Human immunodeficiency virus (HIV), a virus affecting the human body and organs, impairs the immune system and the body’s ability to resist infections, leading to acquired immunodeficiency syndrome (AIDS), a collection of symptoms and infections resulting from damage to the immune system. Medical confusion and prolonged government indifference to the AIDS epidemic was detrimental to early risk reduction and health education efforts.
Initial facts about AIDS targeted unusual circumstances and unusual individuals, thereby situating the cause of AIDS in stigmatized populations and “at risk” individuals. Although current efforts to curb the spread of HIV/AIDS are based on a more realistic understanding of transmission and infections, government policies and educational campaigns still do not fully acknowledge the socioeconomics, drug use practices, cultural attitudes, and sexual behaviors of populations. Global HIV prevalence stabilized with improvements in identification and surveillance techniques, but reversing the epidemic remains difficult. The pervasive spread of HIV in particular populations and geographic areas continues as economic realities influence infection rates.
II. HIV Transmission
III. HIV/AIDS Treatment
V. Early Prevention: Clean Living
VI. Youth and Economic Stratification of HIV/AIDS
VII. HIV-Infected Heterosexual Women
VIII. People Living with AIDS
IX. Blood Transfusion
X. More Celebrities
XI. Strategies for Improvement
XII. False Cures, AZT, Politics, and Science
XIII. Scientific Ideology
Since the first recognized and reported death on June 5, 1981, AIDS has killed more than 25 million people, making HIV/AIDS one of the most destructive epidemics in history. The number of new HIV infections per year peaked in the late 1990s, with over 3 million new infections, but the infection rate never plummeted.
Although the percentage of people infected with HIV leveled off in 2007, the number of people living with HIV continues to increase. The combination of HIV acquisition and longer survival times creates a continuously growing general population. Treatments to decelerate the virus’s progression are available, but there is no known cure for HIV/ AIDS.
According to 2008 statistics — released in December 2009 by the World Health Organization (WHO) Joint United National Program on HIV/AIDS — 60 million people were infected worldwide since the epidemic began. An estimated 33.4 million people were living with HIV, of whom 2.1 million were children under age 15. Within that figure, as many as 610,000 children were born with HIV. Those figures are up slightly from the previous year: about 0.6 percent. Young people account for around 40 percent of new adult (age 15 and above ) HIV infections worldwide. In 2008, as many as 3 million people became newly infected, and some 2 million died that year of AIDS-related complications.
Two strains of HIV, HIV-1 and HIV-2, infect humans through the same routes of transmission, but HIV-1 is more easily conveyed and more widespread. Transmission of HIV occurs primarily through direct contact with bodily fluids — for example, blood, semen, vaginal fluid, breast milk, and preseminal fluid. Blood transfusions, contaminated hypodermic needles, pregnancy, childbirth, breastfeeding, and anal, vaginal, and oral sex are the primary forms of transmission. There is currently some speculation that saliva is an avenue for transmission, as evidenced by children contracting HIV through prechewed food, but research is ongoing to determine if this hypothesis is correct.
Labeling a person HIV-positive or diagnosing AIDS is not always consistent. HIV is a retrovirus that primarily affects the human immune system by directly and indirectly destroying CD4+ T cells, a subset of T cells responsible for fighting infection. AIDS is the severe acceleration of an HIV infection. When fewer than 200 CD4+ T cells per microliter of blood are present, cellular immunity is compromised; in the United States, a diagnosis of AIDS results. In Canada and other countries, a diagnosis of AIDS occurs only if an HIV-infected person has one or more AIDS-related opportunistic infections or cancers. The WHO grouped infections and conditions together in 1990 by introducing a “stage system” for classifying the presence of opportunistic infections in HIV-positive individuals. The four stages of an HIV infection were updated in 2005, with stage 4 as the indicator of AIDS. Definitions for surveillance and clinical staging were clarified and officially revised in 2006. The symptoms of AIDS do not normally develop in individuals with healthy immune systems; bacteria, viruses, fungi, and parasites are often controlled by immune systems not damaged by HIV.
