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HIV-AIDS Research Paper Outline
II. What is HIV and How Does it Progress to AIDS?
III. HIV and AIDS Statistics in the United States
a. Transmission Categories
i. Male-to-Male Sexual Contact (MSM) and MSM Who Inject Drugs
ii. Injection Drug Use
iii. “High-Risk” Heterosexual Contact
iv. Infants and Children Living With HIV/AIDS
IV. Current Treatment Regimens
a. Three Categories of Drugs
b. Combination Therapy
V. Global Impact of HIV/AIDS
VI. Risk Reduction and Prevention Strategies
Since the epidemic first started in 1981, the human immunodeficiency virus (HIV) and the end-stage condition associated with infection with HIV, acquired immunodeficiency syndrome (AIDS), have claimed the lives of 25 million people worldwide (Fernandez & Ruiz, 2006). It is important to note that throughout this research paper we use the term “HIV/AIDS” to refer to individuals infected with HIV as well as those individuals diagnosed with AIDS. However, we will use the term “HIV” when referring only to individuals diagnosed as being infected with HIV and “AIDS” when referring specifically to individuals whose HIV disease has progressed to AIDS. We first address the progression of HIV disease, followed by a review of prevalence of HIV and AIDS both within the United States and globally. Next is a discussion of statistics by transmission category as specified by the Centers for Disease Control and Prevention (CDC). We then discuss past and current treatments for HIV/AIDS, adherence to the treatment regimen, and resistance to medication. Finally, we discuss current projects aimed at prevention. Risk factors associated with becoming infected with HIV and barriers to prevention are discussed throughout the paper.
What is HIV and How Does it Progress to AIDS?
HIV is the retrovirus that causes AIDS (Wessner, 2006). As a retrovirus, HIV has a unique replication cycle, which adds to the complexity of this epidemic; the most notable issue is the virus’s ability to mutate and change in response to the medication used to slow its progression. The replication cycle begins first by the virus attaching to and entering a host cell with a CD4 receptor (often a “T-helper lymphocyte”). Eventually the virus becomes part of the DNA sequence for that cell. Once the virus becomes part of the cell’s DNA, the infected cell duplicates and produces new cells infected with HIV. These newly produced viral cells then attack the healthy cells in the body. As the number of viral cells increases, the person’s immune system becomes increasingly susceptible to opportunistic infections and other illnesses.
In 1993, the CDC established the current definition of AIDS. AIDS pertains to HIV-positive individuals with a CD4 cell or T-helper lymphocyte count of less than 200 cells per milliliter of blood (Wessner, 2006). A normal CD4 is anywhere between 800 and 1,000. Alternatively, individuals are diagnosed as having AIDS if they had one or more opportunistic infections (OIs) from a list established by the CDC. OIs are infections caused by microorganisms that can be present in the human body, but do not normally cause disease in humans (Wessner, 2006). These infections need an “opportunity” to infect the person, and in this case the opportunity is the weakened immune system brought about by HIV.
HIV is an unusual infectious agent, in that it takes a relatively long time before HIV infection progresses to an AIDS diagnosis. In most individuals who do not receive any treatment at all, AIDS will occur six to eight years after the person is initially infected (Wessner, 2006). The progression of HIV infection to AIDS can depend on a number of factors, including adherence or lack of adherence to the treatment regimen, possible resistance to medication, injection drug use, age, and overall health of the individual (CDC, 2005a). In general, data from 2004 show that 40 percent of individuals diagnosed with HIV progressed to AIDS within 12 months after the initial diagnosis (CDC, 2005a). However, a word of caution is in order when interpreting the previous statistic. Just because 40 percent of individuals progressed to AIDS 12 months after their HIV diagnosis does not mean that this progression took only 1 year. The time at which an individual is given an HIV diagnosis is virtually never the time at which that individual was initially exposed to the virus. Most people are asymptomatic for several years after initial exposure to HIV, and, because they are not experiencing any symptoms, they do not seek testing or subsequent treatment. Therefore, those individuals may have been living with HIV for years and only received the actual diagnosis once they started having symptoms and were tested. A more accurate interpretation of this statistic is that there is a large proportion of individuals who are possibly unaware of their HIV status, and therefore do not seek testing or treatment. The CDC (2005a) estimates that 25 percent of individuals living with HIV are unaware that they are infected. This is a significant area of concern and will be discussed in more detail later in the research paper.
