HIV/AIDS Research Paper

This assignment presents a set of research articles focusing on various aspects of the HIV/AIDS epidemic. The papers delve into topics such as alcohol use and its relation to HIV infection risk, the impact of CD4/CD8 ratio on non-AIDS related events in HIV-positive individuals on antiretroviral therapy, hepatitis B co-infection in HIV patients treated with tenofovir, the effectiveness of dried blood spot testing for infant HIV diagnosis in resource-limited settings, and the decline in new HIV infections in South Africa. Additionally, the papers highlight the importance of HIV treatment in ending AIDS, reducing new infections, and avoiding healthcare costs, as well as the role of antiretroviral therapy and pre-exposure prophylaxis in preventing HIV transmission.

Communicable diseases
Student’s Name
Date of Submission

HIV infection Overview
The HIV is a retrovirus which infects the cells inside the immune systems thus altering or
damaging their ability to function. Sub Saharan Arica still continues to bear the largest burden of
HIV burden. Some of the most common routes of HIV transmission include heterosexual
intercourse, female sex worker, injection drug use, and mother to child transmission (Awoleye,
& Thron, 2015). There is a growing need to shift the perception of HIV risk to be in a way that
an individual person views HIV as being influenced by politics, culture, social, and economic
determinants (Ho & Holloway, 2016). There are very many social as well as economic factors
like education, marital status and wealth accumulation which are known to affect the rate of
managing HIV infections. Considering the numerous effects that HIV infection causes, it is
crucial for the government and other stakeholders to come up with programs which aim at
communication, change of behaviors and seeking of medical care services. It is clear that the
effectiveness s of HIV awareness program sis that there is other factor like poor coordination,
politics and poor political will (Dube, et al., 2016). Even when considering the people with
formal employment, there is stigma as well as fear which causes late disease presentation
(Dijkstra et al., 2016). This means that the there are other problems which results from this and
includes low survival rates, and more infection rates.
Generally, HIV is a viral infection which make the host immune system to be weak. It is
among the highest contributor of morbidity, and it is considered to be the sixth cause if
mortalities globally. In fact, the life expectancy of an HIV infected people has significant
process. This is true because of the effectiveness conferred by the antiretroviral drugs which has
enabled many people to cope with HIV infections following the advancement to chronic
infections (Barskey et al., 2016). The initial efforts in HIV managements mainly focused on

prevention strategies as well as the treatment of symptomatic illnesses. The count of CD4
indicate that there is a high level of immunosuppression. It is therefore evident that early
diagnosis of people with HIV leads to an improvement of the effectiveness on the ARVs.
Human immunodeficiency virus infects humans and chimpanzees and two thirds of global HIV
infection is found in Sub Saharan Africa (UNAIDS, 2006).
Generally, HIV infections are life threatening and chronic illnesses which increases the
risks of mortality among the infected people. When left untreated, HIV destroys the numbers of
white blood cells to a level whereby the infected body cannot fight any type of infections,
indicating that any opportunistic infections like cancer, malaria and flue can easily lead to the
death of the victim. In most cases, when a person is unable to fight opportunistic infections, there
are high chances that the white blood cells count is usually at very low a concentration (Serrano-
Villar et al., 2014) It is characterized by acute viremia in excess of five million viral particles per
milliliter of serum. It has also been found that HIV among IDUs is transmitted through sharing
of needles (Baral et al., 2007). Mortality rates have recently decreased due to the improved
effectiveness of highly active antiretroviral therapy. In the year 2013, Kenya had 88,620 new
HIV infections among adults and 12,940 among children (NASCOP 2014). In 2012, Mombasa
county had an adult HIV prevalence of 11.1 % (NASCOP 2014). Since injection drug use is a
common global phenomenon (Dore et al., 2010), infection and transmission of HIV occurs
through sharing of contaminated drug injection equipment’s to either inject or split drugs. Others
include risky sexual behaviors like homosexuality, prostitution, unprotected sex and engaging in
sexual behaviors under the influence of drugs or in exchange of drugs (Chu et al., 2013).
Sub-Saharan Africa contains only 10% of the world’s population and remains the “global
epicenter” of the HIV/AIDS epidemic (UNAIDS, 2006). This is because in 2005, an estimated