HIV affects almost every organ system in the body and increases the risk of developing opportunistic infections. Pneumocystis carinii pneumonia (PCP) and tuberculosis (TB) are the most common pulmonary illnesses in HIV-infected individuals. In developing countries, PCP and TB are among the first indications of AIDS in untested individuals. Esophagitis, the inflammation of the lining of the lower end of the esophagus, often results from fungal (candidiasis) or viral (herpes simplex-1) infections. Unexplained chronic diarrhea, caused by bacterial and parasitic infections, is another common gastrointestinal illness affecting HIV-positive people. Brain infections and dementia are neurological illnesses that affect individuals in the late stages of AIDS. Kaposi’s sarcoma, one of several malignant cancers, is the most common tumor in HIV-infected patients. Purplish nodules often appear on the skin, but malignancies also affect the mouth, gastrointestinal tract, and lungs. Nonspecific symptoms such as low-grade fevers, weight loss, swollen glands, sweating, chills, and physical weakness accompany infections and are often early indications that an individual has contracted HIV.
There is currently no cure or vaccine for HIV/AIDS. Avoiding exposure to the virus is the primary technique for preventing an HIV infection. Antiretroviral therapies, which stop HIV from replicating, have limited effectiveness. Postexposure prophylaxis (PEP), an antiretroviral treatment, can be administered directly after exposure to HIV. The fourweek dosage causes numerous side effects, however, and it is not 100 percent effective. For HIV-positive individuals, the current treatment is “cocktails,” a combination of drugs and antiretroviral agents administered throughout a person’s life span. Highly active antiretroviral therapy (HAART) stabilizes a patient’s symptoms and viremia (the presence of viruses in the blood), but the treatment does not alleviate the symptoms of HIV/AIDS. Without drug intervention, typical progression from HIV to AIDS occurs in 9 to 10 years: HAART extends a person’s life span and increases survival time by 4 to 12 years. Based on the administration of cocktails and the increase in the number of people living with HIV/AIDS, the prevailing medical opinion is that AIDS is a manageable chronic disease. Initial optimism surrounding HAART, however, is tempered by recent research on the complex health problems of AIDS-related longevity and the costs of antiretroviral drugs. HAART is expensive, aging AIDS populations have more severe illnesses, and the majority of the world’s HIV-positive population do not have access to medications and treatments.
In 1981 the U.S. Centers for Disease Control and Prevention (CDC) first reported AIDS in a cluster of five homosexual men who had rare types of pneumonia. The CDC compiled four “identified risk factors” in 1981: male homosexuality, IV drug use, Haitian origin, and hemophilia. The “inherent” link between homosexuality and HIV was the primary focus for many health care officials and the media, with drug use a close second. The media labeled the disease gay-related immune deficiency (GRID), even though AIDS was not isolated to the homosexual community. GRID was misleading, and at a July 1982 meeting, “AIDS” was proposed. By September 1982 the CDC had defined the illness and implemented the acronym AIDS to reference the disease. Despite scientific knowledge of the routes and probabilities of transmission, the U.S. government implemented no official, nationwide effort to clearly explain HIV mechanics or promote risk reduction until the surgeon general’s 1988 campaign. Unwillingness to recognize HIV’s pervasiveness or to fund solutions produced both a national fantasy about the AIDS epidemic and sensationalized public health campaigns in the mass media.
Early Prevention: Clean Living
Prevention advice reinforced ideas of safety and distance. The citizenry was expected to avoid “risky” behavior by avoiding “at risk” populations. Strategies to prevent HIV/ AIDS were directed at particular types of people who were thought to engage in dangerous behaviors. Homosexual sex and drug use were perceived to be the most risky behaviors; thus heterosexual intercourse and not doing drugs were constructed as safe. Disease prevention programs targeted primarily gay populations but were merely health precautions for everyone else — individuals not at risk.
Citizens rarely considered how prevention literature and advice applied to individual lives because the public was relatively uninformed about the routes of HIV transmission. Subcultures were socially stigmatized as deviant, and at-risk populations were considered obscene and immoral. “Risk behavior” became socially constructed as “risk group,” which promoted a limited understanding of how HIV was contracted. The passage of the Helms Amendment solidified both public perceptions and government legislation about AIDS and AIDS education. According to the amendment, federal funding for health campaigns could be renewed each year with additional amounts of money as long as such campaigns did not “promote” homosexuality and promiscuity. Despite lack of funding, much of the risk-reduction information that later became available to the public was generated by advocates within the homosexual community.