HIV and AIDS Statistics in the United States
This section provides a snapshot of the prevalence of HIV and AIDS, in general, in the United States. At the end of 2005, an estimated 249,950 people in the United States were living with HIV and an estimated 425,910 were living with AIDS (CDC, 2005a). Furthermore, approximately 40,000 people in the United States are newly infected with HIV every year, a rate that has remained stable since the 1990s and represents a significant drop from the 150,000 new infections seen during the 1980s (CDC, 2006a). Although the year 2005 saw a slight decrease in the number of new HIV and AIDS diagnoses from the previous year, the number of individuals living with HIV and AIDS increased during this time. This increase is due in large part to the improvements in antiretroviral therapy that will be discussed later in the paper. Men are disproportionately affected by this epidemic, representing 69 percent of individuals living with HIV and 77 percent of those living with AIDS (CDC, 2005a). Although women are the minority in this epidemic, they did experience a slightly higher increase in number of AIDS cases from 2001 to 2005 as compared to men (17 percent vs. 16 percent, respectively; CDC, 2005a).
From 2001 through 2005, the estimated number of new HIV cases increased among European Americans, Asians/ Pacific Islanders, and American Indian/Native Alaskans and decreased among African Americans and Hispanics. Despite this decrease, African Americans still accounted for 48 percent of individuals living with HIV in 2005 (CDC, 2005a). This statistic becomes even more significant when one considers that African Americans constitute only an estimated 13 percent of the U.S. population. In comparison, 34 percent of individuals living with HIV were European American, 16 percent were Hispanic, and less than 1 percent each were Asian/Pacific Islander and American Indian/Native Alaskan (CDC, 2005a). For individuals diagnosed with AIDS, the estimated number of cases steadily increased from 2001 to 2005 across all ethnic groups.
Young people (defined as individuals ages 13–24) represent an increasing proportion of persons with HIV disease. In 2004, approximately 7,761 young people were living with AIDS in the United States, an increase of 42 percent since 2000 (CDC, 2005c). Young people who are African American are particularly at risk, constituting 55 percent of young people diagnosed with HIV in 2005. More specifically, young minority women (specifically African Americans and Hispanics) account for almost 75 percent of HIV infections in women ages 13 to 24 (CDC, 2005d). However, the age group most affected by AIDS, regardless of race/ethnicity, at the end of 2005 was persons ages 35 to 39 (CDC, 2005a). Because the rate of HIV prevalence by age group as reported by the CDC (2005a) occurs in five-year increments, it prevents an in-depth discussion of the differences in HIV and AIDS percentages by age group. See the References and Further Readings and Web Sites sections at the end of this research paper for more on these statistics.
It is well known that HIV is a blood-borne virus that can be transmitted through the exchange of bodily fluids (blood, semen, vaginal secretions, and breast milk), needle sharing, blood and blood product transfusions (not currently a substantial issue in the United States), and mother-to-child transmission. Some of these transmission methods cause more concern than others, and disproportionately affect specific races and ethnicities and age groups. The CDC has identified five primary transmission categories that adults and adolescents (age 13 and older) diagnosed with HIV or AIDS can belong to: male-to-male sexual contact (MSM), injection drug use (IDU), MSM and IDU, “high-risk” heterosexual contact, and other. For children under the age of 13, the CDC has three transmission categories: hemophilia/coagulation disorder, mother with documented HIV infection or HIV risk factor (perinatal transmission), and other. The following sections review each of these transmission categories and some of the differences across gender, race and ethnicity, and age.
Male-to-Male Sexual Contact (MSM) and MSM Who Inject Drugs
In the United States, an estimated 5 to 7 percent of male adolescents and adults identify themselves as men who have sex with men (MSM; Binson et al., 1995). Note that these individuals do not necessarily identify as “gay” or “bisexual,” and further, it is not the label of the person’s sexual orientation that puts an individual at risk but rather the behavior, so throughout this research paper we retain the CDC’s term of MSM. Over a five-year period (2001–2005), the estimated number of HIV and AIDS cases steadily increased among MSM (CDC, 2005a). In 2005, MSM constituted the highest proportion (51 percent) of newly diagnosed individuals with HIV in the United States. At the end of 2005, 49 percent of male adults and adolescents living with HIV became infected by MSM and an additional 4 percent were infected through MSM or injection drug use (because these individuals engaged in both of these types of risk behaviors concurrently, the CDC cannot say for certain what the route of infection was; CDC, 2005a). Across all races and ethnicities, MSM constituted the highest proportion of people with HIV infection over all other transmission categories. The prevalence of new HIV infections among MSM diagnosed from 2001–2004 was greatest for European Americans (43 percent), followed by African Americans (36 percent), Hispanics (19 percent), Asian/Pacific Islanders (1 percent), and American Indian/ Native Alaskans (less than 1 percent; CDC, 2005b). Similar percentages across races and ethnicities occurred for MSM and IDU. Together these two categories accounted for 70 percent of new HIV/AIDS diagnoses among men in 2004, representing at 8 percent increase from the previous year (CDC, 2005c). Rates of HIV infection at the end of 2005 across all MSM who had been diagnosed since the epidemic began were essentially consistent with the racial and ethnic trends for new HIV diagnoses mentioned above.
