AIDS Acquired Immune Deficiency Syndrome

The Human Immunodeficiency Virus (HIV) which causes AIDS has brought about a global epidemic of massive proportions. HIV is a retrovirus and also the term often applied to the infection before the deterioration of the immune system to produce a full-blown picture of AIDS.

Worldwide

It has become a massive problem and according to the World Health Organisation in 2006:¹

• An estimated 38.6 million (confidence limits 33.4 million - 46.0 million) are living with HIV worldwide.
• There were 4.1 million (confidence limits 3.4 million - 6.2 million) newly infected people in 2005
• 2.8 million (confidence limits 2.4 million - 3.3 million) died of AIDS in 2005.

Poor record keeping and returns from some countries make these figures unreliable.

Resources for WHO have risen 5-fold from US$1.6 billion in 2001 to US$8.3 billion in 2005 and there are some encouraging signs for all this investment:

• 6 out of 11 African countries reported declines of 25% or more in HIV prevalence among 15-24 year-olds in capital cities.
• Rates of sex among young people declined in 9 out of 14 sub-Saharan countries.
• Condom use with a non-regular partner increased in 8 out of 11 countries here, although overall use of condoms remains below 50%.
• Use of HIV testing and counselling, an important tool for facilitating both treatment and prevention, quadrupled to 16.5 million people tested in 2005.
• In 58 countries reporting, 74% of primary schools and 81% of secondary schools now provide AIDS education.

While this progress is notable, the HIV prevention response falls short in many areas. The Declaration of Commitment calls for 90% of young people to be knowledgeable about AIDS by 2005, yet surveys indicate that fewer than 50% of young people achieved comprehensive knowledge levels. An area of exceptional concern is the ongoing shortfall in care to prevent mother-to-child HIV infection, in which just 9% of pregnant women are currently covered.

The response to the problem of AIDS varies considerably between countries irrespective of risk. Some are just slow to take the matter seriously whilst others are still denying that it is a problem in their country. In many parts of Africa the prevalence appears to be getting stable. This means that the number of people dying from the disease is roughly equal to the number of new cases.

United Kingdom

According to a report from the Health Protection Agency,² there were an estimated 73,000 adults aged over 15 with HIV in the UK in 2006, a third of whom were unaware of their infection. Since the epidemic began in the early 1980s 16,598 deaths in HIV infected individuals are known to have occurred in the UK. Currently the number of people living with diagnosed HIV is rising each year due to increased numbers of new diagnoses and decreasing deaths due to antiretroviral therapies.

Within the UK the Health Protection Agency Centre For Infections receives information on HIV infections from several sources. The major sources of information are reports from clinicians and laboratories of newly diagnosed infections, an annual survey of all patients seen for HIV related treatment or care, and a family of unlinked anonymous surveys which test blood samples taken for other investigations, after they have been irreversibly unlinked from any patient identifiers. All reporting methods are confidential and avoid the use of names.

AIDS is currently defined as an illness characterised by the development of one or more AIDS-indicating conditions. It is diagnosed in people infected with HIV when they develop certain opportunistic infections or malignancies for the first time. The following list relates to diagnosis in adults. Childhood AIDS has its own article.

When HIV infection is diagnosed in a routine test, as for blood donation, in pregnancy, or after counselling a person with a life style that puts him at risk, there is not usually full AIDS but just infection with HIV. When the disease is suspected HIV counselling must precede testing. There is a characteristic presentation of the infection that is described in the article on Primary HIV infection. Once the diagnosis is made the article Managing HIV Positive Individuals in Primary Care becomes relevant. HIV and Skin Disorders outlines the many dermatological manifestations of the disease.

Awareness of modes of transmission is very important as the key to tackling this disease lies less in treating it than in preventing its spread. The relative importance of the various means of transmission vary considerably from country to country and even within countries. The following is derived from information on the HPA website³ and so is applicable to the UK.

Sex between men

The majority of infections in the UK have occurred through sex between men and this group remains at greatest risk. There has been no evidence in recent years of a decline in the numbers of new infections in this group and over 1,800 new diagnoses of HIV are currently occurring each year.

Despite generally high levels of awareness of the risks for HIV acquisition, in 2004 about a third of HIV infected men who have sex with men had not had their infection diagnosed. In 2004, where reported, 44% of newly diagnosed individuals had a CD4 count of less than 350 cells/mm³ at diagnosis suggesting diagnosis at a fairly late stage of disease progression.
Estimation of current incidence of HIV is difficult. A newly developed laboratory technique, which identifies recently acquired infections, suggests there has been little change in HIV incidence in men who have sex with men over recent years. If there has been a decrease in transmissibility associated with antiretroviral treatment in those diagnosed it may have been offset by an increase in risky behaviours. London has been the main focus of the HIV epidemic in the UK. Of those infected by sex between men, 55% live in London.

This must be a great disappointment to those who have worked hard to educate this group.