Although avoidance tactics were promoted by the national government, precautionary strategies were adopted and utilized by gay communities. Distributing information through newspapers, pamphlets, and talks, the community-based campaigns emphasized safe sex and safe practices. Using condoms regardless of HIV status, communication between sexual partners, and simply avoiding intercourse were universal precautions emphasized in both American and European gay health campaigns. With a nontransmission focus, safe sex knowledge was designed and presented in simple language, not medical terminology, so that the information was easy to understand. Although “don’t ask, don’t tell” strategies were still adopted by many gay men, the universal safe sex strategy employed by the gay community promoted discussions about sex without necessarily calling for private conversations. The visibility and accessibility to information helped gay men understand HIV and promoted individual responsibility. The national pedagogy, by contrast, banned sexually explicit discussions in the public sphere. Individuals were encouraged to interrogate their partners in private without truly comprehending either the questions asked or the answers received. Lack of detailed information and the inability to successfully investigate a partner’s sexual past facilitated a need for an organized method of identifying HIV-positive individuals.
With the intention of stemming HIV, the CDC’s Donald Francis proposed, at the 1985 International Conference on AIDS in Atlanta, that gay men have sex only with other men who had the same HIV antibody status; accordingly, he presented a mathematical model for testing. Shortly thereafter, HIV testing centers were established, and the national campaign, centered on avoiding HIV-positive individuals, was implemented. Instead of adopting safe sex education and behaviors, the government merely inserted technology into existing avoidance paradigms. HIV tests were valid only if the last sexual exchange or possible exposure had occurred within six months to a year earlier. However, many people misinterpreted negative test results as an indicator of who was “uninfected,” thus merely reinforcing educated guesses. With the test viewed as an ultimate assessment for determining a sexual partner’s safety, many individuals relied on HIV test results to confirm individual theories of who was and was not infected. Unrealistic discussions about sexual practices and behaviors were detrimental to the American population, especially adolescents and young adults.
Youth and Economic Stratification of HIV/AIDS
In 1990 epidemiologists confirmed that a wide cross-section of American youth were HIV-positive. Minority and runaway youth were particularly affected, but millions of young people had initiated sexual interactions and drug use in the previous decade. Because health campaigns focused on prevention, there was little and often no help for individuals who were infected. Diagnosing the onset of symptoms and tactics to delay AIDS progression were almost nonexistent. Instead of recognizing the sexual and drug practices of middle-class white kids, society classified young people into categories of “deviance”: deviant individuals contracted HIV; innocent children did not. Refusing to acknowledge that young people were becoming infected, many parents and government officials impeded risk-reduction information. Consequently, few young people perceived themselves as targets of HIV infection, and much of the media attention focused on “tolerance” for individuals living with AIDS.
Under the false assumption that infections among youth occurred through nonsexual transmission, HIV-positive elementary school children and teenagers were grouped together and treated as innocent victims. Although drug use and needle sharing were prevalent behaviors in teenage initiation interactions, the public agenda focused on sexuality as the primary transmission route. Knowing about or practicing safe sex was dangerous; ignorance would prevent HIV. Representations of youth in the media reinforced the naivete and stereotypes that initially contextualized AIDS in the adult population; New York Times articles suggested HIV infections in gay youth were the result of liaisons with gay adults or experimentation among themselves. In a manner reminiscent of the initial constructions of AIDS in the 1980s, HIV-infected youth were effectively reduced to deviant, unsafe populations. Securing heterosexuality became, yet again, a form of safe sex and the primary prevention tactic for HIV. Refusal to acknowledge nonintercourse activities as routes for HIV transmission pervaded government policies of the 20th and 21st centuries.
HIV-Infected Heterosexual Women
Recommendations for avoiding HIV infections were limited in both scope and funding. Because heterosexual women were increasingly becoming infected, the U.S. Food and Drug Administration (FDA) approved the sale of female condoms in 1993. However, female condoms were largely unavailable, and the price was prohibitive for many women. Approved in 1996 by the FDA, the viral load test measured the level of HIV in the body. As with the female condom, the test was expensive and continues to be cost-prohibitive. Needle exchange programs demonstrated great effectiveness in reducing HIV infections via blood transmission. Although the U.S. Department of Health and Human Services recommended needle exchange programs in 1998, the Clinton administration did not lift the ban on the use of federal funds for such purposes. Needle exchange remains stigmatized, and funding continues to come primarily from community-based efforts. In 1998 the first large-scale human trials for an HIV vaccine began, but no vaccine has been discovered. Despite community and government efforts, people continue to become infected with HIV/AIDS.