Risk-taking behaviors are often higher among young MSM than among older MSM (McAuliffe, Kelly, & Sikkema, 1999), particularly young African American MSM. MacKellar and colleagues (2005) conducted a study on young MSM and found that of those young men who tested positive for HIV, 77 percent mistakenly believed they were not infected. This study further showed that approximately 9 out of 10 young African American MSM, as compared with 6 out of 10 young European American MSM, were unaware of their HIV positivity. Some studies (del Rio, 2003; Suarez & Miller, 2001) suggest that the introduction of highly active antiretroviral treatment (HAART) has negatively impacted the AIDS epidemic. As we discuss below, by referring to HIV as a chronic rather than a terminal illness, many individuals may misconstrue what living with HIV means. Researchers (as cited in del Rio, 2003; Stolte, Dukers, Geskus, Coutinho, & de Wit, 2004; Wolitski, 2005) have shown that some MSM (among other infected populations) incorrectly believe that they or their partners are not infectious when they are taking medication or when their viral loads (i.e., the amount of virus present in an individual’s blood) are at an undetectable level (which is the case in many individuals currently taking HAART). These misconceptions can result in increased risk-taking behaviors, most specifically unsafe sex practices.
In addition to a lack of safer sex practices, unknown HIV status is another significant risk factor for MSM. Although the proportion of men who are unaware of their HIV-positive status is high across all adults and adolescents in the MSM group, studies show that African American MSM are more likely than Hispanic or European American MSM to be unaware of their infection (CDC, 2005e). Related to each of the aforementioned risk factors is the stigma (assigned by society in general as well as specific cultures) associated with homosexual practices and the fear of disclosing such practices, HIV status, or both.
Injection Drug Use
At the end of 2005, IDU had accounted for approximately 14 percent of individuals infected with HIV (third behind MSM and “high-risk” heterosexual contact) and 23 percent of individuals whose HIV infection had progressed to AIDS (second behind MSM; CDC, 2005a). In general, IDU is a slightly more significant risk behavior for female adolescent and adult injected drug (ID) users (17 percent were infected this way) than for male adolescent and adult ID users (13 percent). African American women account for the largest proportion (52 percent) of HIV-positive female ID users, followed by European American (30 percent), Hispanic (16 percent), Asian/Pacific Islander (less than 1 percent), and American Indian/Alaskan Native (less than 1 percent) women. A slightly different ethnic trend is seen among male ID users, in that Hispanic males represent the second-highest IDU group, European American males represent the third-highest group, Native American/Alaskan Natives are fourth, and Asian/Pacific Islanders are fifth. African American males represent 50 percent of male ID users.
It is important to note that using injection drugs not only places the user at risk for HIV but also places those individuals intimately connected to the user at risk. In 2000, 28 percent of the 42,146 new cases of AIDS were IDU-associated (CDC, 2002). The term is “IDU-associated” because IDU can contribute to the transmission of HIV both directly and indirectly. Of the 11,635 new IDU-associated AIDS diagnoses in 2000, 73 percent were ID users, 13 percent were sex partners of ID users, 13 percent were both MSM and ID users, and 1 percent were children of ID users or their sex partners. The rates of IDU-associated AIDS diagnoses further differ by sex and race and ethnicity. In general, IDU-associated AIDS diagnoses are more common in adolescent and adult women than in men. Specifically, 57 percent of all AIDS cases among women have been attributed to IDU, either directly (IDU) or indirectly (unprotected sex with an ID user), compared with 31 percent of cases among men. In 2000, IDU-associated AIDS was significantly more prevalent among Hispanic (31 percent) and African American (26 percent) adolescents and adults than among European American (19 percent) adolescents and adults.