Sex between men and women

Nowadays, the number of new cases of AIDS acquired from heterosexual intercourse is greater than from homosexual activity. However, most of these cases were not acquired in this country. Almost 82% are recorded as having been acquired abroad with around 70% of the total from Africa. In the late 1980s and early 1990s the majority of the African infections were acquired in East Africa but more recently the impact of the HIV epidemics in south eastern Africa has been greater. Infections acquired in Asia and in Latin America/Caribbean have shown a slight upward trend since the late 1990s but this is modest compared to the contribution of the African epidemic.

In several other European countries there has been much more heterosexual spread from individuals infected through intravenous drug abuse than in the UK. The numbers of acquisitions from high risk partners diagnosed each year have remained fairly steady and constitute a decreasing percentage of the total of new diagnoses at around 1.5% of the total of new diagnoses amongst heterosexuals.

With the rise in the numbers of those who acquired their infections heterosexually there has been an increase in the number of women diagnosed. The male:female ratio for all new infections diagnosed in 1985/86 was approximately 14:1 whereas in 2002/03 it was about 1.8:1.

It is estimated that around 33% of all HIV infections acquired heterosexually are currently undiagnosed. Many heterosexuals remain undiagnosed until testing is prompted by HIV related symptoms late in the course of illness. Around two thirds of those with heterosexually acquired infection are being diagnosed late with a CD4 count of less than 350 cells/mm³.

Markers of promiscuity, such as the numbers of new cases of gonorrhoea, are increasing among heterosexuals and this must mean an increased risk of HIV transmission too.

Injecting drug users

The total number of cases of HIV in the UK includes about 6% from injecting drug use (IDU). IDU has played a smaller part in the HIV epidemic in the UK than it has in many other European countries and the numbers of new diagnoses have been around 100 for the last few years. The age of diagnosis rose throughout the 1990s, suggesting that new diagnoses are being made on an ageing population largely infected in the mid 1980s and that new infections are becoming less frequent. These figures mask geographical variations and in Eastern Scotland there was rapid HIV spread through IDU in the early to mid 1980s.

HIV infected injecting drug users are predominantly male as are all drug users. This has meant that the relatively small heterosexual spread from infected drug users has been predominantly to women with 74% of those reported infected by this route being female.

Behavioural changes among injectors and the prompt introduction of harm reduction measures such as needle exchange programmes from the mid 1980s probably prevented many other urban areas in the UK experiencing the localised epidemics on the scale seen in Scotland. In the UK sharing rates remain higher than in the mid-1990s with almost one in three injectors in the Unlinked Anonymous survey of injecting drug users reporting direct sharing of needles and syringes in the previous 4 weeks. The continuing transmission of Hepatitis B and Hepatitis C in those aged under 25 shows the potential for further HIV spread among injecting drug users.

Mother to child

There are articles on Congenital HIV and its Prevention and Management of HIV in Pregnancy and so this section will be shortened.

One in every 548 women giving birth in England and Scotland during 2004 were HIV-infected, with the majority being in London.

By the end of 2004, 1,650 HIV diagnoses had been reported in children aged under 15. Of these, 77% (1,119) were reported to have acquired their infection from their mother. Three quarters of these mothers were reported to have been infected in Africa. Almost 40% of children who acquired their infection from their mother were born abroad. Most of the children infected through other routes were infected through blood or blood product treatment in the early 1980s. Since viral inactivation of blood products was introduced in 1985, no transmissions through blood products have been reported in the UK.

About 92% of women with HIV are diagnosed before delivery.They can benefit from interventions which can reduce the risk of mother to child transmission to well under 3%. These interventions include: antiretroviral therapy, caesarean section delivery and avoidance of breastfeeding.

Blood products and blood transfusion

Production of the clotting factor concentrates, mainly to treat patients with haemophilia A and haemophilia B (Christmas disease) involves the pooling of very many donations and a single donation could contaminate a batch of concentrate used to treat many patients. There have been no recorded transmissions of HIV by this route in the UK since the introduction of heat inactivation of concentrates and donor screening in 1985.

Around 1,350 people in the UK have been infected through treatment with blood factor concentrates and all but 13 are male. Two-thirds have died, 31% of them without AIDS having been reported. People with haemophilia may die from liver disease and haemorrhage before the development of an AIDS defining condition.

Since 1985, all blood donations have been screened for HIV antibody. There have been only two proven incidents of antibody negative blood infectious for HIV being accepted for transfusion in the UK since then (the donor being in the "window period" when blood is infectious because of recent HIV infection but too early for antibodies to be reliably detected by the screening antibody test). Most diagnoses from blood transfusions come from areas of the world where screening is unreliable and inconsistent.

Investigations for HIV are described in that article on that subject. Further investigations for AIDS-defining conditions may be indicated. Media interventions can improve the uptake of testing but this might not be sustained.⁴

The basis of management is described in the article on HIV. There may be defining conditions such as Pneumocystis jiroveci (carinii) pneumonia that will need treatment. Highly Active Antiretroviral Therapy (HAART) has improved the prognosis enormously in terms of duration of survival but premature death is to be expected.