24.5 million people were living with HIV/AIDS in this region, whereby 2.7 million people had
new viral infections, 930,000 died of AIDS. The report further indicates that in Kenya, 38.7%
(278/719) of drug users reached through community outreach were reported to be sharing
needles, cookers, filters, rinse water and injection solution. Adoption of a high risk injection
practice called “flash blood” is common among male and female drug users in Tanzania. This is
a practice in which an IDU who cannot afford to purchase heroin injects the blood of another
IDU who recently injected, in the belief that the blood contains heroin and can prevent
withdrawal. In Mombasa, of the 1000 drug users referred through community outreach to HIV
counseling and testing, 31.2% (43/138) of IDUs and 6.3% (352/1546) of non-injection drug users
were HIV positive (Deveau et al., 2006). Some of the abused drugs in this county are heroin,
morphine, cocaine and cannabis. Various classes of drugs are used for HIV management. In the
class of nucleoside reverse transcriptase inhibitors, lamivudine, entecavir and emitricitabine are
examples.
Nucleotide reverse transcriptase inhibitors are tenofovir, and adefovir. The class of non-
nucleoside reverse transcriptase inhibitors includes etravirine, rilpivirine, nevirapine, interferons
and efiverenz (Zhan and Liu, 2011). Out of the approximately 16 million IDUs worldwide, 3
million are infected with HIV-1. A study to show the incidence of HIV-1 in a cohort of IDUs in
central Sydney showed an HIV-1 incidence of 0.17% per 100 people among 426 initially
seronegative IDUs. HIV-1 has two surface proteins (Gp 41 and Gp 120) for viral entry, enzymes
(integrase, reverse transcriptase and protease), and two non-covalently linked single stranded
RNA genome. It is 9,800 base pairs long and has nine genes: vif, pol, gag, env, tat, rev, bif, vpr
and either vpu or vpx. HIV-1 is transmitted via sex with infected persons, mother-to-child,
sharing of sharp infected objects, injection drug use, breastfeeding, and blood transfusion. In

2005, of the 820,000 newly HIV-1 infected infants, 360,000 of them were through breastfeeding
by infected mothers.
HIV in the United States
Dallas, a city in the United States is among the many cities which have a high prevalence
for HIV infections. For instance, in the year 2014, Dallas city had more than 16,000 people who
were living with HIV, which was a 124% increase since the year 2004 (Dallas County Health
and Human Services (2017). The American Africans are the class of people who have recorded
the highest cases of HIV infections between the ages of twenty-five to fifty-four years. In the
United States for instance, the HIV spread so fast because it was linked too social stigma.
Moreover, this pandemic did not receive any support from the government in terms of research
funding and treatments by the CDC. Francis, 2012 reports that when the disease begun
escalating, there were more than 10,000 cases in the United States. In the year 1990, the United
States congress passed an act (Ryan White comprehensive AIDS resource emergency). This act
provided more than 220.5 million dollars to support all programs related to control, research and
management of HIV among its people (HRSA 2011). As Holtgrave et al., 2012 reports, the most
recent progress in HIV management was the introduction of the national HIV/AIDS strategy
during the reign of president Obama. However, it is worth noting that the HIV programs are still
not given the necessary support in form of funding that they actually need. All the prevalence of
HIV/AIDS has had a remarkable decrease in the cases of this disease in the United States
although there are still some problems in terms of program implementation.
Acute and chronic infections
Acute HIV-1 infection is characterized by appearance of the viral markers and antibodies
in blood (Cohen et al., 2011). If left untreated, HIV-1 leads to hyper activation of CD8 and CD4

cells resulting in progression to AID. HIV attacks the white blood cells which are important in
fighting infections, and more specifically, the virus attacks the CD4+ cells. The virus attacks
these cells and destroys them such that the body can no longer fight infections. At this point
when the CD4+ count is very low, the AIDS begins to develop, though this can take varied
periods of time. This is the prime reason as to why a person can live with HIV for many years
without having developed to AIDS. Chronic HIV-1 infection results in development of several
AIDS related cancers associated with human papilloma virus, HBV, hepatitis C virus and herpes
simplex virus due to immunosuppression (Guiguet et al., 2009). Kaposi’s sarcoma (caused by
herpes simplex virus) is a cancer that affects the skin due to immunosuppression in HIV-1
patients. Non-Hodgkin lymphoma consists of lymphoproliferative diseases which affects the
brain, lungs and spinal fluid.
Diagnosis
The most common HIV testing methods are laboratory and rapid tests especially on the
fingerprint derived blood sample. The first and the most recommended test is the rapid test which
uses the HIV p24 antigens against HIV antibodies (Cohen et al., 2016). For the HIV positive
patients, primary care is very crucial role in terms of HIV diagnosis. Therefore, primary care has
a role to play in increasing the uptake of HIV diagnostic testing. Dried blood spots for PCR are
used in HIV-1 diagnosis in infants to prevent mother to child transmission (Sherman et al.,
2005). Screening in children and adults is done using rapid HIV-1 whole blood diagnostic kits
such as determine and ungodly which rely on antigen- antibody reactions. HIV-1 viral load
determination helps clinicians in making decisions on whether to switch to second line treatment
or to prolong the duration of first line treatment regimen. PCR is used to quantify HIV-1 RNA in
plasma and it is useful in assessing the antiviral effects early in infection. Flow cytometry is also