Crack cocaine and IDU are strong predictors of inconsistent condom use for both HIV-infected and uninfected individuals across genders (Hader, Smith, Moore, & Holmberg, 2001). Therefore, in addition to the more obvious HIV risk of needle sharing, unsafe sex is one of the primary risk factors for the transmission of HIV by ID users. Further, the common practice of trading sex for drugs in low-income areas can lead to decreased condom use and therefore increased risk for HIV and AIDS (Hader et al., 2001). Finally, ID users may be less likely to have medical insurance or to seek medical care, both of which act as barriers to receiving HIV testing and treatment and can facilitate the spread of HIV and AIDS among this group of individuals (CDC, 2002).
“High-Risk” Heterosexual Contact
As defined by the CDC (2005a), this transmission category can include sex with an ID user, sex with a bisexual male, sex with a person with hemophilia, sex with an HIV-infected transfusion recipient, or sex with an HIV-infected person—risk factor not specified. As a whole, this category was composed primarily of HIV-positive women (70 percent) in 2005. This may be because women are more easily infected with HIV through vaginal intercourse than are men. Across ethnicities, high-risk heterosexual contact was the leading cause of HIV infection and AIDS for female adults and adolescents. Of the 33,678 women living with HIV who were infected heterosexually, 63 percent were African American, 20 percent were European American, and 16 percent were Hispanic. Asian/Pacific Islanders and American Indian/Native Alaskans each constituted less than 1 percent of the women in this category. Percentages of heterosexually infected male adults and adolescents across races and ethnicities, as compared to the other transmission categories, ranged from 3 percent (European Americans) to 13 percent (African Americans). Researchers have suggested several factors to explain the high prevalence of HIV/AIDS in male and female African Americans. One is the presence of other sexually transmitted diseases (STDs), particularly those that can cause genital sores or lesions, which can provide an access point for HIV (Fleming & Wasserheit, 1999). African Americans currently have the highest rate of STDs, being 18 times as likely as European Americans to have gonorrhea and 5 times as likely to have syphilis, which therefore makes them more susceptible to HIV infection (CDC, 2006a).
There are many factors that place women at an increased risk for HIV infection through high-risk heterosexual contact, and although some are similar to those discussed in previous sections (e.g., unknown HIV status of partner, drug use), others are specific to women. Younger women are at a higher risk for HIV infection at an earlier age (particularly early teens and 20s) than are heterosexual young men because young women are often involved sexually with older men who have had previous exposure to HIV infection (Hader et al., 2001). Another factor is women’s lack of knowledge regarding their sexual partner’s risk for HIV. As previously mentioned, one of the behaviors in this category is sex with a bisexual male. Montgomery and colleagues (2003) examined HIV-infected men and women, specifically focusing on sexual identity and bisexual behavior in men and the proportion of women who acknowledged having a bisexual male sex partner. The researchers found that although 34 percent of African American, 26 percent of Hispanic, and 13 percent of European American MSM in their sample reported having sex with women, only 6 percent of African American, 6 percent of Hispanic, and 14 percent of European American women in their sample acknowledged having a bisexual partner. In other words, many women may not be aware that they are engaging in high-risk sexual contact with a bisexual male.
Women also face significant social challenges that place them at a disadvantage in society and subsequently affect their risk for HIV infection (Hader et al., 2001). For example, in some cultures it is not acceptable for women to express the desire for safer sex practices and to initiate the use of condoms. These women are therefore unable to take the necessary precautions to protect themselves from HIV/AIDS because of cultural and societal norms. Further, the very activities that place women at a high risk for infection (i.e., high-risk heterosexual contact, IDU) may also increase their risk of exposure to violence, abuse, family problems, and a lack of social support (Hader et al., 2001), all of which are known to have a detrimental effect on psychological functioning. These high-risk activities and lack of support can either precede HIV infection or occur as a result of HIV infection.
One last concern specific to women is the interaction between hormonal factors and pregnancy and their HIV medication. Approximately 80 percent of the women living with HIV/AIDS in the United States are of child-bearing age (CDC, 2001). Some HIV medications may decrease the efficacy of oral contraception, thereby increasing the risk of pregnancy among HIV-infected women who do not incorporate an alternative means of birth control (Hader et al., 2001). This leads into the next population to be discussed, infants infected perinatally by their mothers and children living with HIV/AIDS.
