ABMA

PUBLIC HEALTH TRAINING MODULE

LEVEL FIVE DIPLOMA

HIV/AIDS AND TB
(UNIT TWO)
2020 EDITION

COMPILED BY; Jonathan Villeakarl

Email; [email protected]
Phone; 0888670317

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Unit 2 – HIV/AIDS and Tuberculosis

Unit Aim
This unit aims to provide learners with an insight into the impact of human immunodeficiency
virus (HIV)/acquired immune deficiency syndrome (AIDS) and tuberculosis (TB) on individuals
and communities. Learners will consider the challenges of prevention and treatment of
HIV/AIDS and TB at global, national and community levels. The wider issues of political,
economic, social and cultural influences will be considered in addition to public health work
with individuals.

Unit Overview
The unit introduces learners to HIV/AIDS and TB and how these affect the wellbeing of
individuals. Learners will understand how HIV and TB can be spread and the factors needed
for effective control. These include global, national, community and individual efforts. The
unit considers the impact of political, economic, social and cultural factors on the prevention
and treatment of HIV/AIDS and TB. Learners will compare programs to prevent and treat
HIV/AIDS and TB in low and high income countries.

Teaching Guidance

Recommendations for this unit:

• Please be mindful that learners should be aware that HIV/AIDS and tuberculosis
prevention and treatment are public health priorities in many regions in Africa.
• Linking the work in this unit with related topics in other units, for example, Level 4 Unit 3
'Principles of Public Health', Level 4 Unit 5 'Determinants of Health' and Level 5 Unit 1
'Communicable Diseases'.
• Linking the work in this unit with related topics in other units, for example, Level 5 Unit 5
'Health of Women, Children and Young People', Level 6 Unit 2 'Public Health in a Crisis
or Disaster'.
• Use a class agreement to manage sensitive situations such as learners who may
disclose information such as their HIV status. Confidentiality issues can be discussed
with the group.
• Acknowledge that some topics may be sensitive and emotive. Learners may find their
own cultural or religious beliefs challenged, for example regarding sexual practices.
Pastoral support for learners may be helpful.
• Enable learners to make comparisons between the epidemiology, prevention and
treatment of HIV/AIDS and TB in low income and high income countries.
• Ensure learners understand that wider pressures such as politics, economics and social

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attitudes impact the success of public health initiatives relating to HIV/AIDS and TB.
• The learners’ understanding of concepts can be checked with short tests, including
short answer and multiple choice questions.
General recommendations:
• Use a variety of teaching methods to suit various learning styles; for example, colourful
diagrams for visual learners and active tasks for others. Learner participation and, if
possible, guest speakers all help reinforce learning in different ways.
• Use real life examples to illustrate concepts – including case studies and scenarios to
help bring the material into context.
• Set written ‘homework’ tasks to check the learners’ understanding and identify any
learners who may need additional support. The learners would benefit from
individualised feedback which identifies their strengths in addition to any
developmental points. This will help to support learners whose confidence may be
low at the start of the course.
• Ethical issues such as the avoidance of plagiarism need to be addressed during
teaching.
• Learners will benefit from guidance on study skills such as note taking and are likely to
need specific written information on referencing.
• Groupwork, such as thought showers, discussion groups and role play are
recommended. Adult learners are likely to have valuable life and work experience to
contribute and learners can be given opportunities to learn from each other as well
as the teacher. These also enable the teacher to begin to assess each learner’s
strengths and weaknesses and identify any learners with additional learning needs at
an early stage so extra support can be offered.
• It is recommended that learners are advised to keep a ‘reflective log’ as they
proceed through the course. As learners are likely to have personal (and in some
cases professional) experience of health care, this will be an opportunity for them to
reflect on what they have learned and apply it to their own experience.
• Meet the needs of the most able learners and those who want to try extension
activities (see the sections 'Additional Reading' and ‘Websites’ below for examples).
• Exam question practice is recommended wherein learners are provided with
feedback on their answers. This could be followed by timed exam questions and
finally a full mock exam.
• Prepare learners in good time for the unit exam. Teachers should prepare model
answers for learners, especially those which illustrate ‘Pass’, ‘Merit’ and ‘Distinction’
level answers. Guidance on what is required for common ‘command’ words such as
‘Explain’, ‘Analyse’ and ‘Evaluate’ can help learners attain higher grades.
Overall recommendations for teaching the course:
It is recommended that the teaching/learning approach for this unit is participative and
interactive. Whilst the teacher should provide an overview of the key elements of each part

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of the unit, the emphasis should be on encouraging learners to do research and/or look at a
range of public health projects locally, nationally and/or internationally in order to
investigate, analyse, draw conclusions and share their findings with the rest of the group
where possible.
The activities recommended may include:
• Presenting outline information to learners regarding the subject content
• Guiding learners in terms of how and where to research
• Providing examples of public health projects
• Organising presentations and/or group discussions
The material generated is based on reviewing the outcomes of research undertaken by the
learners. For best results, it is recommended that the teaching and learning activities are
informed by the following:
• Independent research carried out using a variety of sources to enhance the learning
opportunities for learners
• Where possible, visits to, and studies of, actual public health projects in order to
provide a variety of learning opportunities for learners
• Scenarios and case studies based on real examples that are current and topical.
These can be provided by either the learner or the teacher.

Learning Outcomes

After successfully completing this unit, the learner will be able to:
1. Explain how living with HIV or AIDS can affect an individual’s wellbeing
2. Describe the spread and prevention of HIV and the treatment of HIV and AIDS
3. Assess the impact of political, economic, social and cultural factors on the prevention
and treatment of HIV and AIDS
4. Explain the spread and effects of TB and its impact on individuals with HIV/AIDS
5. Evaluate the programs to prevent and treat TB in low income and high income countries

Unit Content
In order for the learner to meet each learning outcome, they need to be taught the
following:

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Learning Outcome 1: Explain how living with HIV or AIDS can affect an individual’s
wellbeing
a. Biological effects of HIV and AIDS: how the virus destroys CD4 lymphocytes, symptoms
of HIV infection and AIDS

Effects of HIV/AIDS

HIV/AIDS is often written as one word with one meaning. However, HIV and AIDS are different things.

HIV stands for Human Immunodeficiency Virus. A person becomes infected with HIV (HIV positive) when
the virus enters their blood stream.

HIV attacks the immune system, which is the body’s defence against disease. If a person’s immune
system is severely damaged by the virus, they will develop AIDS (Acquired Immune Deficiency
Syndrome). This means they are likely to get infections and illnesses that their body would normally
fight off.

Being diagnosed with HIV does not mean a person has AIDS or that they are going to die. Treatments
slow down damage to the immune system so that people with HIV can remain well, and live healthy and
fulfilling lives.

How is HIV transmitted?

HIV is found in body fluids such as blood, semen, vaginal fluids and breast milk. Infection only occurs
when body fluids from an infected person enter the blood stream of another person.

HIV can be transmitted by:

 Unsafe sex (sex without a condom)

 Sharing needles, syringes and other equipment for injecting drugs

 Unsterile body piercing or tattooing

 Mother-to-child during pregnancy, childbirth or breastfeeding

 Blood transfusion and/or blood products in some other countries. In Australia, blood
transfusions and blood products are safe.

HIV cannot be transmitted by:

 Coughing

 Sneezing

 Kissing

 Spitting

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  Crying

 Sharing cutlery and crockery

 Bed linen

 Toilets

 Showers

 Insects such as mosquitoes.

How can I avoid getting HIV?

Sex

HIV can be passed on through invisible cuts and scrapes on the surface of the vagina, penis or anus
during unprotected sex (sex without condom) with someone who has HIV.

To avoid transmission of HIV, practice safe sex:

Use a new condom and water-based lubricant (eg. KY jelly or Wet stuff) every time you have vaginal or
anal sex. This also protects you from most other sexually transmissible infections.

How to use a condom?

1. Open packet with care to avoid tearing the condom.

2. Squeeze the tip of the condom between your finger and thumb to remove air and roll the
condom down the penis (pull back the foreskin if necessary before putting the condom on).

3. Once the condom is on the penis, cover with water-based lubricant.

4. Hold the condom at the base of the penis when you withdraw to prevent semen spilling out.

5. Put the condom in the bin. Never re-use a condom.

Injecting drugs, body piercing or tattooing

HIV can be transmitted through sharing needles and syringes, and by having body piercing and tattooing
done with used needles.

To avoid transmission of HIV when injecting drugs:

Don’t share needles, syringes or other injecting equipment.

To avoid transmission of HIV when having body piercing and tattooing:

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Go to a licensed studio (registered premises) where needles and other equipment are properly sterilised
or discarded after use. This also protects you from other viruses such as hepatitis B and hepatitis C.

Mother-to-Child

HIV can be passed on from a HIV positive mother to her child during pregnancy, childbirth, or through
breastfeeding. In Australia, women with HIV who are pregnant are given HIV treatment during
pregnancy and have the baby by caesarean to avoid passing on HIV. If you have HIV, and you are
pregnant or planning to have a baby, it is important to talk to your doctor as soon as possible.

It is recommended that mothers with HIV do not breastfeed. Speak to your doctor about other ways of
feeding your baby.

Blood transfusions and blood products

In Australia, blood transfusions are safe. Donated blood and all blood products are checked for HIV and
people who are HIV positive cannot donate blood. However, blood transfusions in some overseas
countries may not be safe.

How does HIV affect the immune system?

HIV is a virus. Viruses are very tiny organisms that can enter the body and cause disease. There are many
viruses which spread in different ways and cause different diseases. For example, flu is spread through
the air, herpes through physical contact and polio through drinking contaminated water. However, HIV
is only passed on when the body fluids of a person living with HIV enter the bloodstream of another
person.

Your immune system

The immune system is your body’s natural defense system. It protects your body against infection and
disease. It is made up of many different cells which work together to find and destroy viruses, bacteria
and other germs that cause infection and disease. White blood cells (also called CD4 T-cells) are
important immune system cells that help coordinate your immune system.

What HIV does

HIV attacks immune system cells. In particular, it infects and uses CD4 cells as ‘factories’ to reproduce
and destroys CD4 cells in the process. The more CD4 cells destroyed, the weaker the immune system
becomes. As the immune system gets weaker, the risk of developing infections and illness becomes
greater. Over time, and without treatment, the number of CD4 cells can become so dangerously low a
person can develop AIDS.

Your body’s response

To fight HIV, your body will produce antibodies. However, the antibodies cannot keep up with the
amount of virus being reproduced. Taking treatment helps your body fight the virus effectively.

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The HIV life cycle

1. HIV enters the bloodstream

2 &amp 3. HIV attaches to and enters the CD4 cell

4. HIV releases its genetic information into the cell

5. A unique process enables this information to become part of the CD4 cell and to enter the cell
nucleus.

6. The CD4 cell is now infected with HIV forever

7. HIV begins to make copies of itself inside the CD4 cells

8. CD4 cells breaks open and the newly created HIV spill into the blood. The new virus finds more CD4
cells, create more copies, spill more HIV into the blood. The process repeats endlessly.

b. Vulnerability of individuals with HIV to further conditions including opportunistic

infections and AIDS related development of cancers such as Kaposi’s sarcoma

Vulnerability and risk perception in the management of HIV/AIDS: Public priorities in a global
pandemic

Abstract

Understanding the way perception of risk is shaped and constructed is crucial in understanding why it
has been so difficult to mitigate the spread of HIV/AIDS. This paper uses the Pressure and Release (PAR)
model, used to predict the onset of natural disasters as the conceptual framework. It substitutes
vulnerability and risk perception as the trigger factors in the model, in making the case that HIV/AIDS
can be characterized as a slow onset disaster. The implications are that vulnerability must be managed
and reduced by addressing root causes, dynamic pressures, and unsafe conditions that contribute to the
HIV/AIDS pandemic. HIV/AIDS programs must be culturally appropriate and work toward influencing risk
perception, while addressing social norms and values that negatively impact vulnerable populations. By
impacting cultural and social expectations, individuals will be able to more readily adopt safer sex
behaviors. The development of policies and programs addressing the issues in context, as opposed to
individual behaviors alone, allows for effective public health intervention. This may have implications for
public health measures implemented for combating the spread of HIV/AIDS.

Keywords: vulnerability, risk perception, HIV/AIDS, public health intervention

Introduction

Tsunamis, earthquakes, and other natural disasters throughout the history of civilization have captured
worldwide attention, demanding an immediate response. Increasingly with sophisticated technology, a

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global response to disasters has been comprehensive with immediate aid and prevention plans made
against further catastrophe. Yet, the human immunodeficiency virus (HIV), which causes the slow
deterioration of the immune system leading to an acute immune deficiency syndrome (AIDS) has
created chaos within social structures, devastated communities, and killed millions without receiving the
same swift response as natural disasters. According to the Joint United Nations Programme on HIV/AIDS
(UNAIDS), approximately 33.2 million people are currently inflicted with HIV, which makes HIV/AIDS a
pandemic. Even though HIV/AIDS is viewed as a pandemic with potential for catastrophe, many
populations around the world continue to neglect the severe risk involved in practices that make them
vulnerable to HIV/AIDS. Since risk perception is embedded and impacted by the various cultures of the
world, it is not surprising that the spread of HIV/AIDS is so varied in many regions of the world. Perhaps,
the issue lies in understanding risk and how it interplays with HIV/AIDS.

A wide range of risk theories developed over the past decade have incorporated the influence of varying
ideologies in explaining the way we perceive risk. Understanding the way perception of risk is shaped
and constructed is crucial in understanding why it has been so difficult to mitigate the spread of
HIV/AIDS. The association between HIV infection and the perception of risk in different regions of the
world has emphasized the need to reevaluate the public health measures being implemented to control
the spread of HIV/AIDS, particularly for those people most at risk. This paper looks at HIV/AIDS and the
devastating effects the pandemic is having on populations with diverse risk perceptions of the disease,
and makes the case that HIV/AIDS can be characterized as a slow onset disaster.

Risk perception and HIV/AIDS

Risk perception varies in that risk perception is linked to an individual’s predisposition to be risk-averse
or risk-seeking and to the individual’s knowledge regarding the object or situation at hand. However, the
unpredictability of hazards and uneven distribution of knowledge and access to knowledge in societies
means that members of the public are not always in a position to define and understand risk. At some
point, individuals may lack the ability and opportunity to decide which risks affect them and to what
extent. Often the public is forced to place their trust in social structures that are viewed as acting in their
best interests.

Since different groups and stakeholders have different interests at the level of public debate, certain
dangers are attached to particular threats when different perceptions of risk are created. Both social
institutions and social structures thus harbor the power to shape risk perception. This process of
negotiating risk demonstrates how people organize their universe through cultural and social biases and
choose what to fear based on their way of life and patterns of cultural and social norms. These biases
cause selective attention to risk and preferences for different types of risk taking behaviors, informed by
an inherent compulsion to defend one’s way of life.

Furthermore, although it is ultimately social structures that define and shape risk perception in societies,
we see that risk is usually individualized, leading to worry and anxiety among persons regarding specific
threats that have yet to take place. Through this process of individualization, risk becomes associated

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with choice, responsibility, and blame, and the individual rather than society is held accountable for
negative outcomes.

One of the peculiarities of risk is that the knowledge of risk is not in-sync with the actions that should be
taken.4 In other words, the principle of taking the greatest precaution for the worst possible outcome is
not executed. Although it is possible that this is due to lack of awareness, the more likely explanation is
the lack of acceptance. Research regarding risk perception demonstrates that risk that is

(1) involuntary,

(2) unfamiliar, and

(3) potentially catastrophic is the most difficult for people to accept.

Acquiring HIV/AIDS is an involuntary occurrence for most. Lack of knowledge, but more often, lack of
control over social and economic circumstances precipitates individuals to engage in risky behavior that
leads to the transmission of HIV/AIDS. In many cultures, for example, women have little power over
their sexuality and the sexual practices in which they engage. In addition, poverty can lead to both male
and female prostitution. In these cases, individuals place themselves at high risk for acquiring HIV/AIDS
in trying to avoid social exclusion, violence, and poverty.

The risk of contracting HIV/AIDS may also be unfamiliar to many. The perception that HIV/AIDS occurs
only amongst homosexuals is still prevalent.8,9 In addition, because the symptoms of AIDS do not take
full effect for as many as 8 to 10 years from the time of infection, many are unaware of being
seropositive, and those who do know may not fully comprehend or accept the magnitude of the disease.

Finally, HIV/AIDS is catastrophic. The numbers speak for themselves; according to the 2007 UNAIDS
Global AIDS Epidemic Update, an estimated 33.2 million living with HIV, 2.5 million newly infected, and
2.1 million individuals lost lives due to HIV/AIDS world-wide at the end of 2006.1 However, because of
the stigma attached to being HIV-positive in many communities, it is likely that cases of HIV/AIDS are
underreported and thus these numbers may actually be considerably higher.

Although risk perception may be clouded by the individual’s inability to accept the reality of risks that
are involuntary, unfamiliar, and catastrophic, the problem is not necessarily with the individual, but
rather with society at large. Within the discourse of public health, health risks have been individualized
such that it is an individual’s choice to engage in certain behaviors that cause the individual to acquire
HIV/AIDS. This view has led to the labeling of particular groups of individuals and populations as “at-
risk”.5 Populations deemed at-risk for HIV/AIDS include sex workers, men who have sex with men
(MSM), and injection drug users. This narrow definition of those at-risk can also be misleading
considering that heterosexual and mother-to-child transmission of HIV/AIDS is increasing rapidly across
populations. As a result this has led to a limited focus on awareness and education as solutions, and has
allowed those in power to dehumanize, blame, and avoid responsibility for those suffering from
HIV/AIDS.

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Modeling the HIV/AIDS disaster

Disasters are often referred to as unplanned, socially disruptive events with extreme effects. The
characteristics common to environmental and natural disasters mirror the ways in which HIV/AIDS
destroys and impacts communities. These characteristics include a high impact on individuals or
populations; the spanning of spatial and temporal boundaries; large-scale damage to human life; and
root causes that are complex. With regards to the latter, disasters are triggered not by a single event,
but rather through the interaction of a multitude of factors and a buildup of unnoticed events. This is
particularly true for HIV/AIDS.

The vulnerability of a population to HIV/AIDS is rooted in social processes and underlying causes that
may actually be quite unrelated to the end result itself, namely the contraction of HIV/AIDS.The factors
that create vulnerability in populations can be modeled to provide a visual representation of the
potential negative impact of HIV/AIDS. Since risk and risk perception are a function of the degree of
vulnerability and the hazard type, the Pressure and Release (PAR) model first developed by Wisner and
colleagues can be used and adapted to depict the root causes and process of HIV/AIDS transmission. The
PAR model is generally used to outline how disasters are shaped by external conditions that apply
increasing pressure until a release is forced resulting in a disaster. This build-up of pressure is referred to
as a “progression of vulnerability” that consists of three stages:

(1) root causes,

(2) dynamic pressure, and

(3) unsafe conditions.

By building on the PAR model, we can identify sources of vulnerability as root causes of HIV/AIDS
transmission which center around political instability, poverty, and unequal access to power and
resources. Countries such as South Africa, Zimbabwe, and Kenya have some of the highest HIV/AIDS
infection rates since they are nations with populations experiencing unequal access or lack of resources,
poverty, social inequality, and instability.

In the second stage of the model, vulnerability increases via dynamic processes that reduce the ability of
the population or risk group to handle adverse circumstances. Here, local markets and fluctuating
systems of labor play a major contributory role to a disaster. Finally, vulnerability peaks due to unsafe
conditions where the physical and social environment of the population is unsanitary and/or hostile. As
vulnerability increases, so does the risk to the population.

The progression of vulnerability, paired with the hazard of HIV/AIDS creates the ideal setting for rapid
HIV/AIDS transmission (the risk). In other words, risk equates to vulnerability (V) multiplied by the level
of hazard (H) that exists. In this context, risk is defined as the probability that a person may acquire the
HIV infection. Vulnerability to risk is shaped by three factors. First is the resilience of a population, or the
capacity of the people to resist and recover from the outcomes of a disaster. The second component is
the health of the population, or the robustness of individuals, which is most influenced by ‘livelihood’

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and the availability of social operations such as healthcare services. The final factor determining
vulnerability is the degree of preparedness of a population. The level of preparedness is shaped by
societal values and beliefs, which determine what is viewed as a risk and in turn which measures are
taken for protection, if any. It is interesting to note that factors such as poverty and inadequate
government assistance act not only as root causes, but also as dynamic pressures and unsafe conditions.
Needless to say, HIV/AIDS is most prevalent in populations where social inequality persists and where
the disempowered are victimized.

HIV/AIDS as a global concern

Although a stabilization of the HIV/AIDS epidemic has been noted in the last few years, the infection
continues to spread rapidly in actual numbers.17 Of the many reasons why HIV/AIDS stands out as
atypically disastrous is that its impact is gradual and thus referred to as slow onset.18 Although disasters
are often thought of as sudden, the worst consequences of disasters are not necessarily felt at the point
of occurrence and can easily emerge long after the causes and effects have been identified.13 HIV/AIDS
is one such disaster. The inability of populations and in some cases complete disregard of governments
to recognize risk factors, symptoms, and infection rates prevents appropriate response measures from
being implemented.18 It is unfortunate that by the time a response is mounted by public authorities;
numerous individuals have already been infected who may not have been infected if early prevention
measures were in place.

Nowhere is the epidemic more pronounced than in sub-Saharan Africa where over the past decade the
epidemic crossed the continent through migrants and refugees.14 With just over 10% of the world’s
population living in this region, it is disturbing that almost 64% are living with HIV/AIDS.1 Despite the
concentration of HIV/AIDS cases in Africa, the disease continues to spread in other parts of the world as
well. Since the breakup of the Union of Soviet Socialist Republics (USSR), the resulting fifteen new
nations have been experiencing great political, social and economic instability. This social and political
instability has led to increased poverty, driving many to resort to substance abuse. Subsequently,
injection drug use and commercial sex work are both dominant transmission paths for HIV/AIDS in this
region. The Russian Federation and Ukraine alone make up 1.3 million of the 1.5 million cases in Eastern
Europe.

In Asia, an estimated 4.9 million people were living with HIV/AIDS in 2007, with significant growth in
prevalence in Indonesia and Vietnam.1 Injection drug use is a primary transmission method in this area.
In Jakarta, Indonesia 40% of injection drug users tested positive for HIV in 2005.1 In Vietnam, HIV
prevalence among injection drug users increased from 9% in 1996 to 34% in 2005.1 Furthermore, in
most Asian countries condom use remains very low. This cultural norm is contributing to increasing
infection rates among male and female sex workers. Like their international counterparts, the HIV/AIDS
epidemic in Asia is an outcome of social forces, including population mobility, environmental
degradation, economic upheaval, and poverty.

HIV/AIDS cases in Latin America are also on the rise. Much of this increase is attributed to the street
culture present in many Latin countries that encourages illicit drug use and unsafe sex, particularly

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among young males. Young boys in Brazil, for example, are encouraged to lose their virginity to
demonstrate their masculinity.20 In Latin American nations, HIV prevalence is on the rise with
populations at risk. The Latino population outside of Latin America also has an increased risk of
acquiring HIV/AIDS due to cultural factors that contribute to sustained participation in risky behavior.

Despite the broad reach of HIV/AIDS across the globe, governments have failed to acknowledge that
HIV/AIDS remains an ongoing crisis and populations continue to neglect the severe risk involved in
practices that make them vulnerable to HIV/AIDS. The most vulnerable population groups for HIV/AIDS
are women and children. There are approximately 2.5 million children across the world that are living
with HIV/AIDS.1 In 2006 alone, an estimated 420,000 new AIDS cases arose in children under the age of
15 years and the prevalence rate in pregnant women has also increased significantly worldwide.1
Furthermore, more than 40% of new infections worldwide are from the young population in the range
of 15–24 years of age, indicating a sustenance or prolonging of the virus in populations of the
generations to come.1 Thus, understanding the way perception of risk is shaped and constructed is
crucial in identifying why it has been so difficult to mitigate the spread of HIV/AIDS.

