Communicable Diseases: Global HIV Epidemiology, Role of Agent, Host and Environmental Factors
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This paper explores HIV in all its major aspects including global HIV epidemiology, the role of HIV agents, host and environmental factors that affect HIV infection and transmission, and potential policy responses.
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Communicable Diseases2 Human Immunodeficiency Virus (HIV) Introduction The Human Immunodeficiency Virus (HIV) is a type of virus that is only found in human beings and attacks and destroys the immune system thus making the body unable to fight against illnesses and infections. More specifically, HIV breaks down the immune system of the body by attacking the white blood cells thus undermining the entire immune system. HIV virus causes acquired immunodeficiency syndrome (AIDS) which is also its advanced stage. The individuals infected with HIV may manifest signs of AIDS after a long time ranging from months to more than fifteen years. Scientists first discovered strange symptoms of sickness amongst gay men in the US in 1981. The symptoms included rare chest infection and skin diseases, and the lab test indicated a damaged immune system. Subsequently, a new virus was identified by French researchers in 1983 and termed as HIV and as the causative virus for AIDS. This virus was later identified as HIV-1. Another type of HIV was recognized in 1985 as HIV-2 among the sex workers in Senegal.Appay and Sauce (2008) observes thatthe HIV-2 has high prevalence in West Africa and is slightly less harmful and not rapidly transmitted as HIV-1. Advanced researches have also led to the identification of other several strains of HIV such as strain C which is prevalent in South Africa. The initial cases of HIV were identified in gay men, but since then the disease has been reported to be on the highest in marginalized groups and injecting drug users. However, HIV and AIDS are not restricted to gay men or drug users by injection, but instead, it is spread through several kinds of sexual conduct or unintentional exposure to HIV infected blood or any other body fluids.Fettig, Swaminathan, Murrill, and Kaplan (2014) elucidates thatthere have been alternating trends in the prevalence and incidence of HIV worldwide. This paper purposes to explore HIV in all its major aspects. The major sections
Communicable Diseases3 considered in this paper include the global HIV epidemiology, the role of HIV agents, host and environmental factors that affect HIV infection and transmission, and potential policy responses. Global HIV Epidemiology The World Health Organization (WHO, 2013) observed that different populations have varying levels of HIV vulnerability, and they can be determined by centring on certain social and demographic features of a given area. As a result, the global epidemiology in this paper is discussed regionally Sub-Saharan Africa The UNAIDS (2013) note that HIV dominance in sub-Saharan Africa indicates that the frequency of new infections is much lower and death rates associated with AIDS is equally low. The report further suggests that there are over 50% reduction in the incidences of HIV in sub-Saharan Africa between 2000 and 2012 among the adults, consistent with the reduction in HIV infections by one million in 2012 compared with 2000 (UNAIDS, 2013). Additionally, the PLHIV has simultaneously increased by almost six million between 2000 and 2012, and this high survival rate can be ascribed to the use of antiretroviral drugs (ART). Consequently, the mortality rates due to AIDS has also decreased by 1.2 million between 2000 and 2012. Unprotected heterosexual behaviour is still the leading way of HIV epidemic in sub-Saharan Africa (UNAIDS, 2013). Asia The UNAIDS (2013) report indicates that Asia is the second leading continent in HIV prevalence after Africa. Just like in sub-Saharan Africa, there is a decrease in HIV incidences in Asia, but there exist significant epidemiological variations with the noticeable one being
Communicable Diseases4 that HIV infection is prevalent in key populations. Notwithstanding the reduction in the spread of HIV, there was an increase in the PLHIV by 1 million between 2000 and 2012 due to increased survival (UNAIDS, 2013). Furthermore, the AIDS-related mortality rate in Asia among children and adults have gradually reduced by 70,000 from 2005 to 2012. There is improvement in the accessibility to ART services while the PMTCT services are still inadequate, with less than 20% of expectant mothers gaining access to ART. According to the NHFPC (2014) report, the leading countries in the burden of HIV are India and China with the primary transmission mode in China being heterosexual (46.5%) followed by injection drug use (28.4%) (NHFPC, 2014). The report further indicates that sex workers account for 0.3% and MSM for 6.3% of the overall HIV prevalence in China. India reports the highest number of PLHIV in Asia accounting for 2.1 million individuals living with HIV (PLHIV). Nevertheless, the prevalence in India significantly varies by region with the Southern states having higher prevalence rates than the Northern states (UNAIDS, 2013). North Africa and the Middle East The Middle East and North Africa have reported a continuous rise in the cases of new HIV transmissions and death rates, unlike the trend observed in Asia and sub-Saharan Africa. There was an approximate increase in the cases of PLHIV by 50%, AIDS mortality rate by 32%, and the annual rate of new infections by 60% (World Health Organization, 2011). However, the overall prevalence of HIV is still epidemic in sub-Saharan Africa than in the Middle East and North Africa (UNAIDS, 2013). Gökengin, Doroudi, Tohme, Collins, and Madani (2016) have attributed the lower rate of HIV prevalence in the Middle East and North Africa to the decreased incidences of sexual risk conduct and the universal male circumcision. Moreover, available data shows that the common transmission modes for HIV are injection drug use (IDU), MSM and unprotected sex with the prevalence in countries like