Infants and Children Living With HIV/AIDS
HIV transmission from mother to child during pregnancy, labor, delivery, or breast-feeding is known as perinatal transmission (CDC, 2006b). This is the most frequent method of transmission of HIV to children in the United States. There are common misconceptions that all babies birthed by HIV-positive women will be HIV-positive and experience a quick death; however, neither of these is the case. Because an infant has the mother’s antibodies present in his or her blood at birth, the initial HIV test may detect these antibodies and come out positive. But, all this test is detecting is the mother’s HIV infection; the baby’s HIV status will not be known until the infant develops her or his own antibodies. At that point, the infant is tested and the results will indicate whether he or she was truly infected or is actually not infected. Several measures can be taken to reduce the chance of perinatal transmission of HIV, including the mother’s taking antiretroviral medication during her pregnancy (most effectively during the 2nd and 3rd trimesters), having a cesarean section to prevent exposing the infant to the birth canal, administering antiretroviral medication to the infant immediately after birth, and providing the infant with prepared formula as opposed to the mother’s breast milk (Wessner, 2006). If the infant is administered a strict antiretroviral medication for a specified time period after birth, there is a 98 percent chance that the baby will test negative after the mother’s antibodies have left his or her system (Fernandez & Ruiz, 2006). In other words, less than 2 percent of infants born to HIV-positive mothers, who are administered a strict antiretroviral treatment regimen immediately after birth, will become HIV-positive. One final point to make is that for babies who remain HIV-positive the verdict is not necessarily an immediate death sentence. As is mentioned in the treatment section of this research paper, survival after AIDS diagnosis is greatest for children under the age of 13. Of the children who had been infected with HIV perinatally and received a diagnosis of AIDS in 2001, 95 percent were still living more than three years later (CDC, 2005a).
The number of infants infected perinatally has decreased dramatically since the implementation of antiretroviral treatments. The mid-1990s witnessed a peak of 1,750 perinatal transmissions per year; in 2000, the number had declined to 280–370 perinatal transmissions a year and, in 2005, approximately 111 infants were diagnosed with HIV (92) or AIDS (19) as a result of perinatal transmission (CDC, 2001, 2005a). Since the start of the epidemic, approximately 8,779 children who were infected with HIV perinatally were eventually diagnosed with AIDS. Approximately 5,000 of those children have died (CDC, 2006b). In 2004, 47 children who were infected with HIV perinatally were given a diagnosis of AIDS. Consistent with other trends, the prevalence of HIV/AIDS in infants and children varies by ethnicity. Of the 48 children diagnosed with AIDS in 2004 (47 infected perinatally, 1 infected in an unknown way), 29 were African American, 8 were Hispanic, 7 were European American, and 4 were other/race unknown. Of all the perinatally infected individuals living with AIDS at the end of 2005, 67 percent were African American, 18 percent were Hispanic, 14 percent were European American, and less than 1 percent were American Indian/Native Alaskan and/or Asian/Pacific Islanders (CDC, 2005a).
With all the treatment and prevention measures that are available for HIV-positive pregnant women, the main factor associated with perinatal transmission is lack of awareness. This can refer either to unknown seropositive status on the part of the HIV-infected mother or to women who are unaware of information regarding the available treatment and prevention options. It is not uncommon for women to first become aware of their seropositive status once they become pregnant. Although HIV testing rates vary across states, studies have shown that there is a high number of women who are unaware that treatment is available that will reduce the risk of perinatal transmission (Anderson, Ebrahim, & Sansom, 2004). Therefore, prevention efforts to date have focused primarily on increasing the availability of this information to women who are pregnant or considering becoming pregnant.
Current Treatment Regimens
Treatment regimens for individuals living with HIV have progressed significantly since the first antiretroviral drug, Zidovudine (AZT), was approved for the treatment of HIV by the FDA in March of 1987 (Wessner, 2006). So much, in fact, that HIV is now called a chronic rather than a terminal illness (Fernandez & Ruiz, 2006). The implementation of antiretroviral therapy has resulted in an 80 percent decline in AIDS death rates from 1990 to 2003 (Joint United Nations Programme on HIV/AIDS, 2006). The percentage of individuals in the United States who survived for two or more years after being diagnosed with AIDS increased from 64 percent during 1993 to 1995 to 85 percent during 1996 to 2005 (JUNPHA, 2006). Survival rates vary by age at diagnosis, transmission categories, and race and ethnicity. As the age at which an individual is diagnosed with HIV/ AIDS increases, the survival rate decreases, particularly when comparing individuals under the age of 35 to those older than 35. Survival is greatest for children under the age of 13 (CDC, 2005a). Among transmission categories, MSM and infants infected by their mothers have the greatest survival rate, whereas survival is lowest for injection drug users. According to the CDC (2005a), survival was greater for Asian/Pacific Islanders, European Americans, and Hispanics when compared with African Americans.