The role of public health

The spread of HIV/AIDS is exacerbated by social factors that include not only socio-economic status,
political instability, and geographic location, but also gender and sexual practice.14 Perceptions of risk in
contracting HIV/AIDS are shaped by related patterns of social relations and cultural biases. The power to
shape risk perception is usually in the hands of very few; namely those with control over social, political,
and/or economic institutions.

The case can be made that HIV/AIDS causes widespread loss and serious disruption to the functioning of
a community, much like an environmental disaster. Yet, despite the potential of HIV/AIDS to become a
global disaster, many populations continue to neglect the risk involved in practices that make them
vulnerable to HIV/AIDS. This failure to mitigate the spread of the infection may be due to the fact that
perceptions of risk are shaped by patterns of social relations and cultural biases. In addition, the power
to shape risk perception is usually limited to those with control over social, political, and/or economic
institutions. Since the social, political, and economic context plays a role in HIV/AIDS-related risk
perception, there is a need to reevaluate public health measures being implemented to control the
spread of HIV/AIDS.

The purpose of public health is to manage threats to the health of a population through preventative
measures and treatment. Although HIV/AIDS is not only a health problem, but also a developmental
issue, attempts at mitigating the spread of the infection typically occur solely through the health sector.

Risk perception is culturally influenced and therefore risky behavior is a social rather than an individual
issue. However, the mass media often perpetuates risk as an individual issue and unique to selected
populations (intravenous drug users, commercial sex workers and men who have sex with men [MSM]).
Therefore, the role of media must also be recognized in terms of being an important player in
disseminating information on risks as well as promoting a cultural approach to prevent further spread of
HIV/AIDS among a population where social instability exists. As a result, the media plays an integral role

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in shaping or reinforcing risk behavior as an individual phenomenon, where the individual chooses to be
in that risk group. Public health measures implemented to combat the spread of HIV/AIDS must be re-
evaluated with consideration for ways in which culture and media shape risk perception, particularly for
those groups most at-risk. In using the PAR model as a guide, vulnerability must be managed and
reduced by addressing root causes, dynamic pressures, and unsafe conditions that contribute to the
HIV/AIDS pandemic. HIV/AIDS programs must be culturally appropriate and work toward influencing risk
perception, while addressing social norms and values that negatively impact vulnerable populations
such as women and children.

Prevention programs typically focus on raising awareness and using interpersonal strategies, such as
peer education and testimonials to influence behavior change. These initiatives have had mixed results
because often those most at risk are those in poverty, and these individuals have limited means for
effecting change in their circumstances. For this reason, prevention programs aimed at individual
behavior change can be ineffective in many contexts. Even awareness campaigns that are deemed
“culturally-appropriate” have produced mixed results with regards to effectiveness. These approaches
to managing HIV/AIDS fail to consider the evidence that risk perception is culturally influenced and
therefore risky behavior is a social rather than an individual issue. It is wrong to assume that decision-
making and behavior are always rational. Social and economic factors such as relationships, community
expectations, and access to resources have a major impact on behavior, and at times may prevent
individuals from adopting safe sex practices that prevent HIV/AIDS transmission. This indicates that
attempting to reform behavior to reduce HIV transmission risk is unlikely without structural changes –
that is, public health interventions aimed at changing the environment rather than individual behavior
may be more successful in reducing the spread of the infection.

Public health measures to combat the spread of HIV/AIDS must be re-evaluated with consideration for
ways in which culture shapes risk perception. Societal factors, including practices and beliefs about sex,
relationships, and condom-use lead to the inclusion, neglect, or exclusion of people, thereby shaping
individual behavior in ways that are beyond individual control. Addressing social norms and values that
negatively impact vulnerable populations such as women and children can effect change more rapidly
than measures aimed at individual behavior. Thus, the ultimate aim should be to enable people to exert
control over their own risk and to create an environment in which safer behavior can be practiced.

The role of public health policies and programs cannot and should not be limited to individual health
behaviors. Despite the knowledge and experience in the field of public health with regards to the social
determinants of disease, including food and nutrition, shelter, and employment, there has been little
impact on HIV/AIDS policy and programming.

In addition to recognizing the role of social context, policy and program implementation must also not
occur in isolation. Inter-sectoral coordination is necessary to influence risk perception on a macro-level.
Recognition of HIV/AIDS as not only a health problem, but also a social, economic, and development
issue facilitates collaboration between different levels of government and civil society. However, it is
important to stress that the application of public health efforts will differ from one region to another
due to differences in demographics, political context, education levels, social service provision,

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geographic location, cultural beliefs and epidemic patterns, among other factors. For example, data
suggests that in most cultures poverty exacerbates the spread of HIV, but there are also emerging
epidemics among financially secure sectors of society partly because of the economic power to engage
in risky behaviors such as buying sex or drugs. Whether safer behavior is more likely to occur as
economic status increases depends on other factors such as social values, education and gender. This
example illustrates the complexity of vulnerability, and the need to design interventions and policies
that take regional variations into consideration.

Although targeting interventions to the changing needs of the communities for whom they are designed
is crucial to program effectiveness, there are two vulnerable groups, in particular, that demand
attention in all contexts: youth and females. Young people, both male and female, account for most of
the current HIV/AIDS infections in the world today.27 The transition from childhood to adulthood can be
fraught with difficulties such as lack of information, a desire to experiment, or feelings of
“invulnerability”. In most societies, young people have limited rights and are expected to be obedient to
authority. This can impact their propensity to take part in risky behaviors and can diminish the
potentially positive effects of health and social services. Youth are not only victims of the HIV/AIDS
epidemic directly, but also indirectly. For example, it is estimated that the number of children and youth
orphaned by HIV/AIDS will continue to rise for the next several years reaching 40 million by 2010 in
African alone.

Similarly, women and girls often face inequalities in access to education, in income and employment,
and before the law, which places them at a disadvantage and reduces their ability to adopt safe
behaviors. Reversing these inequalities will require cultural, legal, and policy-level changes. In the
absence of policies and programs that bridge the age and gender gaps, efforts aimed at reducing the
spread of HIV/AIDS may be ineffective and short-lived.

Keeping in mind the need to balance context specificity with consideration for cross-cutting issues like
ageism and sexism, a multi-dimensional approach to HIV/AIDS mitigation is recommended. Such a
model involves two dimensions:

(1) persuading vulnerable population groups to change behavior, and

(2) enabling safe behavior by changing societal and contextual factors that contribute to HIV/AIDS
transmission.

Thus far, public health measures have focused on persuasion. This narrow focus on the individual has a
limited impact on communities plagued by poverty, inequality, and injustice. Public health policies and
programs must move to a paradigm of enablement and empowerment by addressing root causes. This is
more challenging than behavior change programs because it requires collaboration across sectors and
because the impact will not be evident in the near future. Cultural changes are gradual. Thus, the
importance of long-term sustainable policies and programs cannot be overemphasized. There is a clear
and definite need for global cooperation on this, especially considering that the lower economic status
of developing countries will result in more acute challenges to the development and maintenance of
necessary programming.

15 | P a g e
Within the discourse of public health, health risks have been individualized such that it is an individual’s
choice to engage in certain behaviors that cause the individual to acquire HIV/AIDS.5 This view has led
to the labeling of particular groups of individuals and populations as “at-risk”. However, the term “at-
risk” is misleading considering that HIV/AIDS is now transmitted in a number of different ways, such as
heterosexually and from mother to child.11 Awareness of risk is no longer sufficient. There must be
acceptance at a cultural and social level that the risk of acquiring HIV/AIDS is not limited to particular
individuals. HIV/AIDS is a threat to everyone and must be considered a shared responsibility. By
reshaping risk perception, public health measures can effect change at the social level, where it matters.

Community-led approaches to HIV/AIDS mitigation have grown in popularity and are often quite
innovative in their response. The advantages of such programs are that local knowledge is utilized and
the focus is on communities as opposed to individuals. Community mobilization, paired with public
health efforts can allow for a naturally evolving response to diversity and changing needs. Despite the
great, untapped capacity of communities, local programs often continue to focus on behavior change
out of context. However, proactive action rather than reactive action is required to ensure policy gets
ahead of the epidemic.

Application of the PAR model

The spread of HIV/AIDS can be modeled much like an environmental disaster that is characterized by a
slow onset and is exacerbated by human action or inaction. If humans can act as agents to mitigate the
effects of hazards and disasters, accountability and responsibility must be acknowledged as not being
limited to a selected group, but shared by all individuals and communities. Discourses surrounding the
global HIV/AIDS crisis must move in this direction; developing a recognition that HIV/AIDS is a shared
responsibility requiring a coordinated response from all nations.

Considering the similarities between HIV/AIDS and other natural and environmental disasters, a disaster
management approach to HIV/AIDS is needed to improve global responses. A disaster management
framework can act as a policy and administrative tool to assist decision makers in determining the
appropriate response to HIV/AIDS. For example, depending on the current level of HIV/AIDS impact and
the potential for future disruption based on vulnerability, societies can be classified into one of three
phases:

(1) pre-disaster phase,

(2) early-warning phase, or

(3) disaster phase.

In order to effectively utilize the PAR model within such a framework, there must be reliable and valid
means for ongoing data collection in the nation, region, or community being studied. Data on social,
economic, and health indicators paired with an understanding of the social and political context is
necessary. In its simplest application, the PAR model can be used as a checklist in which existing factors
are checked off, while factors that are not currently occurring in the target area are left blank. Used in

16 | P a g e
this manner, the PAR model can indicate levels of vulnerability, or in other words the model will reveal
which disaster phase the region is currently in. The model can also highlight which “pressures” should be
released through addressing root causes that achieve safer conditions, thereby reducing the risk of
disaster.

Nations with a low HIV/AIDS prevalence and low vulnerability for progression can be classified under
Phase 1, the pre-disaster phase. With regards to environmental disasters, the pre-disaster phase is
characterized by coordinated, focused development that reduces the likelihood of disastrous events
through a collaborative response. In the context of HIV/AIDS, the pre-disaster phase involves risk
reduction by focusing on high-risk and/or vulnerable populations, including not only sex workers and
injection drug users, but also women and children. While environmental disasters are mitigated through
activities like relocation or elevation of structures, construction of safe rooms, or vegetation
management, HIV/AIDS can be mitigated through policies and laws that promote equality, economic
growth, and cultural norms associated with safe behaviors. In both cases, known hazards are reduced or
eliminated as a prevention mechanism against disaster.

Nations with low HIV/AIDS prevalence and high vulnerability can be classified under Phase 2, the early-
warning phase. Generally, the early-warning phase involves the implementation of existing response
plans, relief assistance, and assessment of initial damages. Similarly, for HIV/AIDS mitigation the early-
warning phase refers to a response involving heightened planning and expanded prevention activities
that are focused on both high-risk groups and the general population.

Finally, nations with very high HIV/AIDS prevalence and high vulnerability can be classified as disaster
situations (Phase 3). For environmental and natural disasters in Phase 3, there is a need to engage in
search and rescue operations, begin reconstruction and rehabilitation, and conduct thorough
assessments of damages. Similarly, recommendations for HIV/AIDS disasters include the mobilization of
resources, reconstruction, and rehabilitation that involves ongoing treatment, care, and prevention
efforts. Unlike the initial two phases of the disaster management framework, the third phase is not
focused on prevention, but rather on treatment and alleviation.

Conclusion

The HIV/AIDS pandemic can be modeled much like an environmental or natural disaster that causes
social disruption and loss of life. Despite the harrowing impact of HIV/AIDS globally, the response from
governments has been slow and ineffective, characterized by cultural norms focused on choice, blame,
and individual responsibility.

A disaster management approach to prevention, treatment, and mitigation can ensure that HIV/AIDS
becomes a priority and is addressed with the same concern and attention as other environmental
disasters. Utilization of the PAR model can direct and enhance disaster management efforts. By using
the PAR model as a guide, public health departments can work towards addressing one or more of the
three features of increasing vulnerability, namely:

(1) root causes such as poverty, access to resources, and gender inequality;

17 | P a g e
(2) dynamic pressures such as migration and employment; and

(3) unsafe conditions such as sanitation, access to healthcare, and stigma.

In addition to reducing vulnerability by addressing root causes, particular attention can be paid to
developing methods for changing perceptions of risk. By impacting cultural and social expectations,
individuals will be able to more readily adopt safer sex behaviors. The development of policies and
programs addressing the issues in context, as opposed to individual behaviors alone, allows for effective
public health intervention – which is needed if we are to prevent the HIV/AIDS pandemic from becoming
a full blown catastrophic disaster.
c. Social effects of HIV and AIDS:

The people affected by HIV/AIDS face the following social problems;

 lack of ability to earn a living,

 lack of care for loved ones,
 unstable relationships and
 engaging in unsafe sexual behaviour,
 stigma and discrimination

d. Psychological effects of HIV and AIDS: anxiety, depression, resilience

Once the diagnosis of HIV is made the following psychological effects are encountered;

 typical feelings include fear,

 shock,

 denial,

 anger,

 shame,

 and guilt.

 Anxiety

 Depression

 resilience

18 | P a g e
 e. Impact of HIV and AIDS on vulnerable and high risk groups including people
who use injected drugs, sex workers and individuals at risk of sexual abuse

Vulnerability and risk perception in the management of HIV/AIDS: Public priorities in a global
pandemic

Abstract

Understanding the way perception of risk is shaped and constructed is crucial in understanding why it
has been so difficult to mitigate the spread of HIV/AIDS. This paper uses the Pressure and Release (PAR)
model, used to predict the onset of natural disasters as the conceptual framework. It substitutes
vulnerability and risk perception as the trigger factors in the model, in making the case that HIV/AIDS
can be characterized as a slow onset disaster. The implications are that vulnerability must be managed
and reduced by addressing root causes, dynamic pressures, and unsafe conditions that contribute to the
HIV/AIDS pandemic. HIV/AIDS programs must be culturally appropriate and work toward influencing risk
perception, while addressing social norms and values that negatively impact vulnerable populations. By
impacting cultural and social expectations, individuals will be able to more readily adopt safer sex
behaviors. The development of policies and programs addressing the issues in context, as opposed to
individual behaviors alone, allows for effective public health intervention. This may have implications for
public health measures implemented for combating the spread of HIV/AIDS.

Keywords: vulnerability, risk perception, HIV/AIDS, public health intervention

Introduction

Tsunamis, earthquakes, and other natural disasters throughout the history of civilization have captured
worldwide attention, demanding an immediate response. Increasingly with sophisticated technology, a
global response to disasters has been comprehensive with immediate aid and prevention plans made
against further catastrophe. Yet, the human immunodeficiency virus (HIV), which causes the slow
deterioration of the immune system leading to an acute immune deficiency syndrome (AIDS) has
created chaos within social structures, devastated communities, and killed millions without receiving the
same swift response as natural disasters. According to the Joint United Nations Programme on HIV/AIDS
(UNAIDS), approximately 33.2 million people are currently inflicted with HIV, which makes HIV/AIDS a
pandemic.1 Even though HIV/AIDS is viewed as a pandemic with potential for catastrophe, many
populations around the world continue to neglect the severe risk involved in practices that make them
vulnerable to HIV/AIDS. Since risk perception is embedded and impacted by the various cultures of the
world, it is not surprising that the spread of HIV/AIDS is so varied in many regions of the world. Perhaps,
the issue lies in understanding risk and how it interplays with HIV/AIDS.

A wide range of risk theories developed over the past decade have incorporated the influence of varying
ideologies in explaining the way we perceive risk. Understanding the way perception of risk is shaped
and constructed is crucial in understanding why it has been so difficult to mitigate the spread of

19 | P a g e
HIV/AIDS. The association between HIV infection and the perception of risk in different regions of the
world has emphasized the need to reevaluate the public health measures being implemented to control
the spread of HIV/AIDS, particularly for those people most at risk. This paper looks at HIV/AIDS and the
devastating effects the pandemic is having on populations with diverse risk perceptions of the disease,
and makes the case that HIV/AIDS can be characterized as a slow onset disaster.

Risk perception and HIV/AIDS

Risk perception varies in that risk perception is linked to an individual’s predisposition to be risk-averse
or risk-seeking and to the individual’s knowledge regarding the object or situation at hand. However, the
unpredictability of hazards and uneven distribution of knowledge and access to knowledge in societies
means that members of the public are not always in a position to define and understand risk. At some
point, individuals may lack the ability and opportunity to decide which risks affect them and to what
extent. Often the public is forced to place their trust in social structures that are viewed as acting in their
best interests.

Since different groups and stakeholders have different interests at the level of public debate, certain
dangers are attached to particular threats when different perceptions of risk are created. Both social
institutions and social structures thus harbor the power to shape risk perception. This process of
negotiating risk demonstrates how people organize their universe through cultural and social biases and
choose what to fear based on their way of life and patterns of cultural and social norms. These biases
cause selective attention to risk and preferences for different types of risk taking behaviors, informed by
an inherent compulsion to defend one’s way of life.

Furthermore, although it is ultimately social structures that define and shape risk perception in societies,
we see that risk is usually individualized, leading to worry and anxiety among persons regarding specific
threats that have yet to take place. Through this process of individualization, risk becomes associated
with choice, responsibility, and blame, and the individual rather than society is held accountable for
negative outcomes.

One of the peculiarities of risk is that the knowledge of risk is not in-sync with the actions that should be
taken.4 In other words, the principle of taking the greatest precaution for the worst possible outcome is
not executed. Although it is possible that this is due to lack of awareness, the more likely explanation is
the lack of acceptance. Research regarding risk perception demonstrates that risk that is

(1) involuntary, (2)

(2) unfamiliar, and

(3) (3) potentially catastrophic is the most difficult for people to accept.

(4) 5 Acquiring HIV/AIDS is an involuntary occurrence for most. Lack of knowledge, but more often, lack
of control over social and economic circumstances precipitates individuals to engage in risky
behavior that leads to the transmission of HIV/AIDS.

20 | P a g e
 In many cultures, for example, women have little power over their sexuality and the sexual
practices in which they engage. In addition, poverty can lead to both male and female prostitution.
In these cases, individuals place themselves at high risk for acquiring HIV/AIDS in trying to avoid
social exclusion, violence, and poverty.

The risk of contracting HIV/AIDS may also be unfamiliar to many. The perception that HIV/AIDS occurs
only amongst homosexuals is still prevalent.8,9 In addition, because the symptoms of AIDS do not take
full effect for as many as 8 to 10 years from the time of infection, many are unaware of being
seropositive, and those who do know may not fully comprehend or accept the magnitude of the disease.

Finally, HIV/AIDS is catastrophic. The numbers speak for themselves; according to the 2007 UNAIDS
Global AIDS Epidemic Update, an estimated 33.2 million living with HIV, 2.5 million newly infected, and
2.1 million individuals lost lives due to HIV/AIDS world-wide at the end of 2006. However, because of the
stigma attached to being HIV-positive in many communities, it is likely that cases of HIV/AIDS are
underreported and thus these numbers may actually be considerably higher.

Although risk perception may be clouded by the individual’s inability to accept the reality of risks that
are involuntary, unfamiliar, and catastrophic, the problem is not necessarily with the individual, but
rather with society at large. Within the discourse of public health, health risks have been individualized
such that it is an individual’s choice to engage in certain behaviors that cause the individual to acquire
HIV/AIDS. This view has led to the labeling of particular groups of individuals and populations as “at-
risk”. Populations deemed at-risk for HIV/AIDS include sex workers, men who have sex with men (MSM),
and injection drug users. This narrow definition of those at-risk can also be misleading considering that
heterosexual and mother-to-child transmission of HIV/AIDS is increasing rapidly across populations. As a
result this has led to a limited focus on awareness and education as solutions, and has allowed those in
power to dehumanize, blame, and avoid responsibility for those suffering from HIV/AIDS.

Modeling the HIV/AIDS disaster

Disasters are often referred to as unplanned, socially disruptive events with extreme effects. The
characteristics common to environmental and natural disasters mirror the ways in which HIV/AIDS
destroys and impacts communities. These characteristics include a high impact on individuals or
populations; the spanning of spatial and temporal boundaries; large-scale damage to human life; and
root causes that are complex. With regards to the latter, disasters are triggered not by a single event,
but rather through the interaction of a multitude of factors and a buildup of unnoticed events. This is
particularly true for HIV/AIDS.

The vulnerability of a population to HIV/AIDS is rooted in social processes and underlying causes that
may actually be quite unrelated to the end result itself, namely the contraction of HIV/AIDS. The factors
that create vulnerability in populations can be modeled to provide a visual representation of the
potential negative impact of HIV/AIDS. Since risk and risk perception are a function of the degree of
vulnerability and the hazard type, the Pressure and Release (PAR) model first developed by Wisner and
colleagues can be used and adapted to depict the root causes and process of HIV/AIDS transmission. The
PAR model is generally used to outline how disasters are shaped by external conditions that apply

21 | P a g e
increasing pressure until a release is forced resulting in a disaster.This build-up of pressure is referred to
as a “progression of vulnerability” that consists of three stages:

(1) root causes,

(2) dynamic pressure, and

(3) unsafe conditions.

By building on the PAR model, we can identify sources of vulnerability as root causes of HIV/AIDS
transmission which center around political instability, poverty, and unequal access to power and
resources.14 Countries such as South Africa, Zimbabwe, and Kenya have some of the highest HIV/AIDS
infection rates since they are nations with populations experiencing unequal access or lack of resources,
poverty, social inequality, and instability.

In the second stage of the model, vulnerability increases via dynamic processes that reduce the ability of
the population or risk group to handle adverse circumstances. Here, local markets and fluctuating
systems of labor play a major contributory role to a disaster. Finally, vulnerability peaks due to unsafe
conditions where the physical and social environment of the population is unsanitary and/or hostile. As
vulnerability increases, so does the risk to the population.

HIV/AIDS pandemic in the context of the PAR model. The progression of vulnerability, paired with the
hazard of HIV/AIDS creates the ideal setting for rapid HIV/AIDS transmission (the risk). In other words,
risk equates to vulnerability (V) multiplied by the level of hazard (H) that exists. In this context, risk is
defined as the probability that a person may acquire the HIV infection. Vulnerability to risk is shaped by
three factors. First is the resilience of a population, or the capacity of the people to resist and recover
from the outcomes of a disaster. The second component is the health of the population, or the
robustness of individuals, which is most influenced by ‘livelihood’ and the availability of social
operations such as healthcare services. The final factor determining vulnerability is the degree of
preparedness of a population. The level of preparedness is shaped by societal values and beliefs, which
determine what is viewed as a risk and in turn which measures are taken for protection, if any. It is
interesting to note that factors such as poverty and inadequate government assistance act not only as
root causes, but also as dynamic pressures and unsafe conditions. Needless to say, HIV/AIDS is most
prevalent in populations where social inequality persists and where the disempowered are victimized.

HIV/AIDS as a global concern

Although a stabilization of the HIV/AIDS epidemic has been noted in the last few years, the infection
continues to spread rapidly in actual numbers. Of the many reasons why HIV/AIDS stands out as
atypically disastrous is that its impact is gradual and thus referred to as slow onset. Although disasters
are often thought of as sudden, the worst consequences of disasters are not necessarily felt at the point
of occurrence and can easily emerge long after the causes and effects have been identified. HIV/AIDS is
one such disaster. The inability of populations and in some cases complete disregard of governments to
recognize risk factors, symptoms, and infection rates prevents appropriate response measures from

22 | P a g e
being implemented. It is unfortunate that by the time a response is mounted by public authorities;
numerous individuals have already been infected who may not have been infected if early prevention
measures were in place.