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Communicable Diseases5 Djibouti, South Sudan, and Somalia being caused by commercial sex workers (UNAIDS, 2013). Gökengin et al. (2016) reports that Pakistan, Oman, Tunisia, and Iran are leading in the spread of HIV through injection drug use. Notwithstanding the declining prevalence of HIV, the mortality incidence associated with AIDS shows the extent of inadequate response to HIV. The UNAIDS report indicated that only 11% of the patients who need ART were enlisted in the intervention program in 2012 (UNAIDS, 2011). Latin America and the Caribbean Latin America has reported fairly steady HIV prevalence for the past ten years, with a gradual decline in the HIV incidence and mortality rates associated with AIDS leading to a considerable growth in the number of PLHIV by approximately over 1 million between 2012 and 2000 (UNAIDS, 2013). De Boni, Veloso and Grinsztejn (2014) points out that the approximate adult HIV incidence rate is greater in the Caribbean compared to South America by 1. The leading proportion of PLHIV in the Caribbean and Latin America are the females (60%) which also represent the highest rate globally. The UNAIDS (2013) reports a decrease in the rate of new infections of HIV among many Caribbean countries by 50% despite the increased HIV burden. The MSM accounts for the highest prevalence rates of HIV with over 60% of the countries in the region recording over 10% prevalence rate among the MSM (UNAIDS, 2013). The study by Beyrer et al. (2012) revists on the prevalence of HIV and shows that the Caribbean region records the leading HIV prevalence rate among the MSM globally in which about 25% of MSM have PLHIV. Incidences of transgender women (TGW) being diagnosed with HIV is also very high in Latin America with over 30% of the cases being reported in Peru. Moreover, De Boni, Veloso and Grinsztejn (2014) point that a significant increase in the coverage of ART throughout Latin America and the Caribbean with 79% of the expectant women and are PLHIV being enlisted for ART.
Communicable Diseases6 Oceania, Western Europe, and North America There exists up-to-date data on HIV prevalence in developed nations such as North America, Oceania, and Western Europe as contrasted to the developing countries (Sullivan, Jones, & Baral, 2014). The PLHIV rate in North America has been observed to be on the rise between 2012 and 2000 by approximately 3 million. However, there is a steady trend in the adults’ prevalence of 0.5% at the same time. The rate of PLHIV in Western Europe has also risen by 290,000 between the year 2000 and 2012, whereas in Oceania it has increased by 17,000 during the same period. The death rates associated with AIDS has significantly reduced in all the three regions in the past decade (UNAIDS, 2013). The CDC (2011) report indicates that all the three areas have reported an increase in the access to ART, with 89% of PLHIV under medication in the US being taken through ART in 2010. Role of Agent Two forms of HIV namely HIV-1 and HIV-2 exist. Both are spread similarly and are related to the same adaptable infections and AIDS. HIV-1 The infection of HIV-1 takes place in the mucosal surfaces or through express inoculation. HIV-1 initially meet the dendritic cells (DC) which later on enhance its spread to CD4+T lymphocytes. Izquierdo-Useros et al. (2012) further note that the HIV-1 is then bonded by the DC-sign at its domain in the absence of specific cellular infection and moves HIV-1 to lymphoid tissue. Both the unaffected and infected cells are then transported in masses to the areas where HIV-1 is found (regional lymph nodes), and it then multiplies within days to weeks (Salazar-Gonzalez et al., 2008). After cells have been infected with HIV-1, the virus then integrates into the genetic structure of the host and either starts phases of duplication or
