking testing and treatment meet all kinds of barriers including disrespectful health staff.

In an ideal world, every group in society would be part of AIDS surveillance, would get targeted interventions and respectful testing, counselling and treatment. But in fact there are important groups that are ignored or discriminated against - firstly, women and girls; secondly, men who have sex with men (MSM); thirdly the elderly; fourthly intravenous drug users. According to the head of UNAIDS, Peter Piot, the biggest problems in tackling the epidemic are not technical, but concern the prejudice in our heads.

Affected Groups who are sometimes bypassed

Women & Girls: Programmes that offer testing and treatment often ignore the reality of half the population. For a married woman in Africa who learns about the risk of HIV infection, the first barrier is the difficulty of preventing her own infection; she has no control over her husband, whether he gets tested and/or uses condoms. If she has suspicions about her own status, the act of getting tested puts her at risk, of rejection by her husband and her community. It has been suggested that to address women seriously in HIV/AIDS programmes, interventions should include offers of alternative housing and income.

For unmarried, younger girls – imagine yourself as one, entering your local health facility and asking for a test. Are you going to get acceptance that you are sexually active, sympathy, confidentiality and good information?

Men who have sex with men (MSM): In Asia, according to UNAIDS, in every major city, there are epidemics of HIV among men who have sex with men and by 2020, half of all new infections in Asia will be among MSM. A major response is needed with targeted prevention but as yet the response “is not there at all”. One of the main reasons, they say, is homophobia (prejudice against people who love the same sex) in all its forms. The same problem presents in Africa. Most African countries do not include this group in their HIV surveillance. In a number of countries homosexual acts are against the law. So MSM, faced with discrimination and illegality, do not come forward voluntarily and services to meet their needs are few. Look at the MSMGF website, and to understand the background read the report summary “Off the Map” (8 pp).

The Elderly: Data on HIV/AIDS is usually collected among people aged 15 to 49. Older people are ignored. But older people can be infected because they were young once - or they may be sexually active for longer than expected. UNAIDS & Helpage International estimate that there are 2.8 million invisible HIV positive older people in the world. One Helpage study in Sudan took samples of men and women of different ages and found that with the women over 60, 100% tested HIV+. Whatever the viral status of older women, they are often the people caring for adults sick with AIDS and for AIDS orphans.  [Source: HelpAge International, for some practical guidelines take a look at: HIV and AIDS guidelines]

Drug Injectors: Out of the 16 million drug injectors worldwide, currently three million are HIV positive. Prevalence varies widely, with 2% prevalence in the UK and 72% in Estonia. This indicates that where there are targeted interventions, as in the U.K., they work. The problem is worse in Eastern Europe, South and South-East Asia and Latin America.

The Drivers of the Epidemic

Underlying these failures in helping are prejudices, or “the drivers of the epidemic - especially gender inequality, stigma and discrimination, deprivation and the failure to protect and realize human rights. It is not a technological fix that is needed… but positive social change. Just expanding programmes, doing more, even much more, is not going to stop this epidemic. To reach universal access  we need to pay attention to the drivers.” According to Peter Piot, UNAIDS (shortened).

So check the prejudices in your head and in the people around you. Ask yourself honestly, in the district where you work, are the four groups catered for properly? Why not? They are part of an epidemic that affects us all. How are you reacting to the list of the four groups? Do you feel equally for each group or do some groups “deserve” good services more than others? Why?  Perhaps it is time that we tackled prejudice.

Facts about the Epidemic: Size

At the end of 2006, 39.5 million people were living with HIV/AIDS and in that year 4.3 million people were newly infected. But in 2007, according to UNAIDS, new infections and deaths from AIDS started to decline.

Treatment of People with HIV/AIDS

Retroviral treatment (HAART or Highly Active Antiretroviral therapy) is now available at relatively low cost. On paper it can be supplied to all governments; treatment can be rolled out to every health facility. In 2007, in low- and middle-income countries, three million people got antiretroviral treatment, up from two million in 2006. However, two thirds of those needing the treatment could not get it.

Mother-to-child infection

Medication can prevent the virus being passed from an infected pregnant woman to her baby during or around childbirth. Some countries are having good success - Botswana has reduced the infection of babies born to infected mothers to 4%. But in 2007 at least a third of infected pregnant women in Africa could not get treatment. Even so, in some African countries they are passing laws to punish women who pass the virus to their babies.

Co-Infections

Most people with AIDS do not die of the disease. But as their viral load gets higher and the number of defensive cells become fewer, they become vulnerable and their risk of infection becomes high. They are at risk from conditions including malaria, hepatitis C and TB 

A New Approach for 2014 - The New A-3B-4C-T of HIV Prevention  Neil M. Orr (MA) & David R. Patient (MHT) South Africa 2014 June 03

The Failure of the ABC Approach  For close to 25 years the standard HIV prevention strategy was the ABC sexual behaviour change strategy: Abstain, be Faithful, and use Condoms. Today, This ‘old’ strategy has all but faded into the background, with only condoms remaining on the tick-list of ‘to do’s’. New infections continued to rise steadily year after year, regardless of ABC. Condoms, although a logical and ideal solution, did not have the impact that was expected. One big reason was because it simply prevented the making of babies (procreational sex).

We need to rethink, and spend our energies and resources with a higher level of efficiency and impact.

The A-3B-4C-T Approach Fortunately, a completely different package of prevention strategies has emerged over the past few years,  the A-3B-4C-T approach. These are the 9 primary HIV transmission risk-reduction strategies that can reduce HIV transmission as stand-alone interventions:

A: Antiretrovirals (ARVs) as prevention, with emphasis upon access and adherence.

B1: Barriers (physical barriers – condoms and microbicides when approved released, - and behavioural barriers - abstinence, delayed sexual debut, multiple partner reduction). Condoms are more effective in specific groups, such as those engaging in sexual behaviour for recreational or economic reasons, as opposed to those having sex for procreational purposes.

B2: Blood precautions (issues concerning breaches of skin and membranes)

B3: Babies (PMTCT) With the new PMTCT (Prevention of Mother-to-Child Transmission) protocols – if they are applied as intended – mother-to-child transmission rates can be reduced from levels about  20% to 25% to close to 1%.

C1: Circumcision (VMMC) - Voluntary Male Medical Circumcision. This reduces the chances of a male becoming infected with HIV by about 50%, and the probability of him later infecting his regular partner by about 50% (WHO).

C2: Co-infection reduction  with TB, gastrointestinal, parasites, malaria, STIs, and others. We need to know more about how co-infections affect the viral load and the role of primary health interventions such as washing hands, kitchen hygiene, cooking methods - and th role of. treatment

C3: Couples HIV testing and counseling  (CHTC) For couples where one person has HIV and is taking ARVs, and the other is HIV-negative, the probability of transmitting HIV to the uninfected partner is close to zero (99.9%) after the treated partner achieves an undetectable viral load. Condoms have re-emerged as an effective part of prevention - as a short-term protective measure while a couple waits for the infected partner’s viral load to drop to safer levels. Then conception of babies can occur without risk of transmission from one partner to another.

C4: Community Viral Load Management (CVLM) - group-focused; primary health and occupational health issues

 T: Testing (HCT)

The nature of the required behaviour changes is different to ABC. They are more closely linked to economics, gender equity, and mental health issues, including motivation towards a better future, communication within relationships, stress and depression, and substance use (especially alcohol).

The results of the A-3B-4C-T approach are dramatic. Naturally, this shift in focus has resulted in a range of new issues, such as ensuring adherence to treatment and early pregnancy detection.

 

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maeve
Maeve Moynihan
Health & PHC Editor

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