HAART represents the use of at least 3 antiretroviral drugs. New therapies and new regimens are being produced and these should all be assessed by RCT. Therefore, as far as possible, everyone with the condition should be included as part of a trial. They will not be expected to take an inert placebo as effective treatments have been demonstrated and so it is a matter of comparing a new regimen with an existing one, not proving that a new drug is better than nothing. Trials should use standard means of assessment so that meta-analysis may be performed.⁵

Treatments with HAART have shown considerable progress in the past decade with impressive improvements in life expectancy and quality of life.⁶ There are still many problems. Although HAART is able to suppress the viral load in the plasma, it fails to eradicate it, and once HAART is initiated, treatment needs to be continued for life. The side effects of long-term HAART include lipodystrophy, lactic acidosis, insulin resistance, and hyperlipidemia. In addition, patients require high adherence to the therapy to achieve viral suppression and prevent the development of a drug-resistant virus. Modern regimes are less onerous than older ones. They are simpler and involve less tablets, whereas it used to be necessary to take 16 to 20 tables a day.

Some people will wish to use herbal remedies and a Cochrane review was able to find a small number of trials, some of which seemed to have adequate methodology.⁷ There was no significant clinical benefit and objective criteria such as CD4 count were unaffected.

There may be some benefits from prophylactic treatment. A Cochrane review found some benefit in treating latent tuberculosis.⁸ Another review found only one trial that examined the benefit of prophylactic co-trimoxazole in children. It was from Zambia and the result was positive.⁹ The value of prophylaxis against oropharyngeal candidiasis is uncertain, especially in children. There may be some benefit but at a risk of resistance developing and for poorer countries the cheaper options should be examined.¹⁰

The impact of AIDS in southern Africa has been devastating. The average expectation of life, that had been improving, has started to decline. Some communities have been very hard hit with many deaths and economic hardship related to loss of the workforce of young adults. Children who have not yet reached 10 years old find that one then both parents become ill and need to be cared for and then die leaving them to care for themselves and younger brothers and sisters. This takes them out of school and so they also miss out on education about AIDS. Social care in the community may be hampered by lack of resources due to so many such cases or they may be shunned because of the social stigma. Vertical transmission means that the troubled child may also become ill and die. They are robbed of their childhood. They are robbed of their lives.

The cost of drugs can be prohibitive in such poor economies. If they are not provided by the state, they can be ill afforded by those who need them. The cost of therapy has come down and the price of drugs is being subsidised but the problem of treating so many poor people remains.

The eradication of AIDS is based on prevention rather than cure and that means education and action. On an international scale there were, and still are, a number of countries that have refused to accept the enormity of the problem. The deny that they have such a disease in their society. This is often a problem in societies that claim to have strict moral values, especially in the Middle East. The scale of the problem is underestimated in the former Soviet Union. Henan is the most populous province in China, with nearly 100 million people, including an estimated 500,000 to 700,000 AIDS sufferers, although official government statistics place the figure at around 5,000.

Even the great Nelson Mandela, when he was president of South Africa, played down the importance of the problem of AIDS for fear that it would reflect badly on his country. However, since then he has acknowledged his mistake and gone to great pains to promote the message that AIDS is a major problem in South Africa and must not be ignored. Unfortunately, this has been undermined by his successor, President Mbeki, who denies that the HIV virus is the cause of AIDS. It might not fulfill all of Koch's postulates but this is a very dangerous stance.

The WHO report was really quite encouraging, especially with regard to Africa. There is still much to do both in Africa and right across the world.

The HPA report makes very sorry reading, suggesting that the British people are ignoring the message and that both homosexuals and heterosexuals are taking risks. The estimate that around a third a of cases of HIV are undiagnosed is a great concern as these are the people most likely to spread it in ignorance. The disease is often at an advanced stage when it presents. The news that much AIDS has been imported by immigrants will be manna to certain sections of the press.

Ignorance is not the only reason why the use of condoms is poor. The Roman Catholic Church has taken a totally inflexible attitude against contraception and, by and large, the poor comply whilst the rich ignore it. In 1980, Monsignore Carlo Cafara, dean of Pope John Paul II's Institute for Marriage and Family Studies at the Vatican, told a conference that when one partner of a married couple is positive for AIDS, it is preferable to risk catching the AIDS virus than to use condoms.¹¹ In 1996 a group of French bishops contradicted the Vatican's ban on condoms.¹² It was also noted that in France mortality from AIDS was 88.5 deaths per million population a year, following Spain with 139 deaths and Switzerland with 89.6 deaths. In contrast, Germany and Great Britain had 20-30 deaths from AIDS per million population a year.¹² Great Britain and Germany are largely protestant Christians, with no adherence to Rome and protestant churches do not bar contraception. The Roman Catholic Church has even tried to tell people that condoms permit passage of the HIV virus.¹³ It will be interesting to see if a change of pope brings a change of attitude.

The advertising slogan was "Don't die of ignorance". The greatest facilitators of the spread of AIDS are ignorance and denial, both here and across the world.