Fighting stigma

Destigmati-sation is necessary for access to care and disease prevention

Fighting stigma

In 2021, HIV/AIDS remains a major public health issue that affects millions of people worldwide. World AIDS Day is an opportunity for public and private partners to spread awareness about the status of the pandemic. Encouraging progress has been made in HIV/AIDS prevention, treatment and care around the world. It has become a key opportunity to raise awareness, remember those who have died and celebrate the victories like increased access to treatment and prevention services.

The theme of World Aids Day 2021 is: End inequalities to end AIDS. On December 1, the WHO is calling on global leaders and citizens to rally to confront the inequalities that drive AIDS and to reach people who are currently not receiving essential HIV services.

The human immunodeficiency virus (HIV) targets the immune system and weakens people’s defence against many infections and some types of cancer that people with healthy immune systems can fight off. As the virus destroys and impairs the function of immune cells, infected individuals gradually become immune-deficient. Immune function is typically measured by CD4 cell count.

The symptoms of HIV vary depending on the stage of infection. The initial period is called acute HIV. People living with HIV tend to be most infectious in the first few months after being infected. In the first few weeks after the initial infection, people may experience no symptoms or an influenza-like illness, including fever, headache, tiredness, sore throat, large tender lymph nodes, a rash on the trunk. As the infection progressively weakens the immune system, they can develop other signs and symptoms, such as weight loss, fever, diarrhoea and cough. Without treatment, they could also develop severe illnesses such as tuberculosis (TB), meningitis, severe bacterial infections and cancers such as lymphomas and Kaposi’s sarcoma.

The initial symptoms are followed by a stage called chronic HIV. Without treatment, this second stage can last from about three years to over 20 years (average, eight years). Typically, there are few or no symptoms at first. However, many people experience fever, weight loss, gastrointestinal problems, and muscle pains near the end of this stage. Between 50 percent and 70 percent of people also develop persistent generalised lymphadenopathy, characterised by unexplained, non-painful enlargement of more than one group of lymph nodes for over three to six months.

In the absence of treatment, an HIV infection will eventually progress to AIDS. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS), which can take many years to develop if not treated. AIDS is defined as an HIV infection with either a CD4+ T cell count below 200 cells per µL or the occurrence of specific diseases associated with HIV infection. The most common initial conditions that alert people to the presence of AIDS are pneumocystis pneumonia, cachexia in the form of HIV wasting syndrome, and oesophagal candidiasis. Other common signs include recurrent respiratory tract infections.

Opportunistic infections may be caused by bacteria, viruses, fungi and parasites that are normally controlled by the immune system. These infections may affect nearly every organ system.

Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness and unintended weight loss. Diarrhoea is another common symptom, present in about 90 percent of people with AIDS. They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.

It spreads by three main routes: sexual contact with an infected individual, significant exposure to infected body fluids or tissues such as blood and blood products, semen, and other genital secretions, or breast milk, and from mother to child during pregnancy, delivery or breastfeeding. HIV frequently spreads among intravenous drug users who share needles or syringes. There is no risk of acquiring HIV if exposed to faeces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.

HIV does not spread by coughing, sneezing, or casual contact (e.g., shaking hands). HIV is fragile and cannot survive long outside the body. Therefore, direct transfer of bodily fluids is required for transmission.

HIV does not spread by coughing, sneezing or casual contact (e.g., shaking hands). HIV is fragile and cannot survive long outside the body. Therefore, direct transfer of bodily fluids is required for transmission.

HIV can be diagnosed through rapid diagnostic tests that provide same-day results. People can also use HIV self-tests to test themselves. However, no single test can provide a full HIV diagnosis; confirmatory testing is required. The most common tests for HIV are the enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR) tests, which screen for viral RNA and therefore, allow detection of the virus after very recent exposure, and Single-Use Diagnostic Screening (SUDS). These tests are very expensive.

Preventive measures include safe sex, needle exchange programmes, treating those who are infected, as well as both pre-and post-exposure prophylaxis. Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication. Attempts to reduce intravenous drug use and to discourage the sharing of needles led to a reduction in infection rates.

Antiretroviral