Three Categories of Drugs
Currently, there are 26 FDA-approved antiretroviral drugs for the treatment of HIV/AIDS, all of which fall into one of three categories: reverse transcriptase (RT) inhibitors, protease inhibitors (PI), and fusion inhibitors. The first category of antiretroviral drugs, reverse transcriptase inhibitors, work at the early stage of HIV infection and interrupt the virus’s ability to make copies of itself. There are two main types of RT inhibitors: nucleoside/nucleotide RT inhibitors (NRTI) and nonnucleoside RT inhibitors (NNRTI). NRTIs block HIV from replicating within a cell, whereas NNRTIs interfere with the virus’s ability to convert HIV RNA into HIV DNA (National Institute of Allergy and Infectious Disease, 2006). These drugs may slow the spread of HIV in the body and delay the onset of opportunistic infections (NIAID). Some examples of NRTIs include AZT, Abacavir, and Tenofovir, whereas Rescriptor and Viramune are examples of NNRTIs. The second category of antiretroviral drugs is protease inhibitors (PI). PIs interrupt the replication cycle of the virus at a later stage in its life cycle. Specifically, these drugs interfere with the protease enzyme that HIV uses to produce infectious viral particles (NIAID). Some examples include Ritonavir, Saquinivir, Indinavir, and Lopinavir. The third class of drugs is fusion inhibitors; these drugs interfere with the virus’s ability to fuse with the cellular membrane, thereby blocking entry into the host cell. There is currently only one fusion inhibitor approved by the FDA, Fuzeon (NIAID).
Before the development of PIs, treatment for HIV-positive individuals involved the administration of either an NRTI or NNRTI, typically referred to as monotherapy (Wessner, 2006). Although RT inhibitors were initially very successful at slowing the progression of HIV, medical researchers soon discovered that some individuals were not responding to these drugs. As mentioned at the beginning of this research paper, HIV is a complex retrovirus that has the ability to mutate and change frequently in response to the drugs administered to combat the infection. Researchers soon discovered mutations of HIV that were resistant to AZT (Fernandez & Ruiz, 2006). But because each drug in this RT category functioned in basically the same way, AZT resistance soon generalized to the other drugs in this class (Wessner, 2006). As resistance to particular drugs became known, researchers devised a new strategy called combination therapy, where more than one medication was given at a time in order to delay the development of resistance. Once PIs were developed, researchers implemented a new type of combination therapy, called highly active antiretroviral therapy (HAART). HAART involves the administration of multiple drugs to combat the virus at several different stages in its development. A typical combination treatment involves three drugs: two NNRTIs and a PI. HAART can be given to anyone infected with HIV, from those who are newly infected to those who have been diagnosed with AIDS. For many people living with HIV/AIDS, HAART dramatically reduces viral replication and the individual’s viral load, increases CD4 counts, and improves the immune system. For many individuals, HAART reduces their viral load to an undetectable level and delays the onset of AIDS indefinitely (Fernandez & Ruiz, 2006).
Clearly, there are many benefits to HAART, but there are also several important drawbacks. Adverse side effects, such as high toxicity, neuropathy (a disease affecting the peripheral nervous system), chronic diarrhea, and extreme fatigue make HAART less appealing to some individuals. Furthermore, until recently, the number of pills and special requirements accompanying each pill (e.g., some with food, some on empty stomach, some at night, some first thing in the morning) made treatment regimens highly complex and difficult to adhere to. Because of the side effects and complexity of these regimens, studies on adherence have suggested that individuals take fewer than half their prescribed doses (Fernandez & Ruiz, 2006). Frequently missing doses can cause a number of problems, including developing further resistance to medication, as will be discussed. One final drawback to antiretroviral therapy in general is the cost of the medication. In the United States, antiretroviral therapy can easily exceed $12,000 per year (Wessner, 2006). These high costs pose a problem not only in the United States, but in all regions of the world.
The significant success of HAART in reducing HIV/ AIDS symptoms and mortality has resulted in improved health status, increased well-being, better quality of life, and more energy for individuals living with HIV/AIDS. However, despite the obvious positive outcomes for individuals living longer and “healthier” with HIV/AIDS, there are still some areas of concern. One negative outcome from individuals feeling healthier is the increase of risk-taking behavior by certain populations of HIV-positive individuals (del Rio, 2003). As noted earlier, many individuals incorrectly believe that because their viral load is currently undetectable as a result of treatment with HAART, they cannot transmit the virus to others (del Rio, 2003).