used to determine the CD4+ cells count because these cells are involved in viral load decline
during primary infection.
Treatment
Nucleotide analogs
They are for HIV-1 management and are taken orally (Sung et al., 2008) and they
suppress HIV replication by inhibiting DNA polymerase/ reverse transcriptase. Trials of NUCs
in HIV patients demonstrate a decrease in viral load, ALT (alanine aminotransferase) levels, and
hepatocellular carcinoma incidence. They are more convenient to take than IFN but the eventual
development of resistance to these drugs limits their long-term utility. Side effects, which vary
by drug, include myopathy and peripheral neuropathy (telbivudine), kidney toxicity and
dysfunction (tenofovir and adefovir), decreased bone mineral density (tenofovir), and lactic
acidosis in patients with liver disease (entecavir).
Figure 1: Structures of some common HIV antiviral drugs. Adapted from Delaney et al.,
2001.
Lamivudine for example is a synthetic cytosine nucleoside nucleoside analogue with
activity against HIV-1, HIV-2 and hepatitis B virus (Sheldon et al., 2005). It is administered for
12 months, that is, 150 milligrams daily. With time, the HBeAg disappears and HBE antibodies

appear. Intracellulary, lamivudine is phosphorylates to its active 5′-triphosphate metabolite,
lamivudine triphosphate (L-TP). L-TP competes with cytosine triphosphates for incorporation
into the new DNA strand thereby inhibits HIV-1 reverse transcriptase by DNA chain termination
after incorporation of the nucleoside analogue into viral DNA. The HAARTs used to manage
HIV-1 are: nucleo(t)side reverse transcriptase inhibitors (lamivudine, efavirenz, combivir,
trizivir, truvada, abacavir, zidovudine and emtricitabine), no nucleoside reverse transcriptase
inhibitors (efavirenz, etravirine, nevirapine) and oral combination pills (atripla and eviplera),
(Sidibe et al., 2014).
Vaccines
HIV vaccine is in the process of development. This process is facing challenges such as
lack of validated animal model, varied HIV-1 structure and lack of natural protective immune
against HIV-1 (Koff et al., 2013). Current vaccine development focuses on chrystallographic
structure of HIV-1 envelope, such that the vaccine will effectively present the viral epitope to the
immune system.
Even though the United States government has been distributing the ARV drugs to the
people, these drugs might not be of much help especially if the patients do not understand on
how to use them well. Lack of treatment adherence is a consequence stigma and long incubation
period thus making treatment to be difficult. Although the ARVs have contributed to the
management of the disease, the long incubation period allows people to live with the virus for so
long without any symptoms. Moreover, there is none of the drugs which is made to cure, but they
contain the condition. As such, the people are advised to take care of their sexual behaviors and
dietary needs.
HIV prevention strategies

Despite the fact that HIV is considered to be a global pandemic, there are some
prevention programs and strategies which have been implemented and for sure they are
achieving significant results in terms of reducing the infection and transmission rates. According
to the UNAIDS 2010 report, within the last ten years, there has been a remarkable decline in the
number of new HIV infections (World Health Organization, 2016). Although there are several
prevention programs which have been put in place, these programs suffer from several
weaknesses. Basically, the main aims of these prevention programs are lowering the rates of
individual infections, and to monitor and bring to controls the various factors that are associated
with HIV such as social, political, legal, and economical factors which make some groups of
people to be more vulnerable to HIV infection than others in the same community or population.
When such programs have weak investments in terms of planning, evaluation and monitoring,
then they might not achieve the set out objectives.
Combination prevention programs
This method provides good prospects that are useful in addressing some common
weaknesses reported in HIV prevention programs. This combination method has been useful in
reducing the incidences of HIV infections and spread in varied settings. However, this program
depends heavily on the evidence, strategic, and informed use of structural, behavioral and
biomedical methodologies (Jones et al., 2014). The combinational approaches are able to achieve
effectiveness among individuals, communities and the general society because it is able to
address diverse needs of the people with respect to HIV. The success rate of the combination
prevention programs is based on the inclusive, transparent, and open programs which are able to
engage various stakeholders like the communities, individuals, and governments in making
analysis of the risk factors that make people vulnerable to HIV infections. It is also worth noting