Communicable Diseases7 remains in a state of inactivity, leading to concealed infection in cellular reservoirs. Cohen et al. (2011) carried out a study on the prevention of HIV-1 infection and notices that the propagation of the virus into the anatomic cells such as the CNS takes place at the initial stages of infection. The quick multiplication of the virus in the most infected cells leads to widespread distribution. Approximately four days and above are required for viremia to be clinically detected. The acute retroviral syndrome appears within two to six week of infection, and these include fatigue, fever, weight loss, nausea, sweating at night and diarrhea (Socías et al., 2011). HIV-2 Burgard et al. (2010) observed in their study on maternal transmission of HIV-2 and was able to note that the transmission modes for HIV-2 are the same as those of HIV-1, and these include the sharing of sharp objects such as needles, sexual contact, and perinatal transmission. Nonetheless, the infectivity of HIV-2 is much lower than HIV-1, an aspect attributed to the lower RNA levels in HIV-2 according to the French Prenatal Cohort. The infection of HIV-2 is remarkable for an extended asymptomatic level and slow advancement to AIDS than the epidemic of HIV-1 (Campbell-Yesufu, & Gandhi, 2011). van der Loeff et al. (2010) also found out that the progression rate of AIDS for HIV-2 in infected people is not constant. While some of those diagnosed with the HIV-2 manifest progressive development of immunodeficiency and illnesses associated to AIDS, and same as to those patients infected with HIV-1, others show usual progress or survival at a slower rate. Furthermore, the HIV-2 infection has high CD4 cell counts and reduced viral levels of RNA when compared to those observed in HIV-1 infection (Campbell-Yesufu, & Gandhi, 2011). Once there is the development of advanced immunodeficiency, the patients infected with HIV-2 have a high death rate. The unique nature of HIV-2 is that it is less virulent, and this
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Communicable Diseases8 has been pointed out as the likelihood of it being used as an acquired immune in the protection against HIV-1 infection. A study conducted by Appay and Sauce (2008) indicated that successive infection from HIV-1 was barred by HIV-2. Host and Environmental Factors Several studies conducted using non-human primate models to demonstrate HIV pathogenesis have shown the significance of viral accessory genes in the development of HIV. As a result, several host factors that regulate viral entry have been explored. Some of these host factors include the HIV-1 co-receptors (CCR5 & CXCR4), CCR2 and CX3CR1 among others. According to Henrich and Kuritzkes (2013) the entrance of the HIV-1 virus into the target cells involves a multi-step process that ends in the integration of the virus and cell membranes. HIV-1 makes use of the CD4 as its primary receptor, and therefore the virus binds itself to CD4 then adaptive deviations in the viral envelope results to the involvement of one of the viral co-receptors, i.e., CXCR4 or CCR5. Studies on genetic polymorphisms have proved to protect HIV-1 infection, all attributed to the CCR532 allele (Perez et al., 2008). On the other hand, polymorphisms in some chemokine receptors seem to apply some protection against HIV-1 infection or disease advancement. The CCR2-641 produces the most persuasive evidence in which there is a substitution of the isoleucine 64 with valine (Bonecchi et al., 2009). Assertions have also been made on the slow progress to AIDS for heterozygous people with CCR2-64I but remain controversial as there exist studies that contradict these conclusions (Liu, Kong, Wu, Ying, & Zhu, 2012). Existing studies have also shown the absence of alterations in the CCR2 or CCR5 levels of surface expression in CCR2- 64I (Mahajan et al., 2010). A study by Narter, Agachan, Sozen, Cincin, and Isbir (2010) showed decreased surface CCR5 and pointed out that CCR2-64I is likely to bind with high
Communicable Diseases9 affinity to CCR5 within the cells and consequently hinder CCR5 expression at the surface of the cell. However, the authors did not prove these findings and thus calling for additional research on the same. The relationship between the environmental factors and HIV have been explored by several researchers and the impact of the association on the individual and society demonstrated. The local natural resources are essential income generating sources in most of the developing countries. Additionally, the health status of the native environment influences individual vulnerability to HIV in two significant ways based on the study by Lane et al. (2011). The first one is that the inadequacy of the resources increases poverty level in the areas that rely on natural resources, especially in sub-Saharan Africa. Studies have reported that poor economic situations can increase the risk of HIV infection by circumstantially forcing people, more so females to involve themselves in commercial sex to meet their daily needs (Lane et al., 2011). Secondly, the shortage of natural resources can result in food insecurity and poor nutrition, which can further weaken the immune system of PLHIV. Mamlin et al. (2009) indicated that the vulnerability of HIV infected people is increased by malnutrition cases and at the same time fostering the risk of transmitting HIV to the baby from the mother during nursing. Studies in Cambodia indicate that the effectiveness of the treatment of HIV/AIDS was undermined by incidences of malnutrition (Argemi et al., 2012). The spread and transmission of HIV are also affected by environmental changes. For instance, Battisti and Naylor (2009) showed that unproductive or wasted environments lead to reduced agricultural production, leading to undernourishment and all its negative impacts on one’s welfare and immunity. According to Mitchell and Borchard (2014) the unavailability of clean water and the long distances to water access increases the possibility of water-borne diseases, a significant aspect of opportunistic infection that impacts PLWHA.