An area of concern that is directly related to the antiretroviral treatment regimen is the emergence of drug-resistant mutations of HIV. Resistance to medication can develop in several ways. First, resistance can develop as the time an individual is on medication increases. As people are living longer with HIV and are on medication longer, the virus is given more time to build up a resistance to the medication. This is not necessarily something that HIV-positive individuals themselves can prevent, which is why some people try to delay taking medication for as long as they can so that they will not develop resistance to it as quickly. HIV-positive individuals do have control over the second way that resistance can develop. Researchers have suggested that nonadherence to the treatment regimen can cause viral resistance (Fernandez & Ruiz, 2006). Nonadherence may occur for any number of reasons including, but not limited to, forgetting, adverse side effects, lack of understanding how to take the medication, life stress, depressed mood, and anxiety (Hader et al., 2001). Individuals who begin a treatment regimen but inconsistently adhere to it by missing doses frequently seem to be more susceptible to viral resistance than those who do not take medication or who rarely take their meds (Fernandez & Ruiz, 2006). For those individuals who infrequently take their medication, once viral resistance has developed it is futile to resume a strict treatment regimen. These same individuals who show low treatment adherence were also more likely to engage in higher rates of risk-taking behaviors (e.g., unprotected sexual intercourse, needle sharing; del Rio, 2003). This suggests the increased potential for the transmission of a drug-resistant variant of HIV to an uninfected individual.
Thus, a final way an individual can be resistant to medication is when he or she is infected with a drug-resistant mutation or strand of the virus. Although researchers have studied transmission of drug-resistant mutations of HIV for at least 10 years; the trends have been ill-defined (Little et al., 2002). Del Rio reported that the prevalence of high-level antiretroviral resistance in recently infected individuals increased from 3.4 percent in 1995 to 1998 to 12.4 percent in 1999 to 2000. Little and colleagues (2002) reported that almost 25 percent of newly infected individuals were infected with a variant of the virus that was resistant to at least one of the commonly used antiretroviral drugs. Little’s group (1999) found that the proportion of newly infected individuals who acquired a variant of HIV that was resistant to at least two or more classes of antiretroviral drugs was 2.7 percent in San Francisco, 2.9 percent in Geneva, 3.8 percent in New York City, and 1.4 percent in Los Angeles, San Diego, Boston, and Denver. Grant and colleagues (2002) assessed 225 individuals recently infected with HIV living in an area that had a high rate of antiretroviral treatment from 1996 through 2001. The researchers found that there was a significant increase in the number of individuals resistant to NNRTIs after 1999, which may have been because of the increase of NNRTI use the previous year. However, they observed that PI-resistance remained relatively stable throughout the duration of their study. Furthermore, they found that resistance to three classes of antiretroviral drug was extremely rare, occurring in only 1 out of 225 participants.
Of note here is the possible occurrence of coinfection among two HIV-positive sexual partners or ID users. Many people assume that two individuals who are both aware of their HIV-positive status do not need to practice safer sex or to refrain from needle sharing because both individuals are already infected with HIV; however, this is not the case. As we just discussed, there are drug-resistant strains of HIV present in many HIV-positive individuals. Individuals who engage in unprotected sex and needle sharing are taking the chance of acquiring a second strain of HIV from their partner, one that could be resistant to some medications, perhaps even the ones they are currently taking.
Finally, a specific issue is that some studies have shown that HIV-positive women report worse physical functioning than do HIV-positive men at similar stages of the disease (as cited in Hader et al., 2001) and are more likely to access emergency department services for their outpatient care (Bozzette et al., 1998). In general, some research has shown that women may be less likely to receive antiretroviral treatment because of their ethnicity, lack of education, IDU, and lack of insurance, among other factors (Hader et al., 2001). Although these factors are all barriers to receiving treatment, they also increase the risk of nonadherence to treatment. Only about 75 percent of women report taking their medications exactly or almost exactly as prescribed (Hader et al., 2001).