that the combinational approach helps in building common sense as well as a feeling of being
accountable as far as HIV infections prevention is concerned.
It is therefore important that the National AIDS authorities use all the available sources of
data to come up with a geographical distribution of new infections and the prevalence of existing
infections so as to help in formulating useful priorities. During the process of planning for the
HIV programs, the affected communities should be actively involved so as to determine the
underlying risk factors and make them active participant in the prevention processes. In some
regions especially the developing countries, gender plays a big role in in terms of discrimination,
unequal wealth distribution, and violation of human rights of the people vulnerable to HIV
infections (Anderson et al., 2014). Moreover, the health program facilitators involved in HIV
prevention programs need to use a common language to organize their schedule and from time to
time, they need to carry out program evaluation based on well-defined procedures.
Effects of HIV infection to the society
Psychological effects
Most adults suffering from HIV live in isolation and hence lack social support. Therefore,
such people score little on social networks as well as the level of social support that they get
from friends and family members (Volk et al..2015). Most HIV positive patients lack social
support because they fear stigma, adopt disclosure and aim at being self-reliant. However, these
factors in older HIV positive patients may be affected by gender, races, route of exposure and the
duration of infection. Another humiliated cause of HIV is that it causes loss of friends by the
victims due to low social networks. It is important to note also that the loneliness and self-
perceived support that the HIV patients face affects their health outcomes especially among the
older adults who are on treatment. On the other hand, social support among people infected with

HIV are associated with adherence to medication, moods and wellbeing (Weiler, 2016). When
such patients are offered nonpharmacologic support, this can help them lower the levels of
depression.
Prevention and healthcare maintenance
In order to prevent the increased HIV spread, it is recommended that primary care
screening is performed based on age consideration (Probst et al., 2017). The patients should also
be asked to refrain from dangerous practices like smoking, and use of alcohol through guidance
and counselling. It is however recommended that top level caution is taken during the process of
screening especially old patients who might have eco-morbidities and polypharmacies. This is
because there could arise some complications during the treatment of these comorbidities and
hence the patient may get more harm than the expected benefits. The HIV infected patients can
also manage their depression and possible development of opportunistic diseases by use of an
alarm clock, urging them to seek social support services and educating patients on the diet and
nutrition. The patients can also be counselled so that they can effectively attend the follow ups at
the health facilities nearer them so that they can raise their adherence levels. When HIV is being
treated at early, late or chronic stages, the health care professionals, need to make discussions
that take note of the student preferences of medications as directed by the law. However, for
patients who are in the advanced stages of care, there is a need to avoid prolonged
hospitalizations and maintenance of patient dependence.
The transmission of HIV virus from one person to another especially from a terminal
disease to a chronic and manageable disease is a clear indication that there is significant increase
in HIV treatment. In fact, the most identified problem associated with HIV infection is the
management of the aging patients. Although there are many similarities between the HIV

infected and negative patients, there distinct properties and problems such as polypharmacy,
social isolation, care integration and end of life plans.
Way forward
Although big and commendable advances have been made concerning the treatment and
management of the people suffering from HIV, there has been a common observation that there
is a large proportion of women who are still living with this health condition (Shisana et al.,
2015). This means that gender and stereotypes need to be evaluated to determine why some of
these conditions predispose a certain proportion of people in the sane community as compared to
others (Probst et al., 2017). As a result, it is crucial if the stakeholders and health care givers
develop a holistic understanding of the impacts of HIV to the society. As such, the research and
management program funders are required to raise their funds while scientific and health
research is advanced. This would lead to development in the markers and coming up with
policies and health services to take care if the women who are infected with HIV. This will in
turn reduce the rate of stigmatization thus enhancing the patients’ health outcomes

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