Nowhere is the epidemic more pronounced than in sub-Saharan Africa where over the past decade the
epidemic crossed the continent through migrants and refugees.14 With just over 10% of the world’s
population living in this region, it is disturbing that almost 64% are living with HIV/AIDS. Despite the
concentration of HIV/AIDS cases in Africa, the disease continues to spread in other parts of the world as
well. Since the breakup of the Union of Soviet Socialist Republics (USSR), the resulting fifteen new
nations have been experiencing great political, social and economic instability. This social and political
instability has led to increased poverty, driving many to resort to substance abuse. Subsequently,
injection drug use and commercial sex work are both dominant transmission paths for HIV/AIDS in this
region. The Russian Federation and Ukraine alone make up 1.3 million of the 1.5 million cases in Eastern
Europe.

In Asia, an estimated 4.9 million people were living with HIV/AIDS in 2007, with significant growth in
prevalence in Indonesia and Vietnam.1 Injection drug use is a primary transmission method in this area.
In Jakarta, Indonesia 40% of injection drug users tested positive for HIV in 2005.1 In Vietnam, HIV
prevalence among injection drug users increased from 9% in 1996 to 34% in 2005.1 Furthermore, in
most Asian countries condom use remains very low. This cultural norm is contributing to increasing
infection rates among male and female sex workers. Like their international counterparts, the HIV/AIDS
epidemic in Asia is an outcome of social forces, including population mobility, environmental
degradation, economic upheaval, and poverty.

HIV/AIDS cases in Latin America are also on the rise. Much of this increase is attributed to the street
culture present in many Latin countries that encourages illicit drug use and unsafe sex, particularly
among young males. Young boys in Brazil, for example, are encouraged to lose their virginity to
demonstrate their masculinity.20 In Latin American nations, HIV prevalence is on the rise with
populations at risk. The Latino population outside of Latin America also has an increased risk of
acquiring HIV/AIDS due to cultural factors that contribute to sustained participation in risky behavior.21

Despite the broad reach of HIV/AIDS across the globe, governments have failed to acknowledge that
HIV/AIDS remains an ongoing crisis and populations continue to neglect the severe risk involved in
practices that make them vulnerable to HIV/AIDS.12 The most vulnerable population groups for
HIV/AIDS are women and children. There are approximately 2.5 million children across the world that
are living with HIV/AIDS.1 In 2006 alone, an estimated 420,000 new AIDS cases arose in children under
the age of 15 years and the prevalence rate in pregnant women has also increased significantly
worldwide.1 Furthermore, more than 40% of new infections worldwide are from the young population
in the range of 15–24 years of age, indicating a sustenance or prolonging of the virus in populations of
the generations to come. Thus, understanding the way perception of risk is shaped and constructed is
crucial in identifying why it has been so difficult to mitigate the spread of HIV/AIDS.

Discussion

23 | P a g e
The role of public health

The spread of HIV/AIDS is exacerbated by social factors that include not only socio-economic status,
political instability, and geographic location, but also gender and sexual practice.14 Perceptions of risk in
contracting HIV/AIDS are shaped by related patterns of social relations and cultural biases. The power to
shape risk perception is usually in the hands of very few; namely those with control over social, political,
and/or economic institutions.

The case can be made that HIV/AIDS causes widespread loss and serious disruption to the functioning of
a community, much like an environmental disaster.23 Yet, despite the potential of HIV/AIDS to become
a global disaster, many populations continue to neglect the risk involved in practices that make them
vulnerable to HIV/AIDS. This failure to mitigate the spread of the infection may be due to the fact that
perceptions of risk are shaped by patterns of social relations and cultural biases. In addition, the power
to shape risk perception is usually limited to those with control over social, political, and/or economic
institutions. Since the social, political, and economic context plays a role in HIV/AIDS-related risk
perception, there is a need to reevaluate public health measures being implemented to control the
spread of HIV/AIDS.

The purpose of public health is to manage threats to the health of a population through preventative
measures and treatment. Although HIV/AIDS is not only a health problem, but also a developmental
issue, attempts at mitigating the spread of the infection typically occur solely through the health sector.

Risk perception is culturally influenced and therefore risky behavior is a social rather than an individual
issue. However, the mass media often perpetuates risk as an individual issue and unique to selected
populations (intravenous drug users, commercial sex workers and men who have sex with men [MSM]).
Therefore, the role of media must also be recognized in terms of being an important player in
disseminating information on risks as well as promoting a cultural approach to prevent further spread of
HIV/AIDS among a population where social instability exists. As a result, the media plays an integral role
in shaping or reinforcing risk behavior as an individual phenomenon, where the individual chooses to be
in that risk group. Public health measures implemented to combat the spread of HIV/AIDS must be re-
evaluated with consideration for ways in which culture and media shape risk perception, particularly for
those groups most at-risk. In using the PAR model as a guide, vulnerability must be managed and
reduced by addressing root causes, dynamic pressures, and unsafe conditions that contribute to the
HIV/AIDS pandemic. HIV/AIDS programs must be culturally appropriate and work toward influencing risk
perception, while addressing social norms and values that negatively impact vulnerable populations
such as women and children.

Prevention programs typically focus on raising awareness and using interpersonal strategies, such as
peer education and testimonials to influence behavior change. These initiatives have had mixed results
because often those most at risk are those in poverty, and these individuals have limited means for
effecting change in their circumstances. For this reason, prevention programs aimed at individual
behavior change can be ineffective in many contexts. Even awareness campaigns that are deemed
“culturally-appropriate” have produced mixed results with regards to effectiveness. These approaches

24 | P a g e
to managing HIV/AIDS fail to consider the evidence that risk perception is culturally influenced and
therefore risky behavior is a social rather than an individual issue. It is wrong to assume that decision-
making and behavior are always rational. Social and economic factors such as relationships, community
expectations, and access to resources have a major impact on behavior, and at times may prevent
individuals from adopting safe sex practices that prevent HIV/AIDS transmission. This indicates that
attempting to reform behavior to reduce HIV transmission risk is unlikely without structural changes –
that is, public health interventions aimed at changing the environment rather than individual behavior
may be more successful in reducing the spread of the infection.

Public health measures to combat the spread of HIV/AIDS must be re-evaluated with consideration for
ways in which culture shapes risk perception. Societal factors, including practices and beliefs about sex,
relationships, and condom-use lead to the inclusion, neglect, or exclusion of people, thereby shaping
individual behavior in ways that are beyond individual control. Addressing social norms and values that
negatively impact vulnerable populations such as women and children can effect change more rapidly
than measures aimed at individual behavior. Thus, the ultimate aim should be to enable people to exert
control over their own risk and to create an environment in which safer behavior can be practiced.

The role of public health policies and programs cannot and should not be limited to individual health
behaviors. Despite the knowledge and experience in the field of public health with regards to the social
determinants of disease, including food and nutrition, shelter, and employment, there has been little
impact on HIV/AIDS policy and programming. In addition to recognizing the role of social context, policy
and program implementation must also not occur in isolation. Inter-sectoral coordination is necessary to
influence risk perception on a macro-level. Recognition of HIV/AIDS as not only a health problem, but
also a social, economic, and development issue facilitates collaboration between different levels of
government and civil society. However, it is important to stress that the application of public health
efforts will differ from one region to another due to differences in demographics, political context,
education levels, social service provision, geographic location, cultural beliefs and epidemic patterns,
among other factors. For example, data suggests that in most cultures poverty exacerbates the spread
of HIV, but there are also emerging epidemics among financially secure sectors of society partly because
of the economic power to engage in risky behaviors such as buying sex or drugs. Whether safer behavior
is more likely to occur as economic status increases depends on other factors such as social values,
education and gender. This example illustrates the complexity of vulnerability, and the need to design
interventions and policies that take regional variations into consideration.

Although targeting interventions to the changing needs of the communities for whom they are designed
is crucial to program effectiveness, there are two vulnerable groups, in particular, that demand
attention in all contexts: youth and females. Young people, both male and female, account for most of
the current HIV/AIDS infections in the world today.The transition from childhood to adulthood can be
fraught with difficulties such as lack of information, a desire to experiment, or feelings of
“invulnerability”. In most societies, young people have limited rights and are expected to be obedient to
authority.This can impact their propensity to take part in risky behaviors and can diminish the
potentially positive effects of health and social services. Youth are not only victims of the HIV/AIDS
epidemic directly, but also indirectly. For example, it is estimated that the number of children and youth

25 | P a g e
orphaned by HIV/AIDS will continue to rise for the next several years reaching 40 million by 2010 in
African alone.

Similarly, women and girls often face inequalities in access to education, in income and employment,
and before the law, which places them at a disadvantage and reduces their ability to adopt safe
behaviors. Reversing these inequalities will require cultural, legal, and policy-level changes. In the
absence of policies and programs that bridge the age and gender gaps, efforts aimed at reducing the
spread of HIV/AIDS may be ineffective and short-lived.

Keeping in mind the need to balance context specificity with consideration for cross-cutting issues like
ageism and sexism, a multi-dimensional approach to HIV/AIDS mitigation is recommended. Such a
model involves two dimensions:

(1) persuading vulnerable population groups to change behavior, and

(2) enabling safe behavior by changing societal and contextual factors that contribute to HIV/AIDS
transmission.

Thus far, public health measures have focused on persuasion. This narrow focus on the individual has a
limited impact on communities plagued by poverty, inequality, and injustice. Public health policies and
programs must move to a paradigm of enablement and empowerment by addressing root causes. This is
more challenging than behavior change programs because it requires collaboration across sectors and
because the impact will not be evident in the near future. Cultural changes are gradual. Thus, the
importance of long-term sustainable policies and programs cannot be overemphasized. There is a clear
and definite need for global cooperation on this, especially considering that the lower economic status
of developing countries will result in more acute challenges to the development and maintenance of
necessary programming.

Within the discourse of public health, health risks have been individualized such that it is an individual’s
choice to engage in certain behaviors that cause the individual to acquire HIV/AIDS. This view has led to
the labeling of particular groups of individuals and populations as “at-risk”. However, the term “at-risk”
is misleading considering that HIV/AIDS is now transmitted in a number of different ways, such as
heterosexually and from mother to child. Awareness of risk is no longer sufficient. There must be
acceptance at a cultural and social level that the risk of acquiring HIV/AIDS is not limited to particular
individuals. HIV/AIDS is a threat to everyone and must be considered a shared responsibility. By
reshaping risk perception, public health measures can effect change at the social level, where it matters.

Community-led approaches to HIV/AIDS mitigation have grown in popularity and are often quite
innovative in their response. The advantages of such programs are that local knowledge is utilized and
the focus is on communities as opposed to individuals. Community mobilization, paired with public
health efforts can allow for a naturally evolving response to diversity and changing needs. Despite the
great, untapped capacity of communities, local programs often continue to focus on behavior change
out of context. However, proactive action rather than reactive action is required to ensure policy gets
ahead of the epidemic.

26 | P a g e
Application of the PAR model

The spread of HIV/AIDS can be modeled much like an environmental disaster that is characterized by a
slow onset and is exacerbated by human action or inaction. If humans can act as agents to mitigate the
effects of hazards and disasters, accountability and responsibility must be acknowledged as not being
limited to a selected group, but shared by all individuals and communities.22 Discourses surrounding the
global HIV/AIDS crisis must move in this direction; developing a recognition that HIV/AIDS is a shared
responsibility requiring a coordinated response from all nations.

Considering the similarities between HIV/AIDS and other natural and environmental disasters, a disaster
management approach to HIV/AIDS is needed to improve global responses. A disaster management
framework can act as a policy and administrative tool to assist decision makers in determining the
appropriate response to HIV/AIDS. For example, depending on the current level of HIV/AIDS impact and
the potential for future disruption based on vulnerability, societies can be classified into one of three
phases:

(1) pre-disaster phase,

(2) early-warning phase, or

(3) disaster phase.

In order to effectively utilize the PAR model within such a framework, there must be reliable and
valid means for ongoing data collection in the nation, region, or community being studied. Data on
social, economic, and health indicators paired with an understanding of the social and political
context is necessary. In its simplest application, the PAR model can be used as a checklist in which
existing factors are checked off, while factors that are not currently occurring in the target area are
left blank. Used in this manner, the PAR model can indicate levels of vulnerability, or in other words
the model will reveal which disaster phase the region is currently in. The model can also highlight
which “pressures” should be released through addressing root causes that achieve safer conditions,
thereby reducing the risk of disaster.

Nations with a low HIV/AIDS prevalence and low vulnerability for progression can be classified under
Phase 1, the pre-disaster phase. With regards to environmental disasters, the pre-disaster phase is
characterized by coordinated, focused development that reduces the likelihood of disastrous events
through a collaborative response. In the context of HIV/AIDS, the pre-disaster phase involves risk
reduction by focusing on high-risk and/or vulnerable populations, including not only sex workers and
injection drug users, but also women and children. While environmental disasters are mitigated through
activities like relocation or elevation of structures, construction of safe rooms, or vegetation
management, HIV/AIDS can be mitigated through policies and laws that promote equality, economic
growth, and cultural norms associated with safe behaviors. In both cases, known hazards are reduced or
eliminated as a prevention mechanism against disaster.

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Nations with low HIV/AIDS prevalence and high vulnerability can be classified under Phase 2, the early-
warning phase. Generally, the early-warning phase involves the implementation of existing response
plans, relief assistance, and assessment of initial damages. Similarly, for HIV/AIDS mitigation the early-
warning phase refers to a response involving heightened planning and expanded prevention activities
that are focused on both high-risk groups and the general population.

Finally, nations with very high HIV/AIDS prevalence and high vulnerability can be classified as disaster
situations (Phase 3). For environmental and natural disasters in Phase 3, there is a need to engage in
search and rescue operations, begin reconstruction and rehabilitation, and conduct thorough
assessments of damages. Similarly, recommendations for HIV/AIDS disasters include the mobilization of
resources, reconstruction, and rehabilitation that involves ongoing treatment, care, and prevention
efforts. Unlike the initial two phases of the disaster management framework, the third phase is not
focused on prevention, but rather on treatment and alleviation.

Conclusion

The HIV/AIDS pandemic can be modeled much like an environmental or natural disaster that causes
social disruption and loss of life. Despite the harrowing impact of HIV/AIDS globally, the response from
governments has been slow and ineffective, characterized by cultural norms focused on choice, blame,
and individual responsibility.

A disaster management approach to prevention, treatment, and mitigation can ensure that HIV/AIDS
becomes a priority and is addressed with the same concern and attention as other environmental
disasters. Utilization of the PAR model can direct and enhance disaster management efforts. By using
the PAR model as a guide, public health departments can work towards addressing one or more of the
three features of increasing vulnerability, namely:

(1) root causes such as poverty, access to resources, and gender inequality;

(2) dynamic pressures such as migration and employment; and (3) unsafe conditions such as sanitation,
access to healthcare, and stigma.

In addition to reducing vulnerability by addressing root causes, particular attention can be paid to
developing methods for changing perceptions of risk. By impacting cultural and social expectations,
individuals will be able to more readily adopt safer sex behaviors. The development of policies and
programs addressing the issues in context, as opposed to individual behaviors alone, allows for effective
public health intervention – which is needed if we are to prevent the HIV/AIDS pandemic from becoming
a full blown catastrophic disaster.

Learning Outcome 2: Describe the spread and prevention of HIV and the treatment of HIV
and AIDS

a. The spread of the HIV virus: sexual transmission, through infected blood transfusions

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and needles, and during pregnancy, birth or breast feeding by mothers who have HIV
infection

There are several common ways that HIV can be passed from person to person, including:

 Having unprotected sex with someone who is infected. Worldwide, most new HIV infections
occur through sex.3 Women are particularly at risk of infection through sex. It's much easier to
get HIV (or to give it to someone else) if a person has a sexually transmitted disease (STD). For
more information, see the Centers for Disease Control and Prevention's The Role of STD
Detection and Treatment in HIV Prevention.

 Transmission from mother to child. Without anti-HIV treatment, an infected mother may pass
the virus to her child during pregnancy, birth, or breastfeeding. Although mother-to-child
transmission is preventable, and transmission is rare in the United States, more than 300,000
infants are infected each year through their mothers globally; most of these infections occur in
sub-Saharan Africa.

 Using needles or syringes that have been used by people who are infected.

 Pre-chewing food for infants. In a few cases, HIV has been spread when HIV-infected caregivers
chewed food (or warmed it in their mouths) and then fed the food to an infant. This practice can
expose the child to HIV if the caregiver has a sore or cut in the mouth. The CDC recommends
that HIV-infected caregivers do not pre-chew food for infants.4

 Receiving infected blood products or transplanted organs. Since 1985, the United States tests all
donated blood and organs for HIV; therefore, the risk of getting HIV in this way in the United
States is now extremely low, and the risk is also decreasing in other countries as they improve
their testing methods.

b. How the virus reproduces, damages the immune system and can be detected by
different sorts of HIV tests

HOW HIV INFECTS THE BODY AND THE LIFECYCLE OF HIV

FAST FACTS

 HIV infects white blood cells in the body’s immune system called T-helper cells (or CD4 cells).

 The virus attaches itself to the T-helper cell; it then fuses with it, takes control of its DNA,
replicates itself and releases more HIV into the blood.

 Knowing how HIV infects the body helps people understand prevention and treatment options,
and why it’s important to start antiretroviral treatment as soon as possible after testing positive.

The HIV lifecycle

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HIV infects a type of white blood cell in the body’s immune system called a T-helper cell (also called a
CD4 cell). These vital cells keep us healthy by fighting off infections and diseases.

HIV cannot grow or reproduce on its own. Instead, the virus attaches itself to a T-helper cell and fuses
with it. It then takes control of the cell’s DNA, replicates itself inside the cell, and finally releases more
HIV into the blood – continuing the multiplication process. This is the HIV lifecycle.

In this way HIV weakens the body’s natural defences and over time severely damages the immune
system. How quickly the virus develops depends on a person’s general health, how soon after getting
HIV they’re diagnosed and start antiretroviral treatment, and how consistently they take their
treatment.

Antiretroviral treatment and the HIV lifecycle

Antiretroviral treatment combines a range of drugs that target different stages in the HIV lifecycle,
making it very effective. If it’s taken correctly, it keeps the immune system healthy, prevents the
symptoms and illnesses associated with AIDS from developing, and means that people can enjoy long
and healthy lives.

If someone doesn’t take their treatment correctly or consistently, drug resistance can develop. At this
point the drugs are no longer stopping the virus from replicating.

Stages of the HIV lifecycle

1. Binding and fusion

The virus attaches itself to a T-helper cell and releases HIV into the cell.

Fusion or entry inhibitor drugs stop this happening.

2. Conversion and integration

Once inside the T-helper cell, HIV changes its genetic material so it can enter the nucleus of the cell and
take control of it.

3. Replication

The infected T-helper cell then produces more HIV proteins that are used to produce more HIV particles
inside the cell.

4. Assembly, budding and maturation

The new HIV particles are then released from the T-helper cell into the bloodstream which infect other
cells; and so the process begins again.

The science of HIV

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Knowing how HIV infects the body helps people understand prevention and treatment options, and why
it’s important to start antiretroviral treatment as soon as possible after testing positive. If you’d like to
find out more about the HIV lifecycle, take a look at our Science of HIV and AIDS section.

Stages of the HIV lifecycle

1. Binding and fusion

The virus attaches itself to a T-helper cell and releases HIV into the cell.

Fusion or entry inhibitor drugs stop this happening.

2. Conversion and integration

Once inside the T-helper cell, HIV changes its genetic material so it can enter the nucleus of the cell and
take control of it.

NRTIs (nucleoside reverse transcriptase inhibitors), NNRTIs (non-nucleoside reverse transcriptase

inhibitors) and integrase inhibitor drugs stop this happening.

3. Replication

The infected T-helper cell then produces more HIV proteins that are used to produce more HIV particles
inside the cell.

4. Assembly, budding and maturation

The new HIV particles are then released from the T-helper cell into the bloodstream which infect other
cells; and so the process begins again.

Protease inhibitor drugs stop this happening.

The science of HIV

Knowing how HIV infects the body helps people understand prevention and treatment options, and why
it’s important to start antiretroviral treatment as soon as possible after

c. Prevention of HIV infection: use of condoms, sexual health education, post

exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP)

To help prevent the spread of HIV:

Use a new condom every time you have sex. Use a new condom every time you have anal or vaginal sex.
Women can use a female condom. If using a lubricant, make sure it's water-based. Oil-based lubricants

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can weaken condoms and cause them to break. During oral sex use a nonlubricated, cut-open condom
or a dental dam — a piece of medical-grade latex.

Consider preexposure prophylaxis (PrEP). The combination drugs emtricitabine plus tenofovir (Truvada)
and emtricitabine plus tenofovir alafenamide (Descovy) can reduce the risk of sexually transmitted HIV
infection in people at very high risk.

Your doctor will prescribe these drugs for HIV prevention only if you don't already have HIV infection.
You will need an HIV test before you start taking PrEP and then every three months as long as you're
taking it. Your doctor will also test your kidney function before prescribing Truvada and continue to test
it every six months.

d. . Treatment of HIV/AIDS: use of combination therapy with antiretroviral drugs and

other medications

Tests to stage disease and treatment

If you receive a diagnosis of HIV/AIDS, several tests can help your doctor determine the stage of your
disease and the best treatment. These tests include:

CD4 T cell count. CD4 T cells are white blood cells that are specifically targeted and destroyed by HIV.
Even if you have no symptoms, HIV infection progresses to AIDS when your CD4 T cell count dips below
200.

Viral load (HIV RNA). This test measures the amount of virus in your blood. A higher viral load has been
linked to a worse outcome.

Drug resistance. Some strains of HIV are resistant to medications. This test helps your doctor determine
if your specific form of the virus has resistance and guides treatment decisions.

Tests for complications

Your doctor might also order lab tests to check for other infections or complications, including:

 Tuberculosis

 Hepatitis

 Toxoplasmosis

 Sexually transmitted infections

 Liver or kidney damage

 Urinary tract infection

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  HIV testing

 Liver function tests

 Urinalysis

Treatment

There's no cure for HIV/AIDS, but many different drugs are available to control the virus. Such treatment
is called antiretroviral therapy, or ART. Each class of drug blocks the virus in different ways. ART is now
recommended for everyone, regardless of CD4 T cell counts. It's recommended to combine three drugs
from two classes to avoid creating drug-resistant strains of HIV.

The classes of anti-HIV drugs include:

 Non-nucleoside reverse transcriptase inhibitors (NNRTIs) turn off a protein needed by HIV to
make copies of itself. Examples include efavirenz (Sustiva), etravirine (Intelence) and nevirapine
(Viramune).

 Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) are faulty versions of the
building blocks that HIV needs to make copies of itself. Examples include Abacavir (Ziagen), and
the combination drugs emtricitabine/tenofovir (Truvada), Descovy (tenofovir
alafenamide/emtricitabine), and lamivudine-zidovudine (Combivir).

 Protease inhibitors (PIs) inactivate HIV protease, another protein that HIV needs to make copies
of itself. Examples include atazanavir (Reyataz), darunavir (Prezista), fosamprenavir (Lexiva) and
indinavir (Crixivan).

 Entry or fusion inhibitors Tblock HIV's entry into CD4 T cells. Examples include enfuvirtide
(Fuzeon) and maraviroc (Selzentry).

 Integrase inhibitors work by disabling a protein called integrase, which HIV uses to insert its
genetic material into CD4 T cells. Examples include raltegravir (Isentress) and dolutegravir
(Tivicay).

When to start treatment

Everyone with HIV infection, regardless of CD4 T cell count, should be offered antiviral medication.

HIV therapy is particularly important for the following situations:

 You have severe symptoms.

 You have an opportunistic infection.

 Your CD4 T cell count is under 350.

 You're pregnant.

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  You have HIV-related kidney disease.

 You're being treated for hepatitis B or C.

Treatment can be difficult

HIV treatment plans may involve taking several pills at specific times every day for the rest of your life.
Each medication comes with its own unique set of side effects. It's critical to have regular follow-up
appointments with your doctor to monitor your health and treatment.