Global Impact of HIV/AIDS
It is clear that the HIV/AIDS epidemic is not exclusive to the United States. Every day, approximately 15,000 people worldwide become newly infected with HIV (Wessner, 2006). As of 2006, an estimated 39.5 million people (37.2 million adults and 2.3 million children under the age of 15) worldwide were living with HIV (JUNPHA, 2006). Included in this estimate are the 4.3 million adults (3.8 million) and children (530,000) newly infected with HIV in 2006. In 2006, the Joint United Nations Programme on HIV/AIDS (UNAIDS) issued an AIDS epidemic update analyzing the recent global and regional trends. In order to assess these trends, researchers broke the world down into 10 different regions. Although each of the 10 regions saw an increase in the number of individuals living with HIV since 2004, the most dramatic increases occurred in the regions of East Asia, Eastern Europe, and Central Asia. However, similar to the situation in the United States, the rate of infection differs by population group and transmission category. We will discuss the two regions that have been the most devastated by this epidemic.
Sub-Saharan Africa has been the region hit hardest by the HIV/AIDS epidemic, and this trend continued in 2006. The estimated 25 million individuals living with HIV in Sub-Saharan Africa constitute 63 percent of all individuals living with HIV globally. Sub-Saharan Africa also had the highest number of deaths from AIDS in 2006 (2.1 million) and the highest number of newly infected individuals during 2006 (2.8 million). The southern part of Africa is the area most devastated by this epidemic, where every country except one (Zimbabwe) saw an increase in the prevalence of HIV. This region includes Swaziland, the country with the most severe HIV epidemic in the world, where an estimated 33 percent of adults were living with HIV in 2005.
The second most-affected continent is Asia, more specifically the region of South and Southeast Asia. This region had the second-highest number of adults and children living with HIV in 2006 (7.8 million), as well as the second-highest number of individuals newly infected with HIV (860,000) and deaths from AIDS (590,000). The high prevalence of HIV/AIDS in this region is due in large part to the high rate of unprotected paid sex by commercial sex workers (CSW) and their clients. Although HIV does affect the general population, its prevalence is largely concentrated around several specific populations. In 2005, 41 percent of individuals living with HIV in South and Southeast Asia were clients of CSW, 22 percent were ID users, 8 percent were CSW, 5 percent were MSM, and 24 percent were others.
In terms of prevention and treatment, the women in these countries who are of childbearing age and infected with HIV are likely not aware of the preventative measures available to reduce perinatal transmission, do not have access to such measures (e.g., formula for the infant, medical technology needed to perform a cesarean section), or there are cultural reasons not to employ them. Further, most individuals living with HIV disease in developing countries do not have access to antiretroviral medication because it is too expensive. This means they die more quickly than do those with HIV/AIDS in places like the United States or Western Europe.
Risk Reduction and Prevention Strategies
Much of the prevention strategies to date have targeted HIV-negative individuals, generally combining theory and education into helping these individuals develop new cognitive, social, and technical skills and competencies associated with safer sex practices and “safe” drug use (del Rio, 2003). Outreach programs have focused on providing educational material, contraceptives, and even clean needles and syringes to those populations who are most at risk. However, some researchers have advocated for a shift in focus, claiming that prevention of further transmission by HIV-positive individuals has been largely neglected in prevention strategies (del Rio, 2003).
Researchers (CDC, 2004; Weinhardt, Carey, Johnson, & Bickham, 1999) have found that individuals who are aware of their HIV serostatus are more likely to change their behavior and engage in safer practices to reduce the risk of transmitting the virus to others. Therefore, one of the primary goals in HIV prevention and risk reduction counseling is to increase the awareness of individuals living with HIV. Furthermore, medical and mental health professionals, risk reduction counselors, and anyone else who may work with HIV-positive persons currently taking antiretroviral medication should make a special effort to inform those individuals that the medication is not a prevention measure against transmitting HIV/AIDS. Rather, it works to slow the progression of HIV/AIDS. These individuals need to be explicitly told that even though their viral loads are low or even undetectable and they are “feeling fine,” they are still able to pass HIV to another person. Finally, with the number of people becoming resistant to medication and/or acquiring resistant strains of the virus increasing, professionals need to make efforts to educate the HIV-positive population about the risks of developing or transmitting resistant strains. Several programs, such as the CDC’s “HIV Prevention Strategic Plan Through 2005” and the Institute of Medicine’s “No Time to Lose: Getting More Out of HIV Prevention,” have been developed and implemented; however, more efforts are needed (del Rio, 2003).
The HIV/AIDS epidemic is a worldwide issue that affects millions of people. This research paper has provided an overview of HIV, current treatments, special populations that are particularly affected, risk factors for HIV infection, the problem of developing resistance, and suggestions for prevention efforts. More research is needed to develop effective prevention strategies and programs to help both HIV-negative and HIV-positive individuals.
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