Communicable Diseases10 Minimal plant diversity and loss of variety of species reduce the accessibility to valuable plants some of which have been found to have properties that are anti-HIV (Ezeaku & Davidson 2008). Potential Policy Responses Due to the disease burden of HIV, several potential policy responses aimed at preventing and managing the infection and transmission of HIV have been made by different countries. Some of these include peer education, harm reduction, and the establishment of relevant laws. Peer Education The Australia Department of Health has majorly used peer education as a practical approach in offering prevention education on HIV (The Department of Health, 2014). The peer-based education approach has been appraised in many quotas to be more effective than training designed and delivered by outside agencies. Bavinton, Gray, and Prestage (2013) assert that peer educators are more successful because they are familiar with the norm and language of a given group or subjects and can readily be welcomed by its subjects. Medley, Kennedy, O'Reilly, and Sweat (2009) carried out a meta-analysis on the efficacy of peer education in the deterrence of HIV and found out that the involvement of former sex workers as peer educators was more operational than engaging external agencies. Cornish and Campbell (2009) also reported peer education to be more successful among commercial sex workers. Harm Reduction Australia has also developed the principle of harm reduction over time as a strategy towards minimizing the negative impacts related to drug and substance abuse. The strategy of harm reduction implemented so far include syringe and needle exchange programs, offering peer education on safe practices in the use of drugs and treatment intervention programs (The
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Communicable Diseases11 Department of Health, 2009). Several reports have been made on the efficacy of Needle and syringe programs (NSPs). For instance, the Commonwealth Department of Health and Ageing and NCHECR (2009) report that the NPS led prevented 32,050 HIV infections which further minimized the cost of preventing infection and spread of HIV (The Department of Health, 2009). Additionally, the Kirby Institute report on the Australian NSPs indicated that HIV transmission through drug injection had maintained below 2.1% (The Kirby Institute, 2015). HIV and the Law The government of Australia has also established a helpful legal framework aimed at emergency response to HIV. According to the UNAIDS (2014) report, the design and development of a helpful legal and policy framework safeguard the HIV infected individuals and by extension their families against discrimination and abuse of human rights. Gupta, Parkhurst, Ogden, Aggleton, and Mahal (2008) contends that prevention strategies have been strengthened by community-based policies and reforms in laws because these ensure that human rights are protected and fostered. Conclusion HIV is among the infectious diseases that have been in existence for long and yet its burden on society is still being felt despite the multiple investments in research on its prevention and management. The global statistics point out that the prevalence of the disease varies based on various factors. However, Sub-Saharan Africa has the greatest incidence of HIV infection and transmission. HIV transmission is affected by factors such as sub-type of HIV, environmental factors among others. Despite the existing potential policies on the prevention and control of HIV infection and transmission, there is still a need for additional investment in research and programmes to curb the re-emergence of the disease. More focus should be put on the high-
Communicable Diseases12 risk populations such as the developing countries who are more vulnerable to infection and transmission due to lack of information, resources, and access to quality health services. Additionally, the economically stable states also require a particular focus on the management and deterrence of HIV due to the possibility of the disease increasing in its prevalence especially through injection drug use and unprotected contact.
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