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Human Immunodeficiency Virus, or HIV, is a retrovirus that specifically attacks CD4 cells, which are a type of T-cell[3]. T-cells are used to develop an immune response by recognizing invaders and remembering them in order to attack any returning pathogens. Because of this, patients with HIV will have weaker immune systems (and thus more prone to other diseases) due to the decrease in CD4 cells. The virus itself has two types, HIV-1 and HIV-2. Scientists affiliated with Nature Research Journal have been able to link the origin of HIV-2 to a species of primates known as the sooty mangabey, but they have not been able to isolate the reservoir for HIV-1[5]. Researchers have determined that HIV was spread primarily through interspecies transmissions, which is most commonly performed through the consumption of primate meat by humans. Once humans were in contact with the virus, transmission was performed through certain bodily fluids such as semen or blood[2].
HIV.gov has estimated approximately 1.1 million people living in the U.S to be living with HIV — 15% of which are unaware. The virus is typically present in urban areas of the United States, but the largest population of HIV infected individuals can be found in sub-Saharan Africa. HIV occurs in three stages: acute infection, clinical latency, and AIDS. During the acute infection stage, the patient will typically develop flu-like symptoms such as fever, joint pain, and swollen glands, and this is the stage in which a patient is most likely to transmit HIV to another person. The clinical latency stage is when little to no symptoms are present. AIDS is the point at which the immune system is heavily damaged and the patient is vulnerable to infection.
Due to the lack of a cure, patients infected with HIV are pushed to follow a daily drug regimen (known as antiretroviral therapy) in order to slow down the destruction of CD4 cells. Following this therapy can prevent HIV from developing into AIDS. Once AIDS has developed, the patient is expected to live for 3 more years if they are receiving treatment and only 1 more year if no treatment is received. With regards to etiological factors, men who have sexual intercourse with other men represent the largest risk group for HIV, having an estimate of 26,000 new infections yearly.
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Another risk group is categorized to be heterosexuals and those who use needles to inject drugs. HIV.gov states that heterosexuals represented 24% of HIV diagnoses in 2017 while injectable drug users represented 6% of HIV diagnoses. The CDC has reported that the decline in HIV infections has reached a flat line due to the unavailability of prevention methods and treatments. Many of those who need resources are unable to get them, and this is shown in the rural southern U.S. states as well as minority populations (especially African Americans and the Latinx community)[3].
How to Solve the Public Health Problem
Currently, there is no cure for HIV, instead, patients are placed into antiretroviral therapy, otherwise known as ART, through which they are placed on a specific drug therapy in order to control or slow down the destruction caused by the retrovirus, thereby reducing the chance that HIV will develop into AIDS. Due to the importance of adhering to the drug regimen, an example of a public health program would be the World Health Organization’s attempts to promote ART in developing countries. To do so, the World Health Organization will try to create a standardized therapy guideline for deciding the type of treatment each person will receive. In addition, the World Health Organization will work to have more people involved in caring for those with HIV, and this will include both trained professionals such as doctors and medical assistants as well as untrained citizens such as community members[6].
Another example of public health intervention would be the efforts to decrease the stigma regarding HIV. Dr. Ronald Valdiserri states that, because HIV is known to be spread through unprotected sex and drug injections, many members of the public tend to look down upon HIV patients. Because of this stigma against HIV patients, those who are potentially affected by the virus are less likely to get screened for it, too ashamed to possibly have the disease. Without screening, these patients will have no idea whether or not they tested positive, allowing them to transmit the disease to others. In addition, there is a hypothesis regarding the effects of homosexual discrimination that correlates it to performing high risk HIV transmittance behavior such as turning to drugs or engaging in unprotected sex for validation. This will also transmit the virus to others unknowingly. [9]
To combat this, efforts are being made in health care facilities in order to decrease the fear and assumptions stemming from misconceptions of the workers. Healthcare workers are placed into educational programs which detail the correct facts about HIV and preventative measures to avoid contamination/transmittance. This way, the workers can treat their patients without stigmatizing behaviors, allowing tha patients to be more comfortable during their treatments. Along with this, there will be policies that prevent discrimination against HIV positive patients in the workforce, letting patients continue to work without fear or self esteem issues which could lead to risky behavior. [8]
An example of a cultural intervention would occur in sub-Saharan Africa, the hub for the largest population (approximately 66% of the worldwide population) of HIV positive individuals. To address these high numbers, many African countries such as Botswana or Kenya have made national efforts to push for HIV testing as well as counseling. Kenya began to introduce self-testing kits in order to encourage more people to screen themselves in case they were to self conscious to go to a clinic. Doing this has increased the number of diagnoses and has managed to test patients as HIV positive earlier on in their infection, allowing them to receive care earlier. Because of the privacy of these initial tests, clinics were able to treat men and adolescents who, before the introduction of such tests, were difficult to contact for screenings[7].
