Communicable Diseases: Global HIV Epidemiology, Role of Agent, Host and Environmental Factors

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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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 that the 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 that there 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

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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

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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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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.

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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

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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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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

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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.

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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

Communicable Diseases 11
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-

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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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