Some of the treatment side effects are:

 Nausea, vomiting or diarrhea

 Heart disease

 Weakened bones or bone loss

 Breakdown of muscle tissue (rhabdomyolysis)

 Abnormal cholesterol levels

 Higher blood sugar

Treatment response

Your doctor will monitor your viral load and CD4 T cell counts to determine your response to HIV
treatment. CD4 T cell counts should be checked every three to six months.

Viral load should be tested at the start of treatment and then every three to four months during
therapy. Treatment should lower your viral load so that it's undetectable. That doesn't mean your HIV is
gone. It just means that the test isn't sensitive enough to detect it.

Lifestyle and home remedies

Along with receiving medical treatment, it's essential to take an active role in your own care. The
following suggestions may help you stay healthy longer:

 Eat healthy foods. Fresh fruits and vegetables, whole grains, and lean protein help keep you
strong, give you more energy and support your immune system.

 Avoid raw meat, eggs and more. Foodborne illnesses can be especially severe in people who are
infected with HIV. Cook meat until it's well-done. Avoid unpasteurized dairy products, raw eggs
and raw seafood such as oysters, sushi or sashimi.

 Get the right immunizations. These may prevent infections such as pneumonia and the flu.
Make sure the vaccines don't contain live viruses, which can be dangerous for people with
weakened immune systems.

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  Take care with companion animals. Some animals may carry parasites that can cause infections
in people who are HIV-positive. Cat feces can cause toxoplasmosis, reptiles can carry salmonella,
and birds can carry cryptococcus or histoplasmosis. Wash hands thoroughly after handling pets
or emptying the litter box.

Alternative medicine

People who are infected with HIV sometimes try dietary supplements that claim to boost the immune
system or counteract side effects of anti-HIV drugs. However, there is no scientific evidence that any
nutritional supplement improves immunity, and many may interfere with other medications you are
taking.

Learning Outcome 3: Assess the impact of political, economic, social and cultural factors
on the prevention and treatment of HIV and AIDS

a. Epidemiology of HIV and AIDS: comparison of prevalence and primary means of spread
of HIV in a range of low resource countries and in high resource countries; impact of HIV
and AIDS at national level: effects on economic growth, education, public services, rise of
‘AIDS orphans’

The Epidemiology of HIV and AIDS

The picture we can draw of the HIV/AIDS epidemic is limited by the data available. To date, the AIDS
case reporting system of the Centers for Disease Control and Prevention (CDC) is the only complete
national population-based data available to monitor the epidemic. Although data are useful in
evaluating disease prevalence and incidence, reported AIDS cases are only the clinical tip of the iceberg
of effects produced by HIV infection. HIV seroprevalence surveys are informative for their description of
the magnitude of the epidemic, but they represent people whose date of infection is unknown; these
surveys are thus limited in their ability to characterize the current direction of the epidemic. HIV
incidence data are far more informative for monitoring the current course of the epidemic.
Nevertheless, because HIV infection is not reportable in all states, and because most studies of HIV have
not included representative samples, these data are of limited value for generalizing to other specific
populations or to the entire U.S. population. HIV surveillance data also provide information that is of
limited value in forecasting the future of the epidemic. To address this limitation, some have argued
(e.g., Centers for Disease Control and Prevention, 1994a; Turner et al., 1989) that a broader monitoring
system of the epidemic should include precursors to AIDS and HIV infection. Better-developed
behavioral epidemiologic data on known risk behaviors (i.e., sexual behavior and drug use) could
provide data on sites of potential transmission and future spread.

Despite these limitations, current epidemiologic data provide valuable insights into the HIV/AIDS
epidemic in the United States. This chapter reviews these data with particular emphasis on the role of
injection drug users. However, before reviewing these data, the panel thought it critical to provide the
reader with a brief review of current knowledge of the underlying biological mechanisms involved in the

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transmission of the virus. The details of these behaviors and processes are important to developing an
appreciation for the complexity of the issues at hand.

Biological Mechanisms Of Transmission

Although the consensus among the research community is that the development of an effective vaccine
for the human immunodeficiency virus (HIV) is still years away, significant strides have been made in
biomedical research. As Rogers (1992:522) stated, ''We now know quite precisely how the virus is
transmitted and how it is not and what it does to human cells and the immune mechanism, and we
know enough about its structure and life-cycle to have identified multiple potential points to get at it."

HIV transmission is limited to sharing of contaminated injection drug paraphernalia, sexual contact,
transmission from infected mother to child, exposure to infected blood or blood products, and
transplantation of infected organs or tissues. As of December 31, 1993, injection drug use and sexual
contact accounted for approximately 92 percent of all adult and adolescent AIDS cases reported to CDC.
We review here postulated mechanisms for transmission through activities associated with injection
drug use, sexual, and perinatal transmission and detail the associated human behaviors.

Injection Drug Use Transmission

Injection drug use involves practices that facilitate the transmission of HIV infection. The primary
category of such practices is direct needle sharing, which involves the reuse of needles and syringes that
have been contaminated through prior use by an infected individual. Penetration of the needle through
the skin is sufficient for contamination and subsequent transmission of HIV infection, as has been
demonstrated in cases of needlestick injuries among health care workers (McCray, 1986). In instances of
occupational exposure of health care workers, in which the amount of blood exposure frequently is
small (Napoli and McGowan, 1987), the risk of transmission is about 3/1,000 exposures (Ippolito et al.,
1994).

Direct Needle Sharing

The higher rates of HIV infection in injection drug users than in health care workers are due to much
more frequent injections (an average of one to two injections per day, according to some published
surveys) and the practice of registering. Registering means that once a needle is inserted, the drug user
will draw back the plunger of the syringe to examine for the presence of blood to ensure that the needle
has been properly placed into a vein. Registering, then, involves contamination of both the needle itself
and the hub, barrel, and plunger of the syringe. Although the syringe is typically rinsed before reuse,
residual blood may adhere or remain, which may be released into the next person who uses the syringe
by subsequent agitation (by drawing up and administrating the drug solution). Studies of the
survivability of HIV in dried or aqueous states (Resnick et al., 1986) suggest that transmission may occur
even if there is a delay of a day or more before the needle and syringe are reused by a different person.

A related practice of direct needle sharing has been termed booting (Inciardi, 1990; Ouellet et al., 1991),
which involves additional steps in the basic injection pattern described above. Booting is the practice

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performed after registering and administering the drug solution. In this process, with the needle still in
the vein, the injector draws back on the plunger of the syringe to fill the barrel with blood and then
reinjects the blood, sometimes repeating this practice several times. More commonly reported with
cocaine than with heroin injection, this practice allegedly enhances the euphoria associated with the
drug's effects. Others, however, describe the motivation for engaging in this practice as economic, that
is, to wash out all traces of the drug when administering it. The volume of blood that remains in the
barrel of the syringe following booting is greater than that for the practice of registering and, at least
theoretically, may be associated with a higher risk of transmission to anyone who subsequently uses a
booted syringe. Empirical data on the risk of transmission for the practice of booting are sparse because
few injection drug users can report reliably on whether previously used syringes were booted.
Nevertheless, in one study, booting was associated with increased HIV seropositivity among injection
drug users (Lamothe et al., 1993).

The setting in which drug injection takes place can also be related to direct sharing. A shooting gallery is
a clandestine location where injection drug users go to rent needles and syringes. As used syringes are
returned to a common container to be rented again, this process amounts to sequential anonymous
sharing of needles and syringes (Friedland and Klein, 1987; Ouellet et al., 1991). Results of a study in
which researchers tested used syringes collected from shooting galleries in Miami shed some light on
the potential risk associated with injection drug use in the context of a shooting gallery. They showed
that 20 percent of those syringes that had visible blood residue were positive for HIV, compared with 5.1
percent of those that had no visible blood residue (Chitwood et al., 1990). In a follow-up study carried
out 2 years later (McCoy et al., 1994), researchers reported that 52 percent of the syringes showing
visible traces of blood tested positive for HIV.

Indirect Needle Sharing

A separate category of drug injection practices can be termed indirect needle sharing because they do
not directly involve passing a contaminated needle and syringe between individuals. Instead, indirect
sharing involves common use of other drug preparation or injection equipment that can become
contaminated. Examples include cookers, cotton, rinse water, and the drug-sharing practices called
frontloading and backloading.

Risk Behaviors and Interventions

Little attention has been given to these risk behaviors in most HIV/AIDS prevention interventions aimed
at injection drug users. In an in-depth ethnographic study, Koester and Hoffer (1994) reported that only
7 percent of the injectors they interviewed in their study were aware that these behaviors represented
any type of risk of becoming infected. These findings are disturbing, given that over 70 percent of their
study participants were participating or had participated in an HIV/AIDS intervention program.

Finally, it must be noted that infectious agents other than HIV can be transmitted by contaminated
injection equipment. Other blood-borne pathogens that have been associated with injection drug use
include malaria, syphilis, hepatitis B and C viruses, and human T-lymphotrophic virus type II, as well as
other bacterial pathogens that cause sepsis and endocarditis (Cherubin, 1967; Sapira, 1968; Louria et al.,

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1967; Levine and Sobel, 1991; Stein, 1990; Haverkos and Lange, 1990; Cherubin and Sapira, 1993;
Stimmel et al., 1975; Novick et al., 1988; Kreek, 1983; Esteban et al., 1989; Donahue et al., 1991; Des
Jarlais et al., 1992; Selwyn and Alcabes, 1994). The recognition of multiple pathogens that can be
transmitted parenterally by injection drug users is important, because development and
implementation of prevention programs directed at HIV infection can be viewed more broadly as
prevention programs for blood-borne pathogens in general.

Sexual Transmission

Sexual intercourse was implicated as a primary mode of transmission of the virus even before the
etiologic agent (HIV) had been identified (Jaffe et al., 1983a, 1983b; Centers for Disease Control, 1981,
1982). However, the sexual transmission of the virus is not highly efficient, and the risk of acquiring the
infection as a result of a single sexual exposure is relatively low (Friedland and Klein, 1987; Institute of
Medicine, 1988; Holmberg et al., 1989). That does not mean that documented evidence of people
becoming infected after one or only a few sexual contacts does not exist (Padian et al., 1988). Sexual
transmission depends on the type and frequency of sexual encounters, as well as the prevalence of
other risk factors (e.g., condom use). Receptive anal intercourse is particularly dangerous regardless of
the sexual orientation of the individuals (Kingsley et al., 1987; Winkelstein et al., 1987), and frequent
sexual exposures (vaginal or anal) to an infected partner also increase the likelihood of transmission
(Padian et al., 1990; Lazzarin et al., 1991).

With respect to heterosexual transmission, as with other sexually transmitted diseases, women are at
higher risk than men (Aral, 1993). Nonetheless, as is also the case with other sexually transmitted
diseases, transmission occurs in both directions (male-to-female and female-to-male). The differential
efficiency of transmission between the sexes has led to some debate about whether current estimates
of female-to-male transmission rates are accurate (Redfield et al., 1985; Haverkos and Edelman, 1985,
1988; Polk, 1985; Handsfield, 1988; Padian et al., 1991; Haverkos and Battjes, 1992; Haverkos and
Needle, 1994; Haverkos, 1994).

Transmission rates may also vary depending on the risk group of the originally infected partner. The risk
of transmission has been shown to be lower for female partners of hemophiliacs and bisexual men and
for partners of transfusion-infected persons than it is for female or male partners of injection drug users
(Padian, 1987; Padian et al., 1987; Curran et al., 1988; De Gruttola and Mayer, 1988; Johnson, 1988).

Delineation of the precise biological mechanisms involved in the heterosexual transmission of HIV has
been complicated by the difficulty of identifying a potential series of sexual encounters in which
exposure to HIV is known to have occurred each time. We know that cell-free virus is infectious for
blood product recipients and that cell-associated virus can infect cell lines in vitro. We simply do not
know the relative contributions of cell-free and cell-associated HIV transmission in various at-risk
circumstances, including drug injection and sexual contact. Furthermore, viral factors that may influence
the efficiency of transmission are so far poorly understood, i.e., certain strains of HIV may be more
easily transmitted than other strains. It is not yet known whether specific viral genotypic or phenotypic
attributes influence the efficiency of viral transmission.

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Transmission is known to be facilitated by a compromise of the integrity of mucosal surfaces and the
presence of other sexually transmitted diseases, such as syphilis and chancroid, particularly in the
recipient (Johnson and Laga, 1988). By increasing circulating lymphocytes and macrophages that may
harbor HIV at the site of local infection, the presence of sexually transmitted diseases may potentially
increase infectiousness as well. As a result, the prevalence of sexually transmitted diseases in a
population of individuals at risk for HIV infection can significantly alter the efficiency of virus spread.

If a virus-transmitting donor has advanced HIV disease, the recipient may also be more likely to become
infected. Furthermore, infection by an advanced-stage donor is associated with a higher incidence of
acute viral syndrome in the recipient (Laga et al., 1989). These phenomena may be due to increased viral
load in the transmitter or to increased virulence of the transmitted strains of HIV (which may be present
after a long period of infection), or both. Infectiousness may also increase over time because plasma-
associated and cell-associated viral load increases with disease progression, and studies show that the
presence of HIV RNA is more likely to occur in the semen of men with lower CD4+ cell counts.

Perinatal Transmission

Female injection drug users or partners of male injection drug users represent the largest number of
HIV-infected women of childbearing age, constituting a sizable threat for perinatal transmission of HIV.
The transmission of HIV from an infected mother to her offspring may occur in utero, during the birth
process (intrapartum), or at some time following birth (postpartum) by breast-feeding. The relative
frequency of the different timings of infection has not been clearly defined and may vary among
different populations and locales. Approximately 25 to 30 percent of neonates born to HIV-seropositive
mothers become infected (Boylan and Stein, 1991; Vermund et al., 1992; Mofenson, 1992).

For infants born to HIV-seropositive mothers, the transplacental transfer of maternal anti-HIV antibodies
complicates the accurate estimate of the number of infants infected in utero versus those infected
during or after birth.1 Furthermore, because many HIV-infected pregnant women are unaware of their
infection, the opportunity for the early diagnosis and treatment of their infected infants frequently may
be missed. Similarly, interventions to prevent postpartum transmission, such as avoidance of breast-
feeding, are not available to women who do not know that they are infected with HIV. Such
interventions may also not be recommended in regions of the world where risks of HIV transmission are
overshadowed by risks for other adverse health outcomes (e.g., diarrheal disease) among infants who
are not breast-fed.

In perinatal transmission, a variety of factors, usually associated with latter-stage disease, including the
presence of maternal p24 antigenemia and low maternal CD4+ lymphocyte counts at the time of
conception, correlate with the likelihood of infection of a neonate. Additional risk factors in perinatal
transmission include high maternal CD8+ T-lymphocyte counts, placental membrane inflammation, and
maternal fever. It is likely that many HIV infections in infants are acquired at birth through contact with
contaminated blood or secretions. Among twins born to HIV-infected mothers, a higher risk of HIV
infection is seen in the firstborn, even for twins delivered by cesarean section, suggesting that factors
related to the delivery process affect the risk of infection.

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The fact that both the virus donor and the recipient are known in the case of perinatal HIV infection
provides potential opportunities for interventions to decrease the risk of viral transmission. Recent
studies have shown that antiviral treatment of an HIV-infected mother with zidovudine (AZT) can
significantly decrease the likelihood of HIV infection in her offspring (Connor et al., 1994). The
availability of an effective intervention to decrease perinatal HIV transmission has increased interest in
screening pregnant women for the presence of HIV infection so that perinatal HIV infection may be
limited.

Conclusion

In summary, much is known about the various modes of HIV transmission. However, it is not possible to
provide accurate estimates of their relative efficiency. It is difficult to identify accurate denominators for
the numbers of individuals and encounters in which exposure has occurred; moreover, transmission of
the virus depends on factors other than the mode of exposure. The dose of virus transferred (inoculum
size), the frequency of exposure, differences in host susceptibility, variations in infectiousness of an
infected person over time, and the differences in virulence among HIV isolates, as well as the presence
of factors such as particular sexual practices and the presence of sexually transmitted diseases, may all
influence the likelihood of transmission.

Epidemiologic Data

HIV and AIDS Surveillance

As of June 1994, AIDS had claimed over 243,000 lives in the United States, and 401,749 cases of AIDS
had been reported to CDC. On January 1, 1993, CDC revised its AIDS surveillance case definition for
adolescents and adults to include three additional clinical conditions and one laboratory marker of
immunosuppression.2 This expansion made for a broader case definition, resulting in a large increase in
AIDS cases reported across all subpopulation groups. In 1993, 105,990 new adolescent and adult AIDS
cases were reported, representing a 127 percent increase over the 46,791 cases reported in 1992.

There were 5,228 pediatric AIDS cases reported to CDC as of December 31, 1993. In 39 percent of cases,
the mother was an injection drug user, and in an additional 17 percent of cases she had sex with an
injection drug user. Thus, over half of all pediatric AIDS cases are associated with the HIV epidemic
among injection drug users. This is likely to be a lower bound estimate because the risk factors for the
mother were unknown for an additional 21 percent of pediatric cases.

In 1992, AIDS had become the eighth leading cause of death in the United States. Among women ages
25 to 44, AIDS was the fourth leading cause of death; for men in this age group, AIDS was the leading
cause of death, surpassing unintentional injuries, heart disease, cancer, suicide, and homicide (Centers
for Disease Control and Prevention, 1994b). Moreover, in New Jersey and New York, AIDS has been
reported to be the leading killer among African American women between the ages of 20 and 40
(Kaplan, 1993). In addition to race, the risk to women also appears to be heavily skewed by social class
(Epstein et al., 1993; Hu et al., 1993; Kaplan, 1993; Phillips et al., 1993; Fife and Mode, 1992). As

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discussed below, the largest recent increases in case reporting were observed for adolescents, women,
racial/ethnic minorities, and individuals infected through injection drug use and heterosexual contact.

The dynamic nature of the epidemic is illustrated by the temporal changes in dissemination within the
United States. In 1984, two cities—New York and San Francisco—reported half of all AIDS cases in this
country; as of December 1993, those two cities accounted for 18 percent of new cases. These two cities
have also differed in the distribution of AIDS cases by mode of exposure: in San Francisco the majority of
cases are related to men who have sex with men; in New York the majority of cases are related to
injection drug use. Figure 1.1 illustrates the variation in AIDS incidence rates across states. Moreover, a
closer look at selected metropolitan area AIDS cases reported in 1993 reveals some substantial
variations within and across regions.

In contrast to surveillance data on AIDS, precise estimates of HIV infection rates in the total U.S.
population remain problematic. National estimates rely on mathematical models that back calculate HIV
incidence from AIDS surveillance data as well as a composite of HIV seroprevalence data from numerous
sources: states' reporting and screening of newborns, blood donors, armed forces recruits, Job Corps
participants, persons attending alternative testing sites and sexually transmitted disease clinics,
admissions to drug abuse treatment centers and prisons, and various other sentinel populations.3 Over
the years, the Public Health Service (PHS) has estimated that there are between 600,000 and 1.2 million
HIV-infected people in the United States and that approximately 40,000 new infections occur each year
among adults and adolescents (U.S. Public Health Service, 1986; Centers for Disease Control, 1987,
1990a; MacQuillan et al., 1993). A discussion of the large observed variations in PHS estimates over the
years is presented in Vermund (1991).

Mode of Acquisition of Infection

Important trends in the mode of acquisition of the HIV infection can be discerned. In this country and
throughout the world, the majority of HIV infections are sexually transmitted (Roper et al., 1993). In
most of the world, over 75 percent of HIV infections are due to heterosexual behavior, approximately 15
percent to homosexual behavior, and a relatively small proportion to injection drug use. However, in the
United States, men who have sex with men account for the largest number of reported AIDS cases (54
percent of all reported cases, that is, 193,652 cases as of December 31, 1993). Yet a review of the
percentage of annual AIDS cases (Figure 1.2), classified according to CDC's exposure categories, reveals
that the proportion of cases of men who have sex with men has decreased steadily over the years (from
74 percent in 1981 to 47 percent in 1993), while the proportion of cases of exposure from injection drug
use has steadily increased over the last 13 years (from 12 percent in 1981 to 28 percent in 1993).

In the United States, gay and bisexual men are still the largest risk group for HIV infection and disease.
Drug users constitute the next-largest risk group, although there is a large overlap between these
groups. Recent CDC estimates of HIV prevalence and incidence (Holmberg, 1993, 1994) indicate that the
HIV/AIDS epidemic in the United States is being driven by three subepidemics: (1) injection drug users
and their sexual partners and offspring (especially in the northeastern United States; Miami, Florida; and

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San Juan, Puerto Rico); (2) young and minority men who have sex with men; and (3) heterosexual
women who use crack. Of these three subepidemics, two are directly linked with drug use, which
underscores its catalytic role in the transmission of HIV infection.

Another noteworthy trend depicted in Figure 1.2 is the substantial increase in the proportion of new
AIDs cases attributed to heterosexual transmission (from 1 percent in 1984 to 9 percent in 1993). The
proportion of reported heterosexually acquired AIDS cases in women increased from 28 to 37 percent
between 1987 and 1991, compared with an increase of 1.1 to 2.7 percent among men during the same
years (Neal et al., 1993). Between 1991 and 1992, the annual reported AIDS cases among women
increased another 9.1 percent, compared with an observed increase of 2.5 percent among men during
the same period (U.S. Public Health Service, 1994). During the latest time period for which annual data
are available (1992 to 1993), the number of reported AIDS cases among women increased 167 percent
(from 6,295 in 1992 to 16,824 in 1993), compared with a 120 percent increase among men (from 40,496
in 1992 to 89,165 in 1993).4

Whereas heterosexual contact accounted for 4 percent of reported AIDS cases among men in 1993, the
figure was 37 percent among women. The majority of new AIDS cases among women occurred among
African Americans (54 percent). Figure 1.3 illustrates that this ethnic/racial disparity also was observed
in new pediatric cases (55 percent were African American). A closer examination of cases by exposure
category reveals that 71 percent of the newly reported cases among African American women were
related to injection drug use; 52 percent of African American women diagnosed with AIDS in 1993
injected drugs, and an additional 19 percent of those cases were attributed to ''sex with injecting drug
user" (i.e., heterosexual contact). That same year, for other racial/ethnic categories of women
diagnosed with AIDS linked with injection drug use, the corresponding proportions were 61 percent of
white women (44 percent injected drugs and 17 percent reported sexual contact with an injection drug
user) and 76 percent of Hispanic women (48 percent injected drugs and 28 percent reported sexual
contact with an injection drug user). Among both male and female injection drug users, this ethnic
disparity is greatest in the northeastern United States.

In sum, these epidemiologic data indicate that injection drug users are currently a major component of
the HIV epidemic in the United States and a key bridge to the heterosexual populations. They
underscore the critical importance of directing prevention efforts to injection drug users and their
sexual partners.

Hiv And Aids Among Injection Drug Users

Surveillance

Prevalence and incidence rates of HIV among injection drug users vary considerably by geographic
location, so the experiences of different communities also vary. In a 1988 review of 92 studies of
intravenous drug users in treatment, Hahn and colleagues (1989) reported HIV seroprevalence rates
that range from 0 to 65 percent. Marked geographic differences were noted: HIV rates were highest in
the Northeast (ranging from 10 to 65 percent), and lower in the West, the Midwest, and the South—5
percent or lower.

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More recent information concerning the prevalence of HIV infection among injection drug users has
been consistent with the findings reported by Hahn et al. (1989). In updates (Prevots et al., 1995) of
CDC's HIV seroprevalence surveys of injection drug users entering drug treatment centers (most sites
were methadone maintenance programs) from 1988 through 1993, seroprevalence rates of 27 percent
in the Northeast, 12 percent in the South, 7 percent in the Midwest, and 3 percent in the West were
reported for all years combined. Although seroprevalence rates were similar among women and men,
observed rates among women were consistently higher than among men in all geographic areas. The
South was the only region in which seroprevalence rates among women were found to be statistically
higher than among men (i.e., 18 percent and 10 percent, respectively). Moreover, in all regions,
seroprevalence rates among African Americans were higher than among whites; African Americans had
a two- to sixfold increased seroprevalence compared with whites (rates ranged from 8 percent among
African Americans compared with 3 percent among whites in the Midwest to 38 percent compared with
21 percent, respectively, in the Northeast). Hispanics in the Northeast were found to have prevalence
rates similar to those of African Americans in the same region, but they were found to have higher rates
than African Americans in the Midwest. These same surveillance data indicate that HIV seroprevalence
has stabilized in most U.S. metropolitan areas. Although a moderate decline in HIV seroprevalence
among the young (<30) white injection drug users was observed in high-seroprevalence areas (>10
percent), trends in annual seroprevalence were found to be stable among age and racial/ethnic
subgroups. Des Jarlais et al. (1994) have also reported such declines in a cross-sectional survey among
young injection drug users entering a detoxification unit in a high-seroprevalence area.

Similar patterns of seroprevalence by geographic areas have been reported by researchers at the
National Institute on Drug Abuse (Battjes et al., 1991) from data collected as part of a series on nonblind
point-prevalence surveys among injection drug users admitted to methadone treatment in seven areas
(New York City; Trenton and Asbury Park, New Jersey; Baltimore, Maryland; Chicago, Illinois; San
Antonio, Texas; and Los Angeles, California) over a 2-year period (from late 1987 through early 1989).
These researchers reported significant variations in seroprevalence across geographical locations. The
highest rates were observed in the Northeast: New York City and Asbury Park had rates ranging from
28.6 to 58.6 percent. Los Angeles (West) had low prevalence rates ranging from 0.9 to 3.4 percent over
the course of this 2-year study. With the exception of Chicago, the multiple data points across time
revealed stable seroprevalence rates within geographic location. In a more recent look (i.e., 1987
through 1991) at the seroprevalence rates in five of those original cities (i.e., New York City, Asbury Park,
Trenton, Baltimore, and Chicago), Battjes et al. (1994) reported similar seroprevalence rates by location.

This reported stabilization of seroprevalence rates within geographical areas is comparable to the
results of mathematical modeling studies that indicate that HIV incidence among injection drug users
has shown a slight to moderate decline since the mid-1980s (Brookmeyer, 1991). Moreover, Drucker
and Vermund (1989) have provided a mathematical model that allows the estimation of prevalence
rates for population subgroups and overcomes some of the limitations that are associated with large-
scale national cross-sectional surveys. National seroprevalence surveys are expensive, and they can
mask significant variations and changes in small local population subgroups. However, the Drucker and

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Vermund model allows the use of local serosurvey data among various injection drug user subgroups to
estimate seroprevalence among key population subgroups in a given geographic area.

Despite the wide variation by geographic location, evidence suggests that, even in areas in which
prevalence is low among injection drug users, the risk of HIV infection should not be viewed with
complacency. In Milan, Edinburgh, New York City, and Bangkok, once HIV became established in a
community of injection drug users (i.e., a prevalence of less than 10 percent), prevalence subsequently
rose dramatically within the next 2 to 4 years (Angarano et al., 1985; Robertson et al., 1986; Des Jarlais
and Friedman, 1988a; Des Jarlais et al., 1994; Kitayaporn et al., 1994). Although this pattern has not
been observed universally (some cities, such as Los Angeles, stabilize prevalence at lower levels), these
examples suggest the need for HIV prevention programs not only when prevalence is moderate or high,
but also when prevalence is low (especially when injection drug users frequently engage in high-risk
behaviors). It is interesting to note, in a study of four cities with sustained low seroprevalence of HIV in
injection drug users, all cities had extensive HIV prevention efforts (Des Jarlais, 1994).

Sexual Transmission Among Injection Drug Users

As mentioned above, gay and bisexual intravenous drug users are not rare, and bisexual intravenous
drug users may act as a conduit for transmission from both the homosexual and the intravenous drug
user communities to heterosexuals, particularly women. In a survey of intravenous drug users recruited
in San Francisco from street outreach and drug treatment programs (Lewis and Watters, 1991), 12
percent (49/396) of intravenous drug-using men were bisexual, based on reports of female partners
prior to entry into the study. However, fewer than half of these men identified themselves as being
bisexual, highlighting the difficulties that female partners have in assessing their male sexual partner's
risk history. This may be particularly important because, in at least one study (Mandell et al., 1994),
bisexual men (along with homosexual men) were more likely to report needle sharing than their
heterosexual counterparts. Bisexual men may also have been important by acting as a conduit for HIV
infection between homosexual men and the injection drug user community, at least in some areas. For
example, in Chicago (Lampinen, 1992), the first reported AIDS case from injection drug use occurred in a
bisexual man, and large numbers of cases involving users who were also gay and bisexual men
continued for several years.

As discussed above, sexual transmission from intravenous drug users to their sexual partners may pose a
greater risk for women than for men. The likelihood that an injection drug user has an injection drug-
using partner is generally quite high, particularly among women (Mandell et al., 1994; Ross et al., 1992;
Dwyer et al., 1994). As estimated, 75 to 90 percent of female injection drug users have a male injection
drug-using partner compared with 20 to 50 percent of male users who have female drug-using partners
(Cohen et al., 1989; Mondanaro, 1990; Donoghoe, 1992). In one survey in New York City (Fordyce et al.,
1991), 2 percent of all currently sexually active women in 1990 reported that they knew they had a
sexual partner who injected drugs. In another survey of risk factors for HIV infection among female
injection drug users in methadone treatment (Schoenbaum et al., 1989), the number of male sexual

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partners who used drugs was strongly associated with HIV infection and was the only risk factor
associated with acquisition of HIV for those women who had not used drugs since 1982.

Female sexual partners of male injection drug users may use sex as a way to obtain drugs (Donoghoe,
1992). They may also share needles with partners, thus exposing themselves to two sources of risk. Such
women may be at even greater risk for sexual transmission of HIV than female partners of male injection
drug users who do not themselves inject drugs—who may, in fact, be less likely to use condoms with
male injection drug-using partners than with their partners who do not inject (Klee et al., 1990; Cohen,
1991; Worth, 1989).

Trading sex for drugs or money increases infection rates between injection drug users and the
heterosexual community. Approximately 25 percent of female injection drug users engage in
prostitution (Cohen et al., 1989; Donoghoe, 1992; Saxon et al., 1991). According to one survey in
Baltimore (Astemborski et al., 1994), women who traded sex for drugs with more than 50 men over the
10 years prior to entry into the study were more likely to be infected with HIV than other female
injection drug users. This finding remained significant after controlling for a range of risk factors for HIV.

In addition, women who use crack (whether or not they use injection drugs) may also trade sex for drugs
and may also serve to bridge the gap between injection drug use and the heterosexual risk of HIV
transmission (Des Jarlais and Friedman, 1988b; Edlin et al., 1994). Through acquisition of large numbers
of partners, many of whom are also injection drug users, women who engage in this practice also
expose themselves to HIV. This problem may be confounded by the profound disinhibition associated
with cocaine use, resulting in little concern for safe sex or safe needle use (Donoghoe, 1992; Hartel et
al., 1992). This may be due in part to the direct effects of crack as a sexual stimulant (Grinspoon and
Bakalar, 1985; Weiss and Mirin, 1987). However, the relative magnitude of the pharmacologic causal
effect of crack (or cocaine) on increased sexual activity is still not well understood. Although there may
be increased sexual activity associated with early stages of use, as use of the drug increases, sexual
dysfunction follows. Even then, there may be heightened sexual activity—sex for crack exchanges—but
at this more advanced stage of drug abuse, the increase in sexual activity appears to be driven by the
compulsion to use the drug and tends to be devoid of pleasurable sensation. Hence, if infected by their
injection drug-using partners, these noninjection drug-using sexual partners also constitute a conduit
into the heterosexual community. Crack may also amplify the spread of HIV because of its strong
association with syphilis. Trading sex for crack has resulted in a large increase in syphilis (Centers for
Disease Control and Prevention, 1992; Greenberg et al., 1992), which may in turn facilitate HIV
transmission by increasing either infectiousness or susceptibility.

Some of the increased rates of transmission from injection drug users to their sexual partners,
compared with transmission rates from infected people from other risk groups to their sexual partners,
may also be attributed to high-risk sexual practices. In one survey of injection drug users who were not
in treatment but who were recruited and interviewed on the street in San Francisco (Lewis and Watters,
1991), 67 percent of the sample reported never using condoms, 15 percent had more than 10 partners,

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and approximately 35 percent engaged in prostitution or practiced anal sex (or both). In a similar
nationwide survey, 70 percent of injection drug users reported never using condoms, and more than 25
percent practiced anal sex (Centers for Disease Control and Prevention, 1990b). In a survey of injection
drug users in treatment taken in the Northeast, Texas, and California, only 14 percent reported using
condoms (Battjes and Pickens, 1988). In another similar study in New York City, only 5 percent reported
condom use at all (Primm et al., 1988); among those who did use condoms, fewer than half used them
for all sexual encounters. In the San Francisco survey described above (Lewis and Watters, 1991), more
than a third of both bisexual and heterosexual male injection drug users reported that they never used
condoms.

In a variety of studies that attempted risk reduction programs among injection drug users, success was
greater in influencing participants to change risky injection behavior than sexual behavior (Des Jarlais
and Friedman, 1988b). Again, for women this may be particularly difficult because the change to safe
sex practices requires the cooperation of the male partner, which may not always be a feasible
proposition (Worth, 1988). An additional concern related to power dynamics in sexual partnerships is
the disclosure of HIV status. In particular, women may fear disclosing their HIV infection to male
partners, thus increasing the likelihood of unsafe sexual practices (North and Rothenberg, 1993).

Part of the increase in transmission rates from injection drug users may be attributed to misclassification
of modes of transmission. What is called sexual transmission may actually be transmission associated
with injection drug use in the partner. Many noninjection drug-using partners of injection drug users
report past injection drug use and recent use of noninjection drugs such as cocaine or crack (Centers for
Disease Control and Prevention, 1991), and many of these partners also report having traded sex for
drugs or money. Furthermore, as mentioned above, because female injection drug users are more likely
to have a male injection drug-using partner, misclassification of female-to-male transmission is probably
more severe than that for male-to-female transmission. Of course, what is labeled as transmission
attributed to injection drug use may in fact be due to heterosexual contact; it is nearly impossible to
separate these effects. The confluence of high-risk sexual practices with injection drug-using behavior
may make it more difficult to intervene because of sources of uncertainty in the mechanisms of
transmission. Nevertheless, simply acknowledging high transmission rates in areas characterized by
injection drug use may be sufficient to justify proper allocation of health care resources and targeting of
prevention messages.

Finally, it is possible that increased rates of transmission may also result from the fact that injection drug
users may be more infectious than individuals from other risk groups or, conversely, their partners may
be more susceptible. In one heterosexual partner study (Padian et al., 1994), rates of male-to-female
transmission were higher from injection drug users to their partners compared with transmission from
men in other risk groups, after controlling for all known risk factors in a multivariate model. An
improved understanding of the postulated biological mechanisms for heterosexual transmission might
shed light on this issue.

b. Impact of politics and economics on HIV prevention, treatment and support for people

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living with HIV and AIDS: global players (e.g. UNAIDS, pharmaceutical companies), need
for political will and leadership, economic stability to fund prevention and treatment
programs

Historically, many of the improvements in public health have their roots in a synergistic combination of
political leadership and science. The potency of this synergy between politics and science is illustrated
by many of the public health advances made in the late 19th and 20th centuries. Improvements in
European children’s health, for example, occurred when politicians responded to calls from their
electorates to end child labor. Similarly, declines in tuberculosis started before treatment was even
available, because of social activism that resulted in improved living conditions. Incidences of tobacco-
related illnesses were finally reduced when doctors and the antismoking lobby prevailed upon
governments to boost taxes and institute smoking bans.

Progress in the response against AIDS is no exception. In fact, the response to AIDS is probably the most
striking contemporary example of how intertwined politics, policy, and public health are.

Why has the global response to AIDS been so highly politicized? One key reason is the prejudice and
discomfort around the ways HIV is transmitted. Another is that the epidemic is fueled by injustices. AIDS
both exposes and exacerbates multiple fault lines of social and economic inequality and injustice, which
in themselves are highly political. An expanding AIDS epidemic reveals a political system’s weak points,
whether at the national or the community level.

Politics has been the main driver of action as well as inaction and denial regarding AIDS. On the one
hand, positive political action at both the grassroots and governmental levels has greatly enhanced the
global response to AIDS. Political action on AIDS has also been an opportunity to correct underlying
injustices and mobilize positive political momentum around issues such as gay rights. On the other hand,
politics has been a negative force at times, blocking important policy developments and evidence-
informed action on AIDS, particularly access to anti-retroviral treatment in poor countries, prevention of
sexual transmission of HIV, and harm reduction in injection drug users. Inaction reflects a political
denial, an unwillingness to engage in sensitive issues, such as those inextricably linked to HIV
transmission. Inaction on AIDS may also result from competition from development issues such as
infrastructure enhancement and income-generation programs. Moreover, the fact that the symptoms of
AIDS do not immediately manifest themselves—either in individuals or in society—allowed the epidemic
to go unnoticed and unchecked at a point when decisive political action could have seriously reduced its
spread and impact.

AIDS has always been highly political, not least because of the nature of HIV transmission and the stigma
associated with sexual intercouse and injection drugs. Initial progress on HIV prevention in the 1980s in
Western countries was largely because of gay activism and community mobilization and, in some
countries, effective government action. In Africa, The AIDS Support Organization, started in Uganda in
1987, is a prime example of community-based action initiated to support those affected by AIDS before
treatment was available, whereas the Treatment Action Campaign, launched in South Africa just over 10

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years later, very effectively used community-driven political and legal action to ensure widespread
access to a scientifically sound response to AIDS in an environment of denial.

In the early years of the epidemic, AIDS was not a mainstream political issue outside of public health and
gay rights circles. This started to change when Jonathan Mann created the special program on AIDS at
the World Health Organization. First, Mann introduced a rights-based approach as the basis for a global
AIDS strategy, which is still a guiding principle of most AIDS programs today. He also worked hard to
engage ministers of health in each country and through the World Health Assembly and global and
regional conferences. His successor, Michael Merson, made the first attempts to widen the AIDS
response beyond the health sector, particularly in Africa, where the epidemic was increasingly affecting
all walks of society.

The quasi-simultaneous introduction of highly effective anti-retroviral therapy in the West and the
launch of the Joint United Nations Programme on HIV/ AIDS (UNAIDS) in 1996 created an entirely
different environment that was ultimately far more conducive to political action on AIDS. In 1997, the
World Bank Multi-Country AIDS Program for Africa started to catalyze new funding for AIDS.

In 2000, a United Nations (UN) Security Council debate—the first ever for a health issue—and a special
session in the UN General Assembly in 2001 both confirmed AIDS as a political issue requiring global
action and recognized that health clearly belonged on foreign policy as well as domestic agendas. UN
Secretary-General Kofi Annan’s call4 for a “war chest” of 7 to 10 billion dollars at a special Organization
of African Unity summit on AIDS in Abuja, Nigeria, gave political leaders a global financial target around
which to mobilize. The setting of financial targets, increased international political will, scientific
progress, the establishment of new institutions and political processes, and increases in official
development assistance all converged to significantly increase financial and political commitments to
AIDS.

The UN General Assembly Special Session on HIV/AIDS (UNGASS) culminated in the Declaration of
Commitment5 adopted in the General Assembly by all member states of the United Nations in 2001. It
was followed in 2002 by the creation of the Global Fund to fight AIDS, Tuberculosis and Malaria and in
2003 by the launch of the United States President’s Emergency Plan for AIDS Relief. As the Economist
wrote 5 years later, “It does not take an over-generous interpretation of history to allow that UNGASS
played a large part in bringing about the changes. . . . The rate at which money has been made available
for AIDS (from all sources, including afflicted countries as well as the taxpayers of the rich world)
underwent a step change in 2001.”

As a result of these and other initiatives, spending on AIDS in developing countries increased to around
$10 billion in 2007, up from $250 million at the creation of UNAIDS. We are starting to see results in the
number of lives saved, through a declining incidence of new HIV infections in a growing number of
countries in Africa, the Caribbean, and Asia and through access to antiretroviral therapy for more than 2
million people living with HIV in the developing world.

Nevertheless, AIDS, like so many other issues, is at risk of being neglected or mishandled because
governmental terms are often not long enough to see the implications of action or inaction or because

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those in power hesitate to lead on controversial issues. Fierce policy debates rage on the issues of sex
workers, homosexuals, and injection drug users, as well as around providing sexual education in schools
and the feasibility of basing HIV prevention policies on “moral grounds.”

Human rights have been a core component of AIDS strategies since the global AIDS program was
launched and have been the anchor of the political and policy-level work of UNAIDS. Political leadership
has been key in advancing agendas, whether by civil society groups (from AIDS activists to religious
organizations), or by government (more than 40 heads of state or their deputies now head national AIDS
bodies) or by those in public health7 who broke away from traditional medical models.

Some leaders, on the other hand, have denied the links between HIV and AIDS, turned a blind eye to the
impact of AIDS on society, and willfully blocked progress. But what is it that motivates some leaders to
take action more than others? Jacob Bor’s analysis of the determinants of AIDS leadership in 54
developing countries points to the fact that “political leaders do not operate in a vacuum”8 and that
freedom of the press and high levels of HIV prevalence were, in general, key determinants of decision
making.

Times change, and political will is one of the things most vulnerable to change in the AIDS response.
Resolutions such as the United Nations General Assembly Declaration of Commitment on HIV/AIDS were
made when the right elements came together. The document is still there and the pledges still stand,
but the political environment continues to evolve, and a constant process of revitalization and coalition
building will be required to build and sustain an exceptional response for many decades. If we had had
today’s level of political leadership and levels of funding for AIDS 10 years ago, we would not be where
we are now: striving to bring down infection levels of more than 4 million new infections a year and
8000 deaths daily. The challenge for us in 2007 is to continue to build and sustain that leadership and
funding over the next 10 to 25 years in the face of changing political priorities and demands.

As the years following the 1994 International Conference on Population and Development revealed, the
political environment in 1994 allowed for a new paradigm of reproductive health and rights. However,
although that paradigm has, to a large extent, been resilient, the realization of the program of action to
come out of that conference has been limited by the political realities in individual countries—a lesson
those working on AIDS would be well advised to heed.

Earmarking funds, for example, is a tactic that has been an opportunity for targeted funding for AIDS,
such as in the US Congress, but it risks making funds hostage to political agendas such as restrictions on
HIV prevention funding that call for one third of HIV prevention resources to be allocated to abstinence-
only prevention education.

Action on AIDS has been truly transformational for public health. AIDS has also introduced a new
paradigm for the involvement of affected individuals and communities and changed the dynamics
between caregivers, the pharmaceutical industry, public health establishment and international
organizations, and affected communities. Arguably the most extreme public health issue of our time,
AIDS has underscored the imperatives to think and act beyond the confines of the classic public health
arena, adopt comprehensive approaches, and engage leadership at all levels.

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Building on the early history of political action around other health issues, the experience of the AIDS
response, both the good political action as well as the challenges of bad politics and denial, has
important lessons for the public health community. Early engagement of political leadership at all levels
is, without doubt, essential to effectively address significant public health issues. Alone, it cannot ensure
an effective response, but in combination with community mobilization, a public health apparatus,
continuing economic development, and innovations in science, it can help bring about advances in even
the most challenging health issues.

c. Social and cultural factors: social attitudes to people living with HIV and AIDS and to
those at high risk such as sex workers and injecting drug users; cultural attitudes and
practices, for example, towards women (multiple factors including low status, early
and/or forced sex increase risk of HIV infection for women)

Understanding HIV Risk Behavior from a Sociocultural Perspective

Although the incidence rate for HIV infection varies by population and geography, global estimates have
shown a modest decline over the past several years . Accordingly, this past July, the XIX International
AIDS Conference that took place in Washington DC adopted the slogan “Turning the Tide Together”,
signifying that a concerted effort has begun to end the epidemic. Nonetheless, it is important to
highlight that within certain communities, these rates have actually increased.

Recently social and cultural aspects such as ethnicity, poverty, gender relations, and geographic region
have also been identified as risk factors and have fueled the epidemic among vulnerable populations
around the globe. The 2011 UNAIDS report on the last 30 years of the epidemic warns about today’s
complex and varied picture at the regional level, with HIV incidence steadily increasing in the Middle
East and North Africa and a reversal of the decline in new infections since 2005 for Eastern Europe and
Central Asia. The report also highlights that for every three people who start treatment, another five are
infected in parts of East and Southern Africa. This information corroborates the considerable variation in
HIV prevalence and epidemiological patterns within countries, and show the existence of “epidemic
hotspots”.

Hotspots exist among men who have sex with men (MSM), ethnic minorities, young women, injection
drug users (IDUs) and population groups historically subject to significant inequality. Within a high-
income country, the Southern United States has become another example of an epidemic hotspot. Over
the course of the HIV epidemic in the U.S., the rate of new infections declined in the early 1990s
primarily amongst white MSM but began to rise amongst minority populations for both MSM and
heterosexual men and women in urban areas and in the rural south. During this time, poverty, lack of
education, injection drug use (IDU) and commercial sex were identified as risk behaviors linked with
horizontal HIV transmission . Among low to middle-income countries, South Africa is a well-known

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example of hyperendemic HIV rates. In these contexts, using a sociocultural1 perspective is key to
understanding and addressing epidemic hotspots around the world and any associated HIV risk
behavior.

Understanding the Individual: The Risk Behavior Paradigm

According to a classical model of human behavior and HIV risk, individuals are subjected to specific life
experiences and, depending upon their underlying personality, can make choices that may put them at
risk for HIV acquisition. Further modifying factors include the concomitant presence of substance abuse,
depression and other mental health disorders. Often the choices made can result in additional harmful
life experiences leading to new risky behaviors . With time, these patterned responses can increase the
likelihood that an individual will establish maladaptive behaviors and addictions; eventually the social
life of the individual can destabilize and fracture.

Inclusive Model of Human Behavior. Environment refers to childhood and early adolescent influences on
personality development which include the family, education, community, and socioeconomic
conditions.

A critical component of this paradigm is the personality. Although debate has surrounded exactly which
factors influence personality development, it is generally accepted that both the environment and
genetics play a role in this process. Environmental factors especially during childhood and early
adolescence that appear to be the most critical include home/family influences, education,
socioeconomic status, and the surrounding community. After adolescence, an individual’s personality is
relatively fixed. Two individuals can respond quite differently to the same intense life experience based
upon their personality. An extroverted, risk-taking perspective might satisfy immediate needs (present-
biased preference) despite future adverse consequences, whereas an introverted, risk-averse
perspective might delay immediate gratification in favor of future benefits. The concept of human
agency adds to the complexity of this model by underscoring the capacity an individual has to challenge
and change adverse circumstances and her/his own personality, thus making unexpected choices in
terms of risk behavior.

Sociocultural Influences on Behavior

“AIDS is also a disease lodged in behavioural patterns and value systems that become adapted to the
presence of the disease. The people performing these shifts of conduct are not as helpless and passive
as our reductionism would have us believe”. The fact that humans are both individual and cultural
beings introduces great complexity and variability to understanding risk behaviors. Thus, the
sociocultural context can impact an individual’s behavior at several access points along the causal
pathway previously described. Most directly, the sociocultural milieu provides various scenarios and
opportunities that can either trigger maladaptive behavior or can create stressful situations that
increase the likelihood risky behavior is undertaken. Furthermore, disruption of the cultural context or
cultural identity can compromise favorable decision-making. Additionally, as stated above, human
agency can also change individual circumstances and even social structures when agency is enacted by
several individuals.