While this has not solved the HIV problem, historically, scientists have been developing the screening tests in order to perfect them for detecting HIV patients. In the mid 1980’s, there were no specific AIDS or HIV tests, and currently, only HIV diagnostic tests exist. The first screening test for HIV was not developed for specifically detecting HIV, for they were intended to be blood screening tests only. To adjust for this, Thomas Alexander set the test to detect the antibodies associated with HIV-1, but while these were sensitive tests, they had a negative window of approximately 3 months.
This window means that a patient will test negatively for up to 3 months or more following transmittance of the virus. At the same time, many false-positive results arose because of other infections or autoimmune diseases. The second generation tests added HIV proteins to better detect the antibodies, and these tests reduced the negative window to 4-6 weeks. To improve this further, IgM detection was added, producing the third generation tests. The IgM and IgG antibody detections reduced the window to 3 weeks.
Then, p24 antigens were shown to be able to detect the virus within 2 weeks, and this was added to the fourth generation tests. However, the tests couldn’t differentiate if the positive results were due to the antigens or antibodies, and the fifth generation was able to isolate the results to make the screening tests more coherent. With this fifth generation, the negative window was brought down to 2 weeks post exposure and gave fewer false positives. While these were not exactly treatments for HIV, the screening tests allowed for healthcare professionals to accurately determine if a patient is HIV positive or not which allowed a patient to receive the needed resources based on their results.[1]
Public Health in the Future
Based on research literature, the biggest issue for public health officials to address would be awareness and access to resources in order to prevent reoccurrence. By spreading awareness, the public is well aware of the risks they take that could lead to HIV exposure. The individuals can then reduce this risk by taking preventative measures such as asking a partner if they have tested for HIV before intercourse, using a condom during intercourse, or not sharing needles when injecting recreational drugs. By spreading awareness, the stigma against HIV patients is also reduced, which would lead to an increase in screenings, allowing individuals to receive proper care in a timely manner. [9]
In addition to increasing awareness, increasing the availability of treatment and resources will enable patients to regulate the virus. ART is available, but since it is a daily medicine and expensive, many are simply unable to take it, allowing the virus to run its course freely and increasing the chance of exposure. The National Institute of Allergy and Infectious Disease (NIAID) has been developing long term methods that will not both require a daily drug dose and will not be as economically draining. These methods include: long acting drugs, neutralizing antibodies, and therapeutic vaccines.
For the long acting drugs, NIAID is developing extended release drugs which have a longer time in between each dosage. Scientists are also developing alternate ways of receiving HIV treatment such as through patches or implants. The broadly neutralizing antibodies, or bNAbs, produce fewer side effects and are modifiable to increase time between each dose. The way they will employ the bNAbs would be one of the following: binding it to the virus itself in order to prevent it from attaching to the CD4 cell, binding it to a CD4 cell with the virus in it in order to prevent apoptosis, or binding it to a part of the HIV virus which will stimulate immune cells to develop a preventative response for when another virus.
Lastly, vaccines are in development for those already infected with the virus. This vaccine will theoretically stimulate the immune system for future encounters with HIV. [4] All of these methods serve to reduce the frequency of HIV drug therapy, making it more likely for patients to adhere to their therapy in order to regulate the virus’ destruction.
In my opinion, I feel like these preventative measures will be a great help. Based on the research I did above, societal opinion has a large correlation to HIV diagnoses, so increasing awareness and normalizing the virus will allow patients to feel more comfortable and less ashamed to be affected by such a disease. By eliminating the stigma associated with HIV, patients will be more likely to receive treatment, and emphasizing the importance of HIV as well as the way it can be transmitted will encourage more screenings or more frequent ones. This will allow medical professionals to assess whether a patient will need therapy and will let that patient know that they have to take more preventative measures to prevent spreading it.
I feel like this will reduce transmittance rates since people will be more aware of the risks and will be less mortified at themselves if they are infected, allowing them to get the help that they need. In addition, making the drug therapy more available to others will prove to work. Based on the information that NIAIDS has provided, making the dosages less frequent will mean that patients will have to purchase less medicines, making it more economically reasonable for them to receive treatment. In addition, introducing a variety of methods will likely increase treatment adherence since I’m sure that many people don’t want to take pills daily and can opt for a patch or a vaccine.