With growing numbers of individuals contracting HIV, the government implemented some treatment strategies. The AIDS Drug Assistance Program (ADAP) was established to pay for HIV treatments for low-income individuals. In 1987 azidothymidine (AZT)/zidovudine (ZDV) became the first HIV/AIDS drug to receive the FDA’s approval. AZT’s toxicity was well documented, but the effectiveness of the long-term monotherapy was questionable. Nevertheless, AZT was administered to the population, and the FDA approved three generic formulations of ZDV on September 19, 2005. AZT continues to be the primary treatment in reducing the risk of mother-to-child transmission (MTCT), especially in developing countries. There were few effective treatments for children until August 13, 2007, when the FDA approved a fixed-dose, three-drug combo pill for children younger than 12 years old. Treatments are improvements for developing awareness of HIV/AIDS, but the realities of transmission and the costs associated with HIV infection remain largely ignored.
People Living with AIDS
People Living with AIDS (PWA, coined in 1983) became the faces of HIV infections, and such individuals provided the impetus for increased attention to the AIDS epidemic. Rock Hudson, an actor world-renowned for his romantic, heterosexual love scenes, appeared on ABC World News Tonight and announced he had AIDS. He died shortly after his October 1985 appearance. President Ronald Reagan, a close friend of Hudson, mentioned AIDS in a public address in 1986, the first time a prominent politician specifically used the words HIV and AIDS. In 1987, the same year the CDC added HIV to the exclusion list, banning HIV-positive immigrants from entering the United States, Liberace, a musician and entertainer, died of AIDS. Newsweek published a cover story titled “The Face of Aids” on October 10, 1987, but the 16-page special report failed to truly dispense with the stereotypes of HIV infection. With the growing number of PWAs, government policies toward HIV changed somewhat. In 1988 the Department of Justice reversed the discrimination policy, stating that HIV/AIDS status could not be used to prevent individuals from working and interacting with the population. December 1, 1988, was recognized as the first World AIDS Day. However, even with such social demonstrations of goodwill, recognizable faces remained aloof; the public “saw” HIV but did not associate HIV with the general population until Ryan White, a so-called normal person, grabbed community attention.
Ryan White, a middle-class, HIV-positive child became one of the most public and media-spotlighted individuals. He had hemophilia and contracted HIV through a blood transfusion. His blood-clotting disorder fit existing innocence paradigms and thus provided opportunities for discussions about HIV, intervention, and government aid. At age 13, White was banned from attending school, prevented from associating with his classmates, and limited to classroom interactions via the telephone. The discrimination White endured throughout his life highlighted how “normal” people were affected by public reactions and government policies. In 1990, the year White died at age 18, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed. With 150,000 reported AIDS cases in the United States, CARE directed attention to the growing incidences of HIV and aroused greater public compassion.
The teen culture of the 1990s continued to be affected as additional celebrities were added to the seropositive list. Earvin “Magic” Johnson, an idolized basketball player and all-time National Basketball Association (NBA) star, announced his HIV-positive status in 1991. The “perversion” labels normally associated with HIV were momentarily suspended as the public discourse tried to fit Johnson’s wholesome role-model status into the existing risk paradigm. Much of the public, including individuals in methadone clinics, referred to positive HIV serostatus as “what Magic’s got” and avoided the stigmatized label of AIDS. The compassion and understanding for HIV-positive individuals was short-lived, however. Freddie Mercury, lead singer of the rock band Queen, died in 1991 of AIDS. Because he was a gay man, Mercury’s life was quickly demonized, and he did not receive the same “clean living” recognition from the press. Preaching compassion was good in rhetoric but not in practice.
Limited public empathy did not quell the diversity of individuals affected by AIDS. In 1992, tennis star Arthur Ashe announced his HIV status. In the same year, teenager Rick Ray’s house was torched (Ray, a hemophiliac, and his siblings were all HIV-positive). During 1993, Katrina Haslip, a leading advocate for women with AIDS in prison, died of AIDS, and Pedro Zamorn, a young gay man living with HIV, appeared as a cast member on MTV’s The Real World. Zamorn died in 1994 at age 22. Olympic Gold Medal diver Greg Louganis disclosed his HIV status in 1995, which sent shock waves into the Olympic community. Louganis had cut his head while diving during the 1988 Olympics, and concern quickly entered scientific and media discussions about HIV transmission. The discrimination Louganis endured affected athletic policies and issues of participation in sports for HIV-positive athletes. Even though HIV/AIDS was the leading cause of death among African Americans in the United States in 1996, the public continued to focus on individuals whose faces, displayed in the media, informed much of the understanding of HIV in the United States.
Strategies for Improvement
During the June 2006 General Assembly High-Level Meeting on AIDS, the United Nations member states reaffirmed their approval of the 2001 Declaration of Commitment. Efforts to reduce the spread of AIDS focused on eight key areas, including reducing poverty and child mortality, increasing access to education, and improving maternal health. Universal access to comprehensive prevention programs, treatment, care, and support were projected outcomes for 2010. Strategies to improve HIV testing and counseling, prevent HIV infections, accelerate HIV/AIDS treatment and care, and expand health systems were four of the five suggestions WHO expected to implement. The sheer numbers of people infected with HIV, however, tempered the hope and optimism surrounding intervention techniques.
India continues to rank third in the world for HIV. Indonesia has the fastest-growing epidemic, and HIV prevalence among men has increased in Thailand. Eastern Europe and Central Asia have more than 1.5 million people living with HIV, a 10 percent decrease compared with 2007 figures. Sub-Saharan Africa continues to be the most affected region, with an average of 22.4 million people living with HIV. Current infection rates continue to be disproportionately high for women in sub-Saharan Africa. Women are more susceptible to HIV-1 infections, but their partners (usually men) are often the carriers and transmitters of HIV. For women as mothers, MTCT can occur in utero during the last weeks of pregnancy, during childbirth, and from breastfeeding. Although risk behavior has changed among young people in some African nations, the mortality rate from AIDS is high because of unmet treatment needs. Delivery of health service and funding remain inadequate for prevention efforts and HIV treatments. The lowest incidence of HIV infection in the world is in Oceania, where considerably less than 1 percent of adults are infected (around 59,000), compared with Sub-Saharan Africa, where 5.2 percent or around 22.4 million adults carry the AIDS virus.
False Cures, AZT, Politics, and Science
The majority of the world’s population does not have adequate access to health care or medical techniques that could prevent HIV infections. Universal precautions, such as avoiding needle sharing and sterilizing medical equipment, are not often followed because health care workers receive inadequate training and there are not enough supplies. Blood transfusions account for 5 to 15 percent of HIV transmissions because the standard donor selection and HIV screening procedures completed in industrial nations are not performed in developing countries. Health care workers’ behaviors and patient interactions are affected by the lack of medical supplies, including latex gloves and disinfectants. Approximately 2.5 percent of all HIV infections in sub-Saharan Africa occur through unsafe health care injections. The implementation of universal precautions is difficult when funding is severely restricted or absent.
Education efforts are also constrained by the lack of funding. HIV prevalence has remained high among injecting drug users, especially in Thailand, where HIV rates are 30 to 50 percent. AIDS-prevention organizations advocate clean needles and equipment for preparing and taking drugs (syringes, cotton balls, spoons, water for dilution, straws, pipes, etc.). Cleaning needles with bleach and decriminalizing needle possession are advocated at “safe injection sites” (places where information about safe techniques are distributed to drug users). When needle exchanges and safe injection sites were established, there was a reduction in HIV infection rates. Individuals, especially young people, engaged in high-risk practices with drugs and sex, often because of a lack of disease comprehension. Although aware of HIV, young people continue to underestimate their personal risk. HIV/AIDS knowledge increases with clear communication and unambiguous information.
Questions surrounding HIV/AIDS have stemmed from both a lack of understanding and a desire to understand the complexities of the disease. Early misconceptions about transmission — casual contact (e.g., touching someone’s skin), and engaging in any form of anal intercourse — created fear and folklore. Certain populations — homosexual men and drug users — were incorrectly identified as the only people susceptible to HIV. National pedagogy mistakenly proclaimed that open discussions about HIV or homosexuality would increase rates of AIDS and homosexuality in schools. The false belief that sexual intercourse with a virgin would “cure” HIV was particularly detrimental to many young women. Although much of the early fictional rhetoric was rectified through the distribution of scientific information, denial and delusion continue to influence individuals’ perceptions of HIV/AIDS.
A small group of scientists and activists questioned the testing and treatment methods of HIV/AIDS, which influenced government policies in South Africa. Established in the early 1990s, the Group for the Scientific Re-Appraisal of the HIV/AIDS Hypothesis launched the Web site virusmyth.net and included a collection of literature from various supporters, including Peter Duesberg, David Rasnick, Eleni Papadopulos- Eleopulos, and Nobel Prize winner Karry Mullis. As a result, Thabo Mbeki, South Africa’s president, suspended AZT use in the public health sector. At issue was whether AZT was a medicine or a poison and whether the benefits of AZT in MTCT outweighed the toxicity of the treatment. Retrospective analyses have raised criticisms about Mbeki’s interference. The expert consensus is that the risks of AZT for MTCT were small compared with the reduction of HIV infection in children. The South African AZT controversy demonstrates how science may be interpreted in different ways and how politics influences public health decisions.
The biological ideology of most scientific inquiry has influenced HIV investigations, with much research focused on understanding the molecular structure of HIV. During the late 1980s, Canadian infectious-disease expert Frank Plummer noticed that, despite high-risk sexual behavior, some prostitutes did not contract HIV. In spite of being sick, weak from malnourishment, and having unprotected sex with men who were known to have HIV, the women did not become seropositive. The scientific community became highly interested in the women (known as “the Nairobi prostitutes”) and hypothesized that the women’s immune systems defended them from HIV. Of the 80 women exposed to HIV-1 and determined to be uninfected and seronegative, 24 were selected for immunological evaluation. Cellular immune responses, like T cells, control the infection of HIV; helper T cells seem to recognize HIV-1 antigens. The small group of prostitutes in Nairobi remained uninfected even though their activities involved prolonged and continued exposure to HIV-1. Cellular immunity — not systemic humoral immunity (i.e., defective viral or HIV-antigens) — prevented HIV from infecting them. The Nairobi prostitutes’ naturally occurring protective immunity from the most virulent strain of HIV was a model for the increased focus on the development of vaccines.
Historically, vaccine production has concentrated on antibodies and how the human body can be tricked into fighting an infection. A benign form of the virus infects the body, and the immune system’s white blood cells respond; antibodies attack the virus in the bloodstream and cytotoxic T lymphocytes (T cells) detect infected cells and destroy them. Vaccines for measles, yellow fever, and pertussis operate within this same paradigm. HIV mutates rapidly, however, and different strains exist within the population. A vaccine for one subtype would not provide immunity to another HIV strain. The unpredictability of HIV requires a scientific transition in the research paradigm and a willingness to use human beings as test subjects.
For the effectiveness of a vaccine to be gauged, thousands of people will have to be part of the research trials. The ethical problems associated with human subjects and the costs of long-term investigations prohibit many researchers from committing to vaccine research. Additionally, the economic market mentality provides more incentive for making a product for mass consumption. The costs and risks of a vaccine limit financial gains for companies; inoculation against HIV reduces the number of consumers who need the product. Instead, antiretroviral medications and treatments are the primary focus for research funding. An AIDS vaccine would benefit the entire world, but no company or country is willing to devote the economic and scientific resources needed for such research. The International AIDS Vaccine Initiative, a philanthropic venture capital firm dedicated to finding a vaccine, has received funding from private and public donations, including significant contributions from the Bill and Melinda Gates Foundation. Researchers, however, continue to reduce the AIDS virus to its genetic components instead of approaching HIV vaccines from new perspectives.
The complexity of HIV creates difficulties in finding a single, permanent solution. Education and prevention have had limited success, and antiretroviral therapies cannot cure the vast number of people infected with HIV/AIDS. A partially effective vaccine or a vaccine that targets only one mutation of HIV is not a solution. Ignoring a population’s behaviors, economic situations, and beliefs has proven detrimental to the AIDS epidemic. The difficulties of the disease make HIV/AIDS a formidable problem.
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