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Directly connecting with human agency, the concept of social capital has shown how positive
community influences grounded in shared cultural identity can empower individuals to change behavior
(by resisting harmful choices) and overcome structural violence. An excellent example of the interaction
of social capital and human agency in the context of the HIV epidemic is the behavioral change that
happened during the 1980s in the tightly knit, US and European middle-class MSM communities with
very intensive support networks and intensive inputs that resulted in effective community-based
prevention strategies.

The clear influence of society and culture in an individual’s health risk behaviors makes a strong case for
improving the traditionally weak (and often absent) relationship between biomedical and sociocultural
paradigms. Effective action to radically change the direction of the HIV epidemic among populations
with an increasing incidence rate has been hindered by an incomplete understanding of the cultural,
social and political contexts within which it exists and how these connect with the biomedical and
psychological realms.

In the case of South Africa and the province of KwaZulu-Natal (KZN), where the HIV prevalence is
currently estimated around 40%, the majority of HIV infections are among black South Africans (mostly
of Zulu ethnicity) and the likelihood of transmission is overwhelming for sexually active individuals, both
the sociocultural and biomedical understandings of the epidemic are key to successfully curbing the
epidemic.

Referring to the HIV epidemic in South Africa, Marais emphasizes: “Contextualising the disease and
linking it to socio-economic and socio-cultural dynamics like poverty, migrant labour, income
inequalities, financial insecurity, and gender relations are crucial platforms of understanding from which
an effective response can be mounted” . Although numerous, high-quality research studies on the South
African HIV epidemic have been generated from the social sciences since the 1990s, the tension and
insufficient collaboration between these and the biomedical sciences has yet to be overcome.

In discussing the dialectics of the HIV epidemic in Central and East Africa, Friedman and Rossi highlight
that as a consequence of colonialism and capitalist processes “…prostitution and unsafe medical
injection [syringes shared for medical purposes] became widespread; patterns of concurrent sexual
relationships developed or were maintained out of the interaction between economic needs, a mixture
of traditional cultural patterns, and their interplay in gender-related and other politics”. Understanding
the effect of recent South African history in the present day is crucial for contextualizing the HIV
epidemic. Differing colonial rules (Dutch and English) and the apartheid regime led to lasting and
deepening poverty, inequality and underfunded medical systems among other crucial factors associated
with the epidemic. Abuses experienced by the non-white population during the apartheid regime
resulted in ethnic discrimination, disrupted communities, customs and settlement patterns, and
entrenched poverty. Black, Indian and Coloured communities were separated (between and within) and
isolated from each other and white populations; in this process of relocation individuals and whole
communities lost their land, other property, and familial and social groups. A large number of men were
separated from their families and sent to work far away in fields and mines, thus breaking the family
structure.

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In looking at the contemporary context, numerous studies have explored why this particular region of
the world has such a large proportion of individuals living with HIV. Political factors such as HIV
denialism (1990s, early 2000s) certainly played a role in the delayed national response to the epidemic
yet there are many other factors that have also been instrumental in the spread of HIV in this region.
Extensive research has examined the influence of individual movement due to migratory labor, the
commercial sex trade along major highway trucking routes, gender violence/inequality, and the
prevalence of multiple concurrent partnerships. Using Friedman and Rossi’s analytical concepts, the
interaction of economic needs coming from high unemployment and underemployment with cultural
patterns (new and old) and their interplay with new social, political, institutional and economic
structures have resulted in risky behavioral patterns favoring the growth of the HIV epidemic in KZN and
South Africa.

Significant stigma has become a barrier for individuals to disclose their status to their partners or seek
care and treatment when treatment for HIV has been shown to be very effective in preventing the
spread of infection . Additionally, among many populations, the individual desire and family/community
pressure to produce offspring can result in a lowered incentive for condom use. These factors are also
clearly associated with depression which has been shown to increase an individual’s tendency for risky
behavior . We posit that the intersection of Western and Traditional African cultures resulted in a
transformed Zulu identity that has been fractured and challenged by structural violence, situating Zulus
in an extremely vulnerable position.

Conclusion

The spread of HIV can be reduced by the application of antiretrovirals universally for those individuals
living with HIV and by the use of pre-exposure prophylaxis, condoms and circumcision for those
individuals at risk for infection; however, reducing behaviors associated with transmission of HIV will
remain a critical component for any prevention strategy in order to “turn the tide”. Unfortunately, many
of the root causes of HIV transmission are quite complex and systemic in certain regions and require
major structural improvements to affect change. These causes include poverty, discrimination, stigma,
inadequate education, gender inequality and challenges to cultural identity all of which need further
understanding and an effective and creative approach to reduce their impact.

d. Requirements for successful programs to prevent HIV and support individuals living
with HIV and AIDS:

 stable, committed political leadership,

 involvement of ‘opinion leaders’ (such as church),
 promotion of condom use,
 ‘harm reduction’ such as needle exchanges,
 availability of preventative and antiviral medication

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e. HIV and AIDS in Africa: challenges for Africa and the global community and success
stories.

HIV AND AIDS IN MALAWI

HIV and AIDS statistics for Malawi 2019

KEY POINTS

Malawi has one of the highest HIV prevalences in the world despite the impressive progress the country
has made in controlling its HIV epidemic in recent years.

Young people are particularly at risk, due to early sexual activity and marriage, with 50% of new HIV
infections affecting those aged 15 to 17 in Malawi.

Stigma remains a key barrier to progress, particularly among men who have sex with men and sex
workers.

Malawi is on track to achieve the UNAIDS 90-90-90 targets by 2020, which include 90% of people with
HIV knowing their status, 90% of these accessing ARVS and 90% of those on treatment being virally
suppressed.

Malawi’s HIV prevalence is one of the highest in the world, with 9.2% of the adult population (aged 15-
49) living with HIV.1 An estimated one million Malawians were living with HIV in 2018 and 13,000
Malawians died from AIDS-related illnesses in the same year.2 The Malawian HIV epidemic plays a
critical role in the country’s low life expectancy of just 57 years for men and 60 for women.

Over the last decade, impressive efforts to reduce the HIV epidemic have been made at both national
and local levels. In 2018, 90% of people living with HIV in Malawi were aware of their status, of which
87% were on treatment, of which 89% were virally suppressed. This equates to 78% of all people living
with HIV in Malawi on treatment and 69% of all people living with HIV being virally suppressed.4

New infections have dramatically declined from 55,000 new infections in 2010, to 38,000 in 2018.5
Malawi has also witnessed a reduction in HIV infections among children. There were 3,500 new
paediatric infections in 2018, compared with 15,000 in 2010.6

Malawi’s HIV epidemic is generalised, which means it affects the general population as well as certain
high-risk groups. Unprotected heterosexual sex between married or co-habiting partners accounts for
67% of all new HIV infections, while unprotected casual heterosexual sex accounts for 12%.7 Beyond

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this, several populations groups such as adolescent girls and young women, sex workers and men who
have sex with men are particularly vulnerable to HIV.

The Malawian HIV epidemic varies greatly across the country. HIV prevalence and density is high in the
urban districts of Lilongwe, Blantyre and Zomba and in the southern region of the country.

Groups most affected by HIV in Malawi

Women

HIV disproportionately affects women in Malawi. A national assessment of the impact of HIV on the
population, carried out by the Malawian Ministry of Health in 2015-2016, found HIV prevalence among
adult women (aged 15-64) to be 12.8%, compared with 8.2% among adult men.9 This disparity is
especially prominent among 25- to 29-year-olds, as HIV prevalence is three times higher among women
than men in this age group (14.1% vs 4.8%).

HIV disproportionately affects women in Malawi. This disparity is especially prominent among 25 to 29-
year-olds, as prevalence is three times higher among women (14.1% vs 4.8%).

Sexual violence is also an issue with 22% of women and 15% of men experiencing sexual violence before
the age of 18. Most of the perpetrators of sexual violence against women are spouses, boyfriends or
romantic partners (sexual violence is also known as ‘intimate partner violence’).

Young people

Roughly a third of all new HIV infections (12,500 out of 36,000) in Malawi in 2016 occurred among
young people (aged 15-24) Of these, 70% were among young women.

In total, 4.5% of young women are living with HIV, compared to 2.2% of men of the same age.13 Of
those young people living with HIV, less than half are aware of their status.

Early sexual activity is high in Malawi with around 15% of young women and 18% of young men (aged
15-24) reporting having sex before the age of 15.Furthermore, girls aged 15-19 are 10 times more likely
to be married than their male counterparts, with 45.9% of women having their first marriage before
they turn 18, nearly one in two. To attempt to deal with this issue, in 2017 Malawi increased the
minimum age of marriage from 15 to 18, criminalising child marriage.

progress towards the 90-90-90 targets in Malawi

With young people engaging in sex at an early age, addressing the sexual and reproductive health needs
of this population is critical. Indeed, knowledge of HIV prevention among young people is improving,
with 78% of young women and 82% of young men demonstrating sufficient knowledge of HIV
prevention in 2016.18 For both genders, comprehensive knowledge about HIV generally increases with

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age, educational attainment, and wealth. Urban young people are more likely than rural young people
to have knowledge of HIV prevention.

Despite increasing knowledge about HIV, condom use remains low among sexually active 15-to-19-year-
olds, with only 25% of married females and 30% of sexually active unmarried females from this age
group using any form of modern contraception. Young people often face obstacles to accessing
contraceptives and health services, which increases their risk of acquiring HIV and other sexually
transmitted diseases.

Sex workers

Sex work is criminalised in Malawi, limiting the amount of available data on this key population, as well
as the support and services sex workers are able to access.

The evidence that is available suggests a major decrease in HIV prevalence among female sex workers,
from 77% in 2006 to 24.9% in 2016, although it remains unacceptably high.

There is also evidence of growing positive trends in the adoption of safer behaviours by female sex
workers that may help to further reduce HIV transmission in the coming years. For example, the
proportion of female sex workers reporting using a condom with their most recent client was high at
85%.

Sex workers in Malawi face high levels of discrimination and stigma when seeking HIV services, further
increasing their vulnerability to HIV, especially from police when seeking victim support services.

Men who have sex with men (MSM)

Men who have sex with men (sometimes referred to as MSM) have been identified as a key affected
population within the Malawian HIV epidemic.

Nearly one in five men who have sex with men are living with HIV. At 17.3%, prevalence remains two
times higher than the rest of the adult male population.

Although prevalence tends to be higher in older men, data from 2017 suggests 11.8% of 18-19-year-old
men who have sex with men are already living with HIV. This highlights the importance of targeting
young people for HIV prevention and testing services, regardless of their gender or sexual orientation.

Worryingly, 80% of men who have sex with men questioned in a 2014 study incorrectly reported that
anal sex carries a lower risk of HIV transmission than vaginal sex and only 23% reported receiving
targeted HIV prevention information. Also of concern is the fact that, in seven of the 28 districts
surveyed, 30% to 45% of men who have sex with men did not know their HIV status. High-risk
behaviours were common, including multiple sexual partners, inconsistent condom use and exchanging
sex for money.

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Homosexuality is illegal in Malawi, punishable by up to 14 years in prison, although prosecutions were
suspended in 2012 Nevertheless, men who have sex with men still face varying levels of punishment -
for example a police officer may still prosecute someone involved in same sex acts under the provision
that they are ‘breaching the peace’.

Furthermore, many men who have sex with men face increased levels of stigma and violence in Malawi.
A 2016 survey of around 200 men who have sex with men found that 39% had experienced a human
rights abuse in some form, including 12% who had been raped.

All of these factors create a hostile environment that increases men who have sex with men’s
vulnerability to HIV while lessening their ability to access HIV prevention and treatment services.

Children and orphans

An estimated 110,000 children (aged 0-14) were living with HIV in 2015 of whom 49% (53,400) were
receiving antiretroviral treatment.

Children and vulnerable children are identified as a key target group by Malawi’s 2015-2020 HIV
strategy.Indeed, the country has shown immense progress in reducing child HIV infection rates. In 2013,
the country had achieved a 67% reduction in children acquiring HIV, the largest country decline across
sub-Saharan Africa.

There is estimated to be 670,000 orphans in Malawi as a result of AIDS. Supporting the needs of
orphans and other children made vulnerable by AIDS is identified as a main element of the national
Malawian HIV response. Factors such as poverty are preventing the roll-out of adequate support and
services for these children.

HIV testing and counselling (HTC) in Malawi

HIV testing and Counselling (HTC) services have increased over the last few years in Malawi, surpassing
national targets.

HTC services are provided in two ways: through client-initiated HTC (also known as ‘voluntary
counselling and testing’), and provider-initiated HTC. Provider-initiated testing, which is when a
healthworker offers an HIV test to a patient, occurs in a wide variety of settings including healthcare
facilities; mobile testing units; people’s homes and at national health events.

Within the first three months of 2017, 982 560 people were tested for HIV, suggesting that testing
services have significantly expanded in recent years. In comparison, 1.8 million people accessed HTC
services in total during 2014.

In 2014, the majority (66%) of people being tested were women. Young men (aged 15-19) in particular
are less likely to know their HIV status compared with young women (51% vs 31%).

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Although HIV self-testing kits are not widely available, UNITAID’s 4-year Self-Testing Africa (STAR)
project is trialling self-testing in the country. Initial results from 2016 suggest that, when HIV self-testing
is provided as part of a community-based approach, it can increase uptake of testing services,
particularly among men and adolescents, and connect people to HIV treatment, particularly among
individuals who are at high risk of HIV infection. For example, 26% of those using the self-testing kits in
2016 were first-time testers, 26% were aged 16–24, and 49% were men (aged 16-65). Overall, testing
coverage among men in areas where STAR operated increased by 24%.

HIV prevention programmes in Malawi

There were 36,000 new HIV infections in Malawi in 2016.

Malawi’s National HIV and AIDS Strategic Plan 2015-2020 has various prevention policies and strategies
for reducing new HIV infections. Some of these strategies are outlined below.

Condom availability and use

The provision of free condoms has been a major element of Malawi’s National HIV Prevention Strategy.

In 2013-2014, more than 40.4 million condoms were distributed. However, only 24.1 million of these
were free of charge. The remaining 16.3 million condoms were for sale (sometimes referred to as
‘socially marketed’). Despite the total number of condoms distributed being double the amount
distributed the year before, this figure was 40% short of Malawi’s yearly target. However, the yearly
target for commercial condoms was surpassed by 64%.

In 2016, despite a challenging environment, about 53,000 condoms and 47,000 lubricant tubes were
distributed to people within the lesbian, gay, bisexual, transgender and intersex (LGBTI) community.

Malawian men demonstrate one of the highest rates of condom use at last high-risk sex (with a non-
marital, non-cohabiting partner) in Eastern and Southern Africa, at 76% (in 2015). However, condom use
among Malawian women engaging in high-risk sex is significantly lower at 50%.

HIV education and approach to sex education

Raising awareness about how to prevent HIV is a key part of Malawi’s prevention strategy. This is
covered in life skills education (LSE) for young people who are both in-school and out-of school. LSE
subjects include the promotion of mutual faithfulness and the use of male and female condoms.

Before 2010, LSE for young people in school was irregular. By 2014, the most recent data available, all
students in primary and secondary schools were exposed to LSE. However, only 53,600 of a target of
150,000 young people out-of school had received LSE.

In 2016, a major push on prevention efforts targeted at adolescents and young adults was carried out.
For example, Adolescents and Youth reached as many as 200,000 adolescents with HIV, sexual and
reproductive health information and treatment services.

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Radio shows are also used to raise awareness of HIV prevention in Malawi. In 2014, just over 220 hours
of radio time was used to air programmes, slots and jingles on HIV and AIDS. This missed the 2014 target
of 300 hours and is a reduction on preceding years.

Prevention of mother-to-child transmission (PMTCT)

Malawi has demonstrated an unprecedented commitment to preventing transmission from mothers

living with HIV to their infants in recent years. Major achievements include the expansion of sites
providing prevention of mother-to-child transmission (PMTCT) services. In July 2011 Malawi became the
first country to implement the Option B+ approach, which means that all pregnant women living with
HIV are offered antiretroviral treatment for life – irrespective of CD4 count.

The impact of this has been huge. Between 2011 and 2016, the proportion of women with HIV who
were diagnosed went from 49% to 84%,51. Between 2011 and 2015, the proportion of pregnant women
with HIV who were virally suppressed jumped from 2% to 48%.52 In 2014, of the more than 520,700
women receiving HIV test results, 7.7% were living with HIV.

PMTCT sites have increased across Malawi since the implementation of the Option B+ approach, with
638 PMTCT sites available as of September 2014, although this is still short of the target of 700.

Around 73% of women offered treatment as part of Option B+ were receiving treatment after 12
months and around 71% after 24 months. This treatment gap is mostly due to the fact that up to 15% of
pregnant women who are diagnosed with HIV do not then go on to start treatment. This could be due to
poor counselling of newly-diagnosed HIV-positive pregnant women in healthcare facilities, poor male
involvement in PMTCT issues and a lack of disclosure to spouses and family.

Clara’s successful story

Clara was 25 when she noticed she had the same symptoms as her parents. But despite knowing she
was living with HIV, guidelines at the time only allowed access to antiretroviral treatment if her CD4
count had fallen below 200 (guidelines now recommend people start treatment as soon as they are
diagnosed). She had to travel 400km just to get a CD4 count test, which confirmed she had advanced
stage HIV infection and a CD4 count of only 32.

Today, with the right treatment, her viral load has been rendered undetectable and her oldest daughter,
who also lives with HIV, is in good health. Her youngest daughter was born HIV-negative, as a result of
improved access to PMTCT services. Clara now co-ordinates national activities for women living with
HIV, offers advice, encourages testing and works to combat stigma and discrimination.

The 2015 Malawi Progress Report identifies early infant diagnosis as a priority for the national HIV and
AIDS response. In 2016, around 31% of infants were diagnosed within the first two months of
birth.However, this is a decline from 2014 levels when 37% received early infant diagnosis. Addressing
the delay between birth and diagnosis is crucial for reducing infant mortality as a result of HIV infection.

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Voluntary medical male circumcision (VMMC)

Another effective prevention strategy that has been scaled-up across Malawi is voluntary medical male
circumcision (VMMC), which is now a key national prevention strategy.

The availability of VMMC has increased since 2012, with 129,975 circumcisions performed in 2016
although this is far below the country’s stated target of 250,000.58

Overall, the proportion of circumcised men in Malawi has increased marginally, from 21.5% in 2010 to
27.8% in 2016.59

A number of barriers limit the uptake of VMMC. Misconceptions about the efficacy and unintended
consequences of this intervention are high. Malawi’s National AIDS Commission (NAC) reports how
some men perceive VMMC as a guaranteed protection against HIV, which may promote high-risk sexual
behaviour, while others have expressed concerns about its adverse effects on sexual pleasure and
performance. Infections and gangrene have also been reported in some districts following VMMC, which
are likely to have negatively affected demand.

Pre-exposure prophylaxis (PrEP)

Pre-exposure prophylaxis (PrEP) is not available in Malawi, though a feasibility study was planned to
start in late 2017 by the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT)
Network. The study is looking at adherence among HIV-uninfected pregnant adolescents and young
women (aged 16-24) and is expected to complete in 2019/2020.

Antiretroviral treatment (ART) availability in Malawi

Malawi has a ‘test and treat’ strategy, which calls for all people living with HIV to begin antiretroviral
treatment (ART) as soon as possible, irrespective of their CD4 count.

Malawi’s ART rollout has significantly expanded, with 68% of adults living with HIV receiving ART in
2016, an increase of 18% from 2013.

In 2016, of the 900,000 adults (aged 15-64) living with HIV, 70% were aware of their status. Of these,
89% were on ART and 89% were virally suppressed.63 Viral suppression is when levels of HIV are so low
in the body that a person is likely to be in good health and unable to transmit HIV to others.

In 2016, the percentage of men living with HIV who were on ART and virally suppressed was found to be
significantly lower than that of women (58.6% vs 72.9%). This is a direct result of the majority of
Malawian men living with HIV being unaware of their HIV status.

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Just under half of all children (aged 0-14) living with HIV are on ART. To increase the number of children
on ART, Malawi began piloting easier-to-take ARV formulations (known as ritonavir-boosted lopinavir –
or LPV/r – pellets) for infants and young children in 2016.

As a result of expanded access to treatment, AIDS-related deaths decreased by almost two thirds
between 2004 and 2016 with more Malawians living healthy lives on ART than ever before. However, as
far fewer men living with HIV are on ART than women, they are 1.3 times more likely to die from AIDS-
related illnesses. In 2016, 11,200 men died of AIDS-related illnesses compared with 8,800 women. This is
despite prevalence being significantly higher among women than men.

A further important element of any treatment programme is ensuring effective follow-up. Yet recent
studies have found ART follow-up procedures in Malawi to be inconsistent, with many patients missing
treatment sessions.

This is reflected by the fact that adherence levels in Malawi are lower than the rate of 85%
recommended by the World Health Organization (WHO).In 2014, 78% of people living with HIV who had
begun ART were still on it after 12 months. At 24 and 60 months, the proportion of people living with
HIV who remained in care was 73% and 59%, respectively.

Adherence levels are lower among adolescents than adults. Recent research found that 45% of
adolescents living with HIV reported missing ART in the past month. The most commonly reported
reason was forgetting (more than 90%), travel from home (14%) and busy doing other things (11%).
Alcohol use, violence in the home and low treatment self- efficacy were all associated with worse
adherence.

Data on HIV drug resistance (HIVDR) in Malawi is very limited, but globally prevalence of HIV drug
resistance is now estimated to be 9%. In 2016, the WHO estimated that pre-treatment resistance to
NNRTIs (a type of antiretroviral treatment drug) had reached 11% in Southern Africa. Weak health
systems, limited viral load monitoring, and low levels of adherence are key issues for Malawi in
addressing drug resistance.

HIV and tuberculosis (TB) in Malawi

HIV remains the most important risk factor for developing active TB in Malawi: 52% of people with TB
are also living with HIV.73 In addition, TB is the leading cause of death among people living with HIV and
AIDS, accounting for around 40% of AIDS-related deaths in Malawi each year.74

In 2015, around 95% of registered TB patients know their HIV status and 92% of those were on ART
during their TB treatment period.

Despite high levels of TB/HIV co-infection, until the mid 2010s TB and HIV were traditionally treated
under separate programmes. However, Malawi’s National TB Control Program (NTP) and the Malawian
Ministry of Health are increasingly working together to integrate TB and HIV services.

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Barriers to the HIV response in Malawi

Cultural barriers

Malawi’s National HIV and AIDS Strategic Plan 2015-2020 recognises that certain cultural norms are a
barrier to HIV prevention. Socio-cultural factors such as initiation ceremonies and rituals have been
found to lead to unprotected sex, increasing young people’s vulnerability to HIV, especially among girls.

Multiple and concurrent sexual partners, which can increase the transmission of HIV, is a feature of
Malawian culture. The 2015-2016 health survey found that 13% of men had two or more partners
during the 12 months prior to the survey, compared to 1% of women.78 For married men, this figure
increases to 16%.

A 2013 study based on in-depth interviews with around 70 women found marriages in Malawi to be
characterised by such stark gender inequalities that marriage itself is a risk factor for HIV infection in
women. Respondents generally reported they had remained faithful while their husbands had girlfriends
or had taken an additional wife within a polygamous marriage, which is legal in Malawi.

Legal barriers

Malawi has no legal restrictions that discriminate against people living with HIV entering and residing in
the country. In December 2017, the long-deliberated HIV Bill, which had the potential to be a major legal
barrier to an effective HIV response in the country, was rejected by parliament. The bill included
provisions to make HIV testing and treatment mandatory for certain populations and sought to
criminalise HIV exposure and transmission.

However, punitive laws are hindering an effective response for key affected populations, particularly sex
workers and men who have sex with men.

Stigma and violence experienced by key populations, linked closely to their criminal status under
Malawian law, often prevents these groups from accessing HIV testing, prevention and treatment
services. For example, in a 2016 survey of Malawian men who have sex with men, 17.5% reported being
afraid to seek healthcare of any kind.

Data issues

While Malawi’s current national HIV reporting system is robust, there is limited age-and sex-
disaggregated data available. This impedes the country’s response as it means there is a lack of
information about which population groups are being reached with services effectively and which
populations are currently under-served. This is a significant issue, particularly given the need for HIV

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programmes that are targeted at young people. Use of electronic medical records system (EMRS) can
facilitate reporting on age and gender, but currently EMRS is only available in a limited number of sites.

Structural and resource barriers

Gains made in addressing the HIV epidemic in Malawi are threatened by key weaknesses in the
country’s overall health system. Malawi has one of the most severe health workforce crises in Africa,
with the lowest physician-to-population ratio at 2:100,000 and second lowest nurse to population ratio
at 28:100,000.

Of the 719 functioning health facilities across the country, 81% are in rural areas. These are unevenly
distributed, forcing many people to walk more than 10km to access services. In addition, 40% of public
health facilities have no regular electricity supply, only half have running water, and two thirds do not
have toilet facilities.

Another key issue is a lack of adequate infrastructure to meet the needs of HIV testing services as well
other HIV treatment services. In 2016, 11% of facilities reported a stock-out of HIV testing kits.
Laboratory systems are also weak and cannot efficiently support viral load testing.

Funding for HIV in Malawi

In 2016, Malawi received 74% of funding for its HIV response from the Global Fund to Fight AIDS,
Tuberculosis and Malaria and the Presidents Emergency Plan For AIDS Relief (PEPFAR) and a further 12%
from other donors, with the remaining 14% coming from domestic funding.85 Significant progress has
been made on the proportion of domestic funds being made available for the HIV response, however, as
this stood at only 1.7% in 2010-2011.

The majority of funding (47%) is spent on treatment and care, leaving gaps in financial support for non-
biomedical interventions. Only 5% of 2014 expenditure went on PMTCT and 23% went on prevention.87
Additionally, funding gaps are present that limit opportunities to effectively provide HIV services and
fully implement the National HIV and AIDS Strategic Plan.

Issues of corruption within the government have severely affected overseas development aid provision.
Sometimes, funds are not available or inconsistently disbursed, impeding the roll-out of HIV prevention
programmes and the provision of treatment.

The future of HIV in Malawi

Malawi has made impressive progress in responding to its HIV epidemic, particularly PMTCT which has
dramatically reduced infections in new-born babies.

In its 2015-2020 HIV strategy, NAC states that Malawi will aim to meet the UNAIDS 90-90-90 treatment
targets. However, a number of gaps in the country’s response may lessen its ability to reach these goals.
In particular, reaching the first target on testing, especially among men and young people, represents

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the country’s greatest challenge. In addition, more effective behaviour change programmes for young
people are needed to increase condom use.

Malawi also faces challenges with regard to ensuring adequate funding for both its HIV response and its
healthcare system in general, a challenge shared by many countries across sub-Saharan Africa. A severe
shortage of healthworkers, poorly-equipped healthcare facilities and laboratories unable to carry out
viral load testing continue to restrict progress.

Greater effort is also required to support sex workers, LGBTI people and men who have sex with men via
comprehensive prevention programmes and campaigns that challenge stigma and discrimination. Unless
these groups’ needs are properly addressed, significant gaps in Malawi’s HIV response will remain.

HIV disproportionately affects women in Malawi. This disparity is especially prominent among 25 to 29-
year-olds, as prevalence is three times higher among women (14.1% vs 4.8%).

Sexual violence is also an issue with 22% of women and 15% of men experiencing sexual violence before
the age of 18. Most of the perpetrators of sexual violence against women are spouses, boyfriends or
romantic partners (sexual violence is also known as ‘intimate partner violence’).

Learning Outcome 4: Explain the spread and effects of TB and its impact on individuals
with
HIV/AIDS

a. Introduction to TB: epidemiology of TB, causative bacterium and how it spreads, latent
and active TB

Tuberculosis

Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria.
Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections do
not have symptoms, in which case it is known as latent tuberculosis. About 10% of latent infections
progress to active disease which, if left untreated, kills about half of those affected. The classic
symptoms of active TB are a chronic cough with blood-containing mucus, fever, night sweats, and
weight loss. It was historically called "consumption" due to the weight loss. Infection of other organs can
cause a wide range of symptoms.

Tuberculosis is spread through the air when people who have active TB in their lungs cough, spit, speak,
or sneeze. People with latent TB do not spread the disease. Active infection occurs more often in people
with HIV/AIDS and in those who smoke. Diagnosis of active TB is based on chest X-rays, as well as
microscopic examination and culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin
test (TST) or blood tests.

Prevention of TB involves screening those at high risk, early detection and treatment of cases, and
vaccination with the bacillus Calmette-Guérin (BCG) vaccine. Those at high risk include household,

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workplace, and social contacts of people with active TB. Treatment requires the use of multiple
antibiotics over a long period of time. Antibiotic resistance is a growing problem with increasing rates of
multiple drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB).

As of 2018 one-quarter of the world's population is thought to be infected with TB. New infections
occur in about 1% of the population each year. In 2017, there were more than 10 million cases of active
TB which resulted in 1.6 million deaths. This makes it the number one cause of death from an infectious
disease. More than 95% of deaths occurred in developing countries, and more than 50% in India, China,
Indonesia, Pakistan, and the Philippines. The number of new cases each year has decreased since 2000.
About 80% of people in many Asian and African countries test positive while 5–10% of people in the
United States population test positive by the tuberculin test. Tuberculosis has been present in humans
since ancient times.

Signs and symptoms

The main symptoms of variants and stages of tuberculosis are given, with many symptoms overlapping
with other variants, while others are more (but not entirely) specific for certain variants. Multiple
variants may be present simultaneously.

Tuberculosis may infect any part of the body, but most commonly occurs in the lungs (known as
pulmonary tuberculosis). Extrapulmonary TB occurs when tuberculosis develops outside of the lungs,
although extrapulmonary TB may coexist with pulmonary TB.

General signs and symptoms include ;

 fever,

 chills,

 night sweats,

 loss of appetite,

 weight loss, and

 fatigue.

Pulmonary

If a tuberculosis infection does become active, it most commonly involves the lungs (in about 90% of
cases). Symptoms may include chest pain and a prolonged cough producing sputum. About 25% of
people may not have any symptoms (i.e. they remain "asymptomatic"). Occasionally, people may cough
up blood in small amounts, and in very rare cases, the infection may erode into the pulmonary artery or
a Rasmussen's aneurysm, resulting in massive bleeding. Tuberculosis may become a chronic illness and
cause extensive scarring in the upper lobes of the lungs. The upper lung lobes are more frequently

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affected by tuberculosis than the lower ones. The reason for this difference is not clear. It may be due
to either better air flow, or poor lymph drainage within the upper lungs.

Extrapulmonary

In 15–20% of active cases, the infection spreads outside the lungs, causing other kinds of TB. These are
collectively denoted as "extrapulmonary tuberculosis". Extrapulmonary TB occurs more commonly in
people with a weakened immune system and young children. In those with HIV, this occurs in more than
50% of cases. Notable extrapulmonary infection sites include the pleura (in tuberculous pleurisy), the
central nervous system (in tuberculous meningitis), the lymphatic system (in scrofula of the neck), the
genitourinary system (in urogenital tuberculosis), and the bones and joints (in Pott disease of the spine),
among others. A potentially more serious, widespread form of TB is called "disseminated tuberculosis",
also known as miliary tuberculosis. Miliary TB currently makes up about 10% of extrapulmonary cases.

Causes

The main cause of TB is Mycobacterium tuberculosis (MTB), a small, aerobic, nonmotile bacillus. The
high lipid content of this pathogen accounts for many of its unique clinical characteristics. It divides
every 16 to 20 hours, which is an extremely slow rate compared with other bacteria, which usually
divide in less than an hour. Mycobacteria have an outer membrane lipid bilayer. If a Gram stain is
performed, MTB either stains very weakly "Gram-positive" or does not retain dye as a result of the high
lipid and mycolic acid content of its cell wall. MTB can withstand weak disinfectants and survive in a dry
state for weeks. In nature, the bacterium can grow only within the cells of a host organism, but M.
tuberculosis can be cultured in the laboratory.

Using histological stains on expectorated samples from phlegm (also called "sputum"), scientists can
identify MTB under a microscope. Since MTB retains certain stains even after being treated with acidic
solution, it is classified as an acid-fast bacillus. The most common acid-fast staining techniques are the
Ziehl–Neelsen stain and the Kinyoun stain, which dye acid-fast bacilli a bright red that stands out against
a blue background. Auramine-rhodamine staining and fluorescence microscopy are also used.

The M. tuberculosis complex (MTBC) includes four other TB-causing mycobacteria: M. bovis, M.
africanum, M. canetti, and M. microti. M. africanum is not widespread, but it is a significant cause of
tuberculosis in parts of Africa. M. bovis was once a common cause of tuberculosis, but the introduction
of pasteurized milk has almost completely eliminated this as a public health problem in developed
countries. M. canetti is rare and seems to be limited to the Horn of Africa, although a few cases have
been seen in African emigrants. M. microti is also rare and is seen almost only in immunodeficient
people, although its prevalence may be significantly underestimated.

Other known pathogenic mycobacteria include M. leprae, M. avium, and M. kansasii. The latter two
species are classified as "nontuberculous mycobacteria" (NTM). NTM cause neither TB nor leprosy, but
they do cause lung diseases that resemble TB.

Risk factors

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A number of factors make people more susceptible to TB infections. The most important risk factor
globally is HIV; 13% of all people with TB are infected by the virus. This is a particular problem in sub-
Saharan Africa, where rates of HIV are high. Of people without HIV who are infected with tuberculosis,
about 5–10% develop active disease during their lifetimes; in contrast, 30% of those coinfected with HIV
develop the active disease.

Tuberculosis is closely linked to both overcrowding and malnutrition, making it one of the principal
diseases of poverty. Those at high risk thus include: people who inject illicit drugs, inhabitants and
employees of locales where vulnerable people gather (e.g. prisons and homeless shelters), medically
underprivileged and resource-poor communities, high-risk ethnic minorities, children in close contact
with high-risk category patients, and health-care providers serving these patients.

Chronic lung disease is another significant risk factor. Silicosis increases the risk about 30-fold.[43] Those
who smoke cigarettes have nearly twice the risk of TB compared to nonsmokers.

Other disease states can also increase the risk of developing tuberculosis. These include alcoholism and
diabetes mellitus (three-fold increase).

Certain medications, such as corticosteroids and infliximab (an anti-αTNF monoclonal antibody), are
other important risk factors, especially in the developed world.

Genetic susceptibility also exists, for which the overall importance remains undefined.

Active tuberculosis

Diagnosing active tuberculosis based only on signs and symptoms is difficult, as is diagnosing the disease
in those who have a weakened immune system. A diagnosis of TB should, however, be considered in
those with signs of lung disease or constitutional symptoms lasting longer than two weeks. A chest X-ray
and multiple sputum cultures for acid-fast bacilli are typically part of the initial evaluation. Interferon-γ
release assays and tuberculin skin tests are of little use in the developing world. Interferon gamma
release assays (IGRA) have similar limitations in those with HIV.

A definitive diagnosis of TB is made by identifying M. tuberculosis in a clinical sample (e.g., sputum, pus,
or a tissue biopsy). However, the difficult culture process for this slow-growing organism can take two to
six weeks for blood or sputum culture. Thus, treatment is often begun before cultures are confirmed.

Nucleic acid amplification tests and adenosine deaminase testing may allow rapid diagnosis of TB. These
tests, however, are not routinely recommended, as they rarely alter how a person is treated. Blood tests
to detect antibodies are not specific or sensitive, so they are not recommended.

Latent tuberculosis

Mantoux tuberculin skin test

The Mantoux tuberculin skin test is often used to screen people at high risk for TB. Those who have
been previously immunized with the Bacille Calmette-Guerin vaccine may have a false-positive test

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result. The test may be falsely negative in those with sarcoidosis, Hodgkin's lymphoma, malnutrition,
and most notably, active tuberculosis. Interferon gamma release assays, on a blood sample, are
recommended in those who are positive to the Mantoux test. These are not affected by immunization or
most environmental mycobacteria, so they generate fewer false-positive results. However, they are
affected by M. szulgai, M. marinum, and M. kansasii. IGRAs may increase sensitivity when used in
addition to the skin test, but may be less sensitive than the skin test when used alone.

The US Preventive Services Task Force (USPSTF) has recommended screening people who are at high risk
for latent tuberculosis with either tuberculin skin tests or interferon-gamma release assays. While some
have recommend testing health care workers, evidence of benefit for this is poor as of 2019. The
Centers for Disease Control and Prevention (CDC) stopped recommending yearly testing of health care
workers without known exposure in 2019.

Prevention

Tuberculosis prevention and control efforts rely primarily on the vaccination of infants and the detection
and appropriate treatment of active cases. The World Health Organization (WHO) has achieved some
success with improved treatment regimens, and a small decrease in case numbers.

Vaccines

The only available vaccine as of 2011 is Bacillus Calmette-Guérin (BCG). In children it decreases the risk
of getting the infection by 20% and the risk of infection turning into active disease by nearly 60%.

It is the most widely used vaccine worldwide, with more than 90% of all children being vaccinated. The
immunity it induces decreases after about ten years. As tuberculosis is uncommon in most of Canada,
the United Kingdom, and the United States, BCG is administered to only those people at high risk. Part
of the reasoning against the use of the vaccine is that it makes the tuberculin skin test falsely positive,
reducing the test's usefulness as a screening tool. A number of vaccines are in development as of 2011.

Public health

The World Health Organization (WHO) declared TB a "global health emergency" in 1993,and in 2006, the
Stop TB Partnership developed a Global Plan to Stop Tuberculosis that aimed to save 14 million lives
between its launch and 2015. A number of targets they set were not achieved by 2015, mostly due to
the increase in HIV-associated tuberculosis and the emergence of multiple drug-resistant tuberculosis. A
tuberculosis classification system developed by the American Thoracic Society is used primarily in public
health programs.

Tuberculosis management

Treatment of TB uses antibiotics to kill the bacteria. Effective TB treatment is difficult, due to the
unusual structure and chemical composition of the mycobacterial cell wall, which hinders the entry of
drugs and makes many antibiotics ineffective.

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Latent TB is treated with either isoniazid alone, or a combination of isoniazid with either rifampicin or
rifapentine. The treatment takes at least three months. People with latent infections are treated to
prevent them from progressing to active TB disease later in life.

Active TB disease is best treated with combinations of several antibiotics to reduce the risk of the
bacteria developing antibiotic resistance.

New onset

The recommended treatment of new-onset pulmonary tuberculosis, as of 2010, is six months of a

combination of antibiotics containing rifampicin, isoniazid, pyrazinamide, and ethambutol for the first
two months, and only rifampicin and isoniazid for the last four months. Where resistance to isoniazid is
high, ethambutol may be added for the last four months as an alternative.

Recurrent disease

If tuberculosis recurs, testing to determine which antibiotics it is sensitive to is important before

determining treatment. If multiple drug-resistant TB (MDR-TB) is detected, treatment with at least four
effective antibiotics for 18 to 24 months is recommended.

Medication administration

Directly observed therapy, i.e., having a health care provider watch the person take their medications, is
recommended by the World Health Organization (WHO) in an effort to reduce the number of people not
appropriately taking antibiotics. The evidence to support this practice over people simply taking their
medications independently is of poor quality. There is no strong evidence indicating that directly
observed therapy improves the number of people who were cured or the number of people who
complete their medicine. Moderate quality evidence suggests that there is also no difference if people
are observed at home versus at a clinic, or by a family member versus a health care worker. Methods to
remind people of the importance of treatment and appointments may result in a small but important
improvement.

Medication resistance

Primary resistance occurs when a person becomes infected with a resistant strain of TB. A person with
fully susceptible MTB may develop secondary (acquired) resistance during therapy because of
inadequate treatment, not taking the prescribed regimen appropriately (lack of compliance), or using
low-quality medication. Drug-resistant TB is a serious public health issue in many developing countries,
as its treatment is longer and requires more expensive drugs. MDR-TB is defined as resistance to the two
most effective first-line TB drugs: rifampicin and isoniazid. Extensively drug-resistant TB is also resistant
to three or more of the six classes of second-line drugs.Totally drug-resistant TB is resistant to all
currently used drugs.[98] It was first observed in 2003 in Italy, but not widely reported until 2012, and
has also been found in Iran and India. Bedaquiline is tentatively supported for use in multiple drug-
resistant TB.

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XDR-TB is a term sometimes used to define extensively resistant TB, and constitutes one in ten cases of
MDR-TB. Cases of XDR TB have been identified in more than 90% of countries.

Progression from TB infection to overt TB disease occurs when the bacilli overcome the immune system
defenses and begin to multiply. In primary TB disease (some 1–5% of cases), this occurs soon after the
initial infection. However, in the majority of cases, a latent infection occurs with no obvious symptoms.
These dormant bacilli produce active tuberculosis in 5–10% of these latent cases, often many years after
infection.

The risk of reactivation increases with immunosuppression, such as that caused by infection with HIV. In
people coinfected with M. tuberculosis and HIV, the risk of reactivation increases to 10% per year.
Studies using DNA fingerprinting of M. tuberculosis strains have shown reinfection contributes more
substantially to recurrent TB than previously thought, with estimates that it might account for more
than 50% of reactivated cases in areas where TB is common. The chance of death from a case of
tuberculosis is about 4% as of 2008, down from 8% in 1995.

Epidemiology of tuberculosis

In 2007, the number of cases of TB per 100,000 people was highest in sub-Saharan Africa, and was also
relatively high in Asia.

Tuberculosis deaths per million persons in 2012

0–3

4–7

8–16

17–26

27–45

46–83

84–137

138–215

216–443

444-1,359

Roughly one-quarter of the world's population has been infected with M. tuberculosis, with new
infections occurring in about 1% of the population each year. However, most infections with M.
tuberculosis do not cause TB disease, and 90–95% of infections remain asymptomatic. In 2012, an
estimated 8.6 million chronic cases were active. In 2010, 8.8 million new cases of TB were diagnosed,

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and 1.20–1.45 million deaths occurred, most of these occurring in developing countries. Of these 1.45
million deaths, about 0.35 million occur in those also infected with HIV.

Tuberculosis is the second-most common cause of death from infectious disease (after those due to
HIV/AIDS).The total number of tuberculosis cases has been decreasing since 2005, while new cases have
decreased since 2002. China has achieved particularly dramatic progress, with about an 80% reduction
in its TB mortality rate between 1990 and 2010. The number of new cases has declined by 17% between
2004 and 2014. Tuberculosis is more common in developing countries; about 80% of the population in
many Asian and African countries test positive in tuberculin tests, while only 5–10% of the US
population test positive. Hopes of totally controlling the disease have been dramatically dampened
because of a number of factors, including the difficulty of developing an effective vaccine, the expensive
and time-consuming diagnostic process, the necessity of many months of treatment, the increase in
HIV-associated tuberculosis, and the emergence of drug-resistant cases in the 1980s.

In 2007, the country with the highest estimated incidence rate of TB was Swaziland, with 1,200 cases per
100,000 people. India had the largest total incidence, with an estimated 2.0 million new cases. In
developed countries, tuberculosis is less common and is found mainly in urban areas. Rates per 100,000
people in different areas of the world were: globally 178, Africa 332, the Americas 36, Eastern
Mediterranean 173, Europe 63, Southeast Asia 278, and Western Pacific 139 in 2010. In Canada and
Australia, tuberculosis is many times more common among the aboriginal peoples, especially in remote
areas. In the United States Native Americans have a fivefold greater mortality from TB,and racial and
ethnic minorities accounted for 84% of all reported TB cases.

The rate of TB varies with age. In Africa, it primarily affects adolescents and young adults. However, in
countries where incidence rates have declined dramatically (such as the United States), TB is mainly a
disease of older people and the immunocompromised (risk factors are listed above). Worldwide, 22
"high-burden" states or countries together experience 80% of cases as well as 83% of deaths.

The routine use of rifabutin instead of rifampicin in HIV-positive people with tuberculosis is of unclear
benefit as of 2007.

b. Symptoms of TB, diagnostic tests, psychological and social impact of TB, stigma

What Are the Symptoms of TB?

A person with TB infection will have no symptoms. A person with active TB disease may have any or all
of the following symptoms:

 A persistent cough

 Constant fatigue

 Weight loss

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  Loss of appetite

 Fever

 Coughing up blood

 Night sweats

These symptoms can also occur with other diseases so it is important to see a healthcare provider and
to let them find out if you have TB. A person with TB disease may feel perfectly healthy or may only have
a cough from time to time. If you think you have been exposed to TB, get a TB test.

What Causes TB

Tuberculosis is an infection caused by bacteria. It's spread through the air—when an infected person
coughs, sneezes, laughs, etc. However, it is not easy to become infected with tuberculosis. Usually, a
person has to be close to someone with TB disease for a long period of time. TB is usually spread
between family members, close friends, and people who work or live together. TB is spread most easily
in closed spaces over a long period of time.

Most cases of active TB result from the activation of latent TB infections or old infections in people with
impaired immune systems. People with clinically active TB will often but not always display symptoms
and can spread the disease to others.

What Are the Risk Factors of TB?

The chances of getting infected by the TB germ are highest for people that are in close contact with
others who are infected. This includes:

 Family and friends of a person with infectious TB disease

 People from parts of the world with high rates of TB, including India and parts of Asian and
Africa.

 People in groups with high rates of TB transmission, including the homeless persons, injection
drug users, and people living with HIV infection

 People who work or reside in facilities or institutions that house people who are at high risk for
TB such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential
homes for those with HIV

Not everyone who is infected with the TB germ (latent TB) develops clinically active TB disease. People
at highest risk for developing active TB disease are those with a weak immune system, including:

 Babies and young children, whose immune systems have not matured

 People with chronic conditions such as diabetes or kidney disease

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  People with HIV/AIDS

 Organ transplant recipients

 Cancer patients undergoing chemotherapy

 People receiving certain specialized treatments for autoimmune disorders such as rheumatoid
arthritis or Crohn's disease

Preventing Tuberculosis

If you have become infected with TB, but do not have active TB disease, you may get preventive
therapy. This treatment kills germs that are not doing any damage right now, but could so do in the
future. The most common preventive therapy is a daily dose of the medicine isoniazid (INH) for 6 to 9
months.

If you take your medicine as instructed by your healthcare provider, it can keep you from developing
active TB disease.

There is a vaccine against TB called BCG, or bacillus Calmette-Guerin. It is used in many foreign countries
where TB is more common. However, it is not used very often in the United States because the chances
of being infected with TB in the U.S. is low. It can also make TB skin tests less accurate. Recent evidence
has shown that BCG is effective at reducing the incidence of TB in children by about half in populations
with a high prevalence of active TB but is much less effective in adults.

Addressing the social determinants of TB

Poverty is a powerful determinant of tuberculosis. Crowded and poorly ventilated living and working
environments often associated with poverty constitute direct risk factors for tuberculosis transmission.
Undernutrition is an important risk factor for developing active disease. Poverty is also associated with
poor general health knowledge and a lack of empowerment to act on health knowledge, which leads to
risk of exposure to several tuberculosis risk factors, such as HIV, smoking and alcohol abuse.

Poverty alleviation reduces the risk of tuberculosis transmission and the risk of progression from
infection to disease. It also helps to improve access to health services and adherence to recommended
treatment. Actions on the determinants of ill health through “health-in-all-policies” approaches will
immensely benefit tuberculosis care and prevention. The required social, economic and public health
policies include those that:

 pursue overarching poverty reduction strategies and expanding social protection;

 reduce food insecurity;

 improve living and working conditions;

 improve environment and living conditions in prisons and other congregate settings;

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  address the social, financial, and health situation of migrants; and

 promote healthy diets and lifestyles, including reduction of smoking and harmful use of alcohol
and drugs.
c. Preventing spread of TB: BCG vaccination, testing immunity with the Mantoux
test, infection control measures

TB prevention consists of several main parts.

Firstly there is a need to stop the transmission of TB from one adult to another.

This is done through firstly, identifying people with active TB, and then curing them through the
provision of drug treatment. With proper TB treatment someone with TB will very quickly not be
infectious and so can no longer spread TB to others.

If someone is not on treatment, then precautions such as cough etiquette, must be taken to prevent TB
spreading from one adult to another.

Anything which increases the number of people infected by each infectious person, such as ineffective
treatment because of drug resistant TB, reduces the overall effect of the main TB prevention efforts. The
presence of TB and HIV infection together also increases the number of people infected by each
infectious person. As a result it is then more likely that globally the number of people developing active
TB will increase rather than decrease.

Other TB prevention activities

There are several other TB prevention activities. This includes preventing people with latent TB from
developing active, and infectious, TB disease.

TB infection control including the use of respirators and masks, which means preventing the
transmission of TB in such settings as hospitals & prisons.

The pasteurization of milk also helps to prevent humans from getting bovine TB.

There is a vaccine for TB, but it makes only a small contribution to TB prevention. It does little to
interrupt the transmission of TB among adults.

TB precautions, cough etiquette

TB is caused when a person breathes in TB bacteria that are in the air. So it is important that people with
TB, who are not on effective treatment, do not release TB bacteria into the air when they cough.

Cough etiquette means that if you have TB, or you might have TB, then when you cough you should
cover your mouth and nose with a tissue. You should put your used tissue in a bin. If you don't have a
tissue then you should cough or sneeze into your upper sleeve or elbow. You should not cough into your
hands. After you have coughed you should wash your hands.1

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TB prevention - the BCG vaccine

The vaccine called Bacillus Calmette-Guerin (BCG) was first developed in the 1920s. It is one of the most
widely used of all current vaccines, and it reaches more than 80% of all new born children and infants in
countries where it is part of the national childhood immunization programme.2However, it is also one of
the most variable vaccines in routine use.

The BCG vaccine has been shown to provide children with excellent protection against the disseminated
forms of TB. However protection against pulmonary TB in adults is variable. Since most transmission
originates from adult cases of pulmonary TB, the BCG vaccine is generally used to protect children,
rather than to interrupt transmission among adults.

The BCG vaccine will often result in the person vaccinated having a positive result to a TB skin test.

TB education

TB education is necessary for people with TB. People with TB need to know how to take their TB drugs
properly. They also need to know how to make sure that they do not pass TB on to other people. But TB
education is also necessary for the general public. The public needs to know basic information about TB
for a number of reasons including reducing the stigma still associated with TB.

TB treatment as TB prevention

TB drug treatment for the prevention of TB, also known as chemoprophylaxis, can reduce the risk of a
first episode of active TB occurring in people with latent TB. The treatment of latent TB is being used as
a tool to try and eliminate TB.

Isoniazid is one of the drugs used to prevent latent TB from progressing to active TB or TB disease.
Isoniazid is a cheap drug, but in a similar way to the use of the BCG vaccine, it is mainly used to protect
individuals rather than to interrupt transmission between adults. This is because children rarely have
infectious TB, and it is hard to administer isoniazid on a large scale to adults who do not have any
symptoms. Taking isoniazid daily for six months is difficult in respect of adherence, and as a result many
individuals who could benefit from the treatment, stop taking the drug before the end of the six month
period.

There have also been concerns about the possible impact of TB treatment for prevention programmes
on the emergence of drug resistance. However, a review of the scientific evidence has now shown that
there is no need for this to be a concern. The benefit of isoniazid preventative therapy for people living
with HIV, and who have, or may have had latent TB, has also recently been emphasized.3

Preventing TB transmission in households, masks

Actions to be taken

In order to reduce exposure in households where someone has infectious TB, the following actions
should be taken whenever possible:

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Houses should be adequately ventilated;

Anyone who coughs should be educated on cough etiquette and respiratory hygiene, and should follow
such practice at all times;

While smear positive, TB patients should:

 Spend as much time as possible outdoors;

 If possible, sleep alone in a separate, adequately ventilated room;

 Spend as little time as possible on public transport;

 Spend as little time as possible in places where large numbers of people gather together.

 Educating people about TB is also an important part of TB prevention, as well as ensuring that
people who need treatment receive it as soon as possible.

Households where someone has culture positive MDR TB

It is not fully known how differences between drug susceptible, and drug resistant TB, as well as HIV
status, affect the risk of TB transmission. However it is thought that people with drug resistant TB
remain infectious for much longer, even if treatment has been started, and this may prolong the risk of
transmission in the household.

In households with culture positive MDR TB patients, the following guidance should therefore be
observed in addition to the measures given above.

Culture positive MDR TB patients who cough should always practice cough etiquette (including use of
masks) and respiratory hygiene when in contact with people. Ideally health service providers should
wear respirators when attending patients with infectious MDR TB in enclosed spaces;

Ideally, family members living with HIV, or family members with strong clinical evidence of HIV infection,
should not provide care for patients with culture positive MDR TB;

Children below five years of age should spend as little time as possible in the same living spaces as
culture positive MDR TB patients.

Face masks are different from respirators and can be made from either cloth or paper. A face mask worn
by someone with infectious TB can help to prevent the spread of M. tuberculosis from the patient to
other people. The face mask can capture large wet particles near the mouth and nose of the patient,
preventing the bacteria from being released into the environment. Cloth masks can be sterilized and
reused. The use of a face mask does not protect health care workers against TB, and so a health care
worker or other staff should not wear a face mask in a household (or indeed in a health care) setting.

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Respirators can protect health care workers from inhaling M. tuberculosis in certain circumstances, but
they are expensive to purchase

Households where someone has XDR TB

If someone has culture positive XDR TB, then they should be isolated at all times, and any person in
contact with a culture positive XDR TB patient should wear a particulate respirator. If at all possible, HIV
positive family members, or family members with strong clinical evidence of HIV infection, should not
share a household with a culture positive XDR TB patient.

Physical measures for TB prevention

Before drug treatment for TB became available, removing TB patients from their homes and putting
them in isolation in sanatoria, was the main way of reducing the transmission of TB.

However this policy changed in the vast majority of countries, after studies showed that if patients
stayed at home and were treated on an “outpatient” basis, this did not increase the risk of TB among
the household contacts of the people with TB. This is because drug treatment quickly makes a TB patient
uninfectious, and most household contacts who do become infected, will have already become infected
before the diagnosis of TB has been made.

So generally there is now no need for people to leave their homes because they have TB. The only
exception to this is, as described above, when someone has infectious XDR TB, and it is not feasible to
isolate them at home. Also people may still need to go into a health care facility because there are
complications arising from their condition, or their treatment. Within a health care facility there may be
a need for some separation of people in order to reduce the chances of transmission.

The measures described above also mainly apply to resource poor settings, and the recommendations
can be different where more resources are available.

TB prevention in health care facilities

Doctors and other health care workers who provide care for patients for TB, must follow infection
control procedures to ensure that TB infection is not passed from one person to another. Every country
should have infection control guidance which clearly needs to take into account local facilities and
resources, as well as the number of people being provided with care. However, infection control
guidance must not only be written but also implemented.

d. Treatment of TB with antibiotics, regime, side effects, access to treatment and support
for individuals living with TB. Public health crisis of emerging multi-drug resistant strains
of TB

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Diagnosis

The most commonly used diagnostic tool for tuberculosis is a simple skin test, though blood tests are
becoming more commonplace. A small amount of a substance called PPD tuberculin is injected just
below the skin of your inside forearm. You should feel only a slight needle prick.

Blood tests

Blood tests may be used to confirm or rule out latent or active tuberculosis. These tests use
sophisticated technology to measure your immune system's reaction to TB bacteria.

These tests require only one office visit. A blood test may be useful if you're at high risk of TB infection
but have a negative response to the skin test, or if you've recently received the BCG vaccine.

Imaging tests

If you've had a positive skin test, your doctor is likely to order a chest X-ray or a CT scan. This may show
white spots in your lungs where your immune system has walled off TB bacteria, or it may reveal
changes in your lungs caused by active tuberculosis. CT scans provide more-detailed images than do X-
rays.

Sputum tests

If your chest X-ray shows signs of tuberculosis, your doctor may take samples of your sputum — the
mucus that comes up when you cough. The samples are tested for TB bacteria.

Sputum samples can also be used to test for drug-resistant strains of TB. This helps your doctor choose
the medications that are most likely to work. These tests can take four to eight weeks to be completed.

Treatment

Medications are the cornerstone of tuberculosis treatment. But treating TB takes much longer than
treating other types of bacterial infections.

For active tuberculosis, you must take antibiotics for at least six to nine months. The exact drugs and
length of treatment depend on your age, overall health, possible drug resistance and the infection's
location in the body.

Most common TB drugs

If you have latent tuberculosis, you may need to take only one or two types of TB drug. Active
tuberculosis, particularly if it's a drug-resistant strain, will require several drugs at once. The most
common medications used to treat tuberculosis include:

 Isoniazid

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  Rifampin (Rifadin, Rimactane)

 Ethambutol (Myambutol)

 Pyrazinamide

If you have drug-resistant TB, a combination of antibiotics called fluoroquinolones and injectable
medications, such as amikacin or capreomycin (Capastat), are generally used for 20 to 30 months. Some
types of TB are developing resistance to these medications as well.

Some drugs may be used as add-on therapy to the current drug-resistant combination treatment,
including:

 Bedaquiline (Sirturo)

 Linezolid (Zyvox)

Medication side effects

Serious side effects of TB drugs aren't common but can be dangerous when they do occur. All
tuberculosis medications can be highly toxic to your liver. When taking these medications, call your
doctor immediately if you experience any of the following:

 Nausea or vomiting

 Loss of appetite

 A yellow color to your skin (jaundice)

 Dark urine

A fever that lasts three or more days and has no obvious cause

Completing treatment is essential

After a few weeks, you won't be contagious and you may start to feel better. It might be tempting to
stop taking your TB drugs. But it is crucial that you finish the full course of therapy and take the
medications exactly as prescribed by your doctor. Stopping treatment too soon or skipping doses can
allow the bacteria that are still alive to become resistant to those drugs, leading to TB that is much more
dangerous and difficult to treat.

To help people stick with their treatment, a program called directly observed therapy (DOT) is
recommended. In this approach, a health care worker administers your medication so that you don't
have to remember to take it on your own.

Treatment for tuberculosis is a complicated and lengthy process. But the only way to cure the disease is
to stick with your treatment. You may find it helpful to have your medication given by a nurse or other

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health care professional so that you don't have to remember to take it on your own. In addition, try to
maintain your normal activities and hobbies and stay connected with family and friends.

Keep in mind that your physical health can affect your mental health. Denial, anger and frustration are
normal when you must deal with something difficult and unexpected. At times, you may need more
tools to deal with these or other emotions. Professionals, such as therapists or behavioral psychologists,
can help you develop positive coping strategies.

Preparing for your appointment

If you suspect that you have tuberculosis, contact your primary care doctor. You may be referred to a
doctor who specializes in infectious diseases or lung diseases (pulmonologist).

e. Close relationship between HIV/AIDS and TB. Why individuals with HIV/AIDS are
susceptible to TB, mortality rates from TB for people with HIV/AIDS

HIV and Tuberculosis (TB)

Key Points

Tuberculosis (TB) is a disease caused by bacteria that spread in the air. TB can spread from person to
person.

Once in the body, TB can be inactive or active. Inactive TB is called latent TB. Active TB is called TB
disease.

TB usually affects the lungs, but TB-causing bacteria can attack any part of the body, including the
kidneys, spine, or brain. If not treated, TB disease can cause death.

HIV weakens the immune system, increasing the risk of TB in people with HIV.

People who have both HIV and TB should be treated for both diseases; however, when to start
treatment and what medicines to take depends on a person’s individual circumstances.

What is tuberculosis?

Tuberculosis (TB) is a contagious disease that can spread from person to person. TB is caused by bacteria
called Mycobacterium tuberculosis. The TB bacteria spread in the air.

TB usually affects the lungs. But TB-causing bacteria can attack any part of the body, including the
kidneys, spine, or brain. If not treated, TB can cause death.

How does TB spread from person to person?

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A person with TB disease of the lungs or throat can spread droplets of TB bacteria in the air, particularly
when they cough or sneeze. People who breathe in the TB bacteria can get TB.

Once in the body, TB can be inactive or active. Inactive TB is called latent TB. Active TB is called TB
disease. The image below shows the difference between latent TB and TB disease.

What is the connection between HIV and TB?

TB is an opportunistic infection (OI). OIs are infections that occur more often or are more severe in
people with weakened immune systems than in people with healthy immune systems. HIV weakens the
immune system, increasing the risk of TB in people with HIV.

Infection with both HIV and TB is called HIV/TB coinfection. Latent TB is more likely to advance to TB
disease in people with HIV than in people without HIV. TB disease may also cause HIV to worsen.

Treatment with HIV medicines is called antiretroviral therapy (ART). ART protects the immune system
and prevents HIV infection from advancing to AIDS. In people with HIV/TB coinfection, ART reduces the
chances that latent TB will advance to TB disease.

How common is HIV/TB coinfection?

Worldwide, TB disease is one of the leading causes of death among people with HIV. In the United
States, where HIV medicines are widely used, fewer people with HIV get TB than in many other
countries. But TB still affects many people with HIV in the United States, especially those born outside
the United States.

Should people with HIV get tested for TB?

Yes, all people with HIV should get tested for TB infection, preferably at the time of HIV diagnosis. If test
results show that a person has latent TB, additional testing is needed. More testing will determine
whether the person has TB disease.

What are the symptoms of TB?

People with latent TB don’t have any signs of the disease. But if latent TB advances to TB disease, there
will usually be signs of the disease. Common symptoms of TB disease include:

 A persistent cough that may bring up blood or sputum

 Chest pain

 Fatigue

 Loss of appetite

 Weight loss

 Fever

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  Night sweats

What is the treatment for TB?

In general, TB treatment is the same for people with HIV and people without HIV. TB medicines are used
to prevent latent TB from advancing to TB disease and to treat TB disease. The choice of TB medicines
and the length of treatment depend on whether a person has latent TB or TB disease.

People with HIV/TB coinfection should be treated for both diseases; however, when to start treatment
and what medicines to take depends on a person’s individual circumstances. Taking certain HIV and TB
medicines at the same time can increase the risk of drug-drug interactions and side effects. People being
treated for HIV/TB coinfection are carefully monitored by their health care providers.

If you have HIV/TB coinfection, talk to your health care provider about a treatment plan that works for
you.

Learning Outcome 5: Evaluate programs to prevent and treat tuberculosis in low income
countries

a. Risk factors for TB:

 poverty,
 undernutrition,
 overcrowding,
 smoking,
 other conditions causing a weakened immune system,
 lack of access to medical care

Tuberculosis (TB)

Some people develop TB disease soon after becoming infected (within weeks) before their immune
system can fight the TB bacteria. Other people may get sick years later, when their immune system
becomes weak for another reason.

Overall, about 5 to 10% of infected persons who do not receive treatment for latent TB infection will
develop TB disease at some time in their lives. For persons whose immune systems are weak, especially
those with HIV infection, the risk of developing TB disease is much higher than for persons with normal
immune systems.

Generally, persons at high risk for developing TB disease fall into two categories:

 Persons who have been recently infected with TB bacteria

 Persons with medical conditions that weaken the immune system

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  Persons who have been Recently Infected with TB Bacteria

This includes:

 Close contacts of a person with infectious TB disease

 Persons who have immigrated from areas of the world with high rates of TB

 Children less than 5 years of age who have a positive TB test

 Groups with high rates of TB transmission, such as homeless persons, injection drug users, and
persons with HIV infection

 Persons who work or reside with people who are at high risk for TB in facilities or institutions
such as hospitals, homeless shelters, correctional facilities, nursing homes, and residential
homes for those with HIV

 Persons with Medical Conditions that Weaken the Immune System

Babies and young children often have weak immune systems. Other people can have weak immune
systems, too, especially people with any of these conditions:

 HIV infection (the virus that causes AIDS)

 Substance abuse

 Silicosis

 Diabetes mellitus

 Severe kidney disease

 Low body weight

b. Global plans to combat TB: the World Health Organization (WHO) End TB Strategy
and how these fit with the Sustainable Development Goals

The Global Plan to End TB 2016 - 2020

The Global Plan is a 5-year investment plan that represents the roadmap to accelerating impact on the
TB epidemic and reaching the targets of the WHO End TB Strategy.

This is the 4th Global Plan since the inception of Stop TB Partnership in 2000. This plan, based on the
End TB strategy, aims to end TB and "walks away" from the limited approach aimed to "controlling" the
diseases only.

 Specifically it speaks about preventing TB,

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  active case finding and contact tracing,

 focusing attention to key vulnerable and marginalized groups,

 developing and roll out of new tools, and

 implementing TB services packages that are comprehensive and work in different type of
epidemic and socioeconomic environments.

What is the investment needed? Accoording toWHO;

 US$ 65 billion globally

 Of this, most is for implementation in countries

 Of this, US$ 29.4 billion needed in Global Fund eligible countries.

 Of this, US$ 9 billion needed to fund R&D for new tools - including diagnosis, drugs, drug
regimens and vaccines.

What will the world achieve by investing in the Global Plan?

 45 million people prevented from getting TB

 29 million people treated

 10 million lives saved

 US$ 1.2 trillion overall economic return on investment

 US$ 85 return on each dollar invested

c. Prevention and treatment of TB in communities:

 main players including government,

 nongovernmental organisations (NGOs),
 community health workers

d. Challenges:

 hard to reach groups,

 access to medical care,
 health education,
 non-compliance with treatment regimes

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e. Prevention and treatment programs which address both TB and HIV/AIDS

To help prevent the spread of HIV:

Use a new condom every time you have sex. Use a new condom every time you have anal or vaginal sex.
Women can use a female condom. If using a lubricant, make sure it's water-based. Oil-based lubricants
can weaken condoms and cause them to break. During oral sex use a nonlubricated, cut-open condom
or a dental dam — a piece of medical-grade latex.

Consider preexposure prophylaxis (PrEP). The combination drugs emtricitabine plus tenofovir (Truvada)
and emtricitabine plus tenofovir alafenamide (Descovy) can reduce the risk of sexually transmitted HIV
infection in people at very high risk.

Your doctor will prescribe these drugs for HIV prevention only if you don't already have HIV infection.
You will need an HIV test before you start taking PrEP and then every three months as long as you're
taking it. Your doctor will also test your kidney function before prescribing Truvada and continue to test
it every six months.

You need to take the drugs every day. They don't prevent other STIs, so you'll still need to practice safe
sex. If you have hepatitis B, you should be evaluated by an infectious disease or liver specialist before
beginning therapy.

Tell your sexual partners if you have HIV. It's important to tell all your current and past sexual partners
that you're HIV-positive. They'll need to be tested.

Use a clean needle. If you use a needle to inject drugs, make sure it's sterile and don't share it. Take
advantage of needle-exchange programs in your community and consider seeking help for your drug
use.

If you're pregnant, get medical care right away. If you're HIV-positive, you may pass the infection to your
baby. But if you receive treatment during pregnancy, you can cut your baby's risk significantly.

Consider male circumcision. There's evidence that male circumcision can help reduce the risk of getting
HIV infection.

Preventing TB transmission in households

Actions to be taken

In order to reduce exposure in households where someone has infectious TB, the following actions
should be taken whenever possible.

Houses should be adequately ventilated;

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Anyone who coughs should be educated on cough etiquette and respiratory hygiene, and should follow
such practice at all times;

While smear positive, TB patients should:

 Spend as much time as possible outdoors;

 If possible, sleep alone in a separate, adequately ventilated room;

 Spend as little time as possible on public transport;

 Spend as little time as possible in places where large numbers of people gather together.

 Educating people about TB is also an important part of TB prevention, as well as ensuring that
people who need treatment receive it as soon as possible.

Households where someone has culture positive MDR TB

It is not fully known how differences between drug susceptible, and drug resistant TB, as well as HIV
status, affect the risk of TB transmission. However it is thought that people with drug resistant TB
remain infectious for much longer, even if treatment has been started, and this may prolong the risk of
transmission in the household.

In households with culture positive MDR TB patients, the following guidance should therefore be
observed in addition to the measures given above.

Culture positive MDR TB patients who cough should always practice cough etiquette (including use of
masks) and respiratory hygiene when in contact with people. Ideally health service providers should
wear respirators when attending patients with infectious MDR TB in enclosed spaces;

Ideally, family members living with HIV, or family members with strong clinical evidence of HIV infection,
should not provide care for patients with culture positive MDR TB;

Children below five years of age should spend as little time as possible in the same living spaces as
culture positive MDR TB patients.

Face masks are different from respirators and can be made from either cloth or paper. A face mask worn
by someone with infectious TB can help to prevent the spread of M. tuberculosis from the patient to
other people. The face mask can capture large wet particles near the mouth and nose of the patient,
preventing the bacteria from being released into the environment. Cloth masks can be sterilized and
reused. The use of a face mask does not protect health care workers against TB, and so a health care
worker or other staff should not wear a face mask in a household (or indeed in a health care) setting.

Respirators can protect health care workers from inhaling M. tuberculosis in certain circumstances, but
they are expensive to purchase

Households where someone has XDR TB

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If someone has culture positive XDR TB, then they should be isolated at all times, and any person in
contact with a culture positive XDR TB patient should wear a particulate respirator. If at all possible, HIV
positive family members, or family members with strong clinical evidence of HIV infection, should not
share a household with a culture positive XDR TB patient.

Physical measures for TB prevention

Before drug treatment for TB became available, removing TB patients from their homes and putting
them in isolation in sanatoria, was the main way of reducing the transmission of TB.

However this policy changed in the vast majority of countries, after studies showed that if patients
stayed at home and were treated on an “outpatient” basis, this did not increase the risk of TB among
the household contacts of the people with TB. This is because drug treatment quickly makes a TB patient
uninfectious, and most household contacts who do become infected, will have already become infected
before the diagnosis of TB has been made.

So generally there is now no need for people to leave their homes because they have TB. The only
exception to this is, as described above, when someone has infectious XDR TB, and it is not feasible to
isolate them at home. Also people may still need to go into a health care facility because there are
complications arising from their condition, or their treatment. Within a health care facility there may be
a need for some separation of people in order to reduce the chances of transmission.

The measures described above also mainly apply to resource poor settings, and the recommendations
can be different where more resources are available.

Resources
Textbooks
Rogstad, K. (2011). ABC of Sexually Transmitted Infections. 6th ed. Chichester, West Sussex;
Hoboken, NJ: Wiley-Blackwell.9
Rutanga, J. (2011). Control and Prevention of Infectious Diseases: Interventions for Control

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and Prevention of Tuberculosis and HIV Infectious Diseases in Sub-Saharan Africa. LAP
LAMBERT Academic Publishing.10
Skolnik, R. (2017). Global Health 101. Burlington, MA: Jones & Bartlett Learning.11
Whiteside, A. (2016). HIV & AIDS: A Very Short Introduction. 2nd ed. Oxford: Oxford
University
Press.12
Additional Reading
Flint, A. (2011). HIV/AIDS in Sub-Saharan Africa: Politics, Aid and Globalization. Basingstoke;
New York: Palgrave Macmillan.13
Portman, M. (2018). HIV Prevention Strategies. Medicine, [online] 46(5), pp.293-299. Available
at: https://www.medicinejournal.co.uk/article/S1357-3039(18)30049-5/fulltext [Accessed 12
Sep. 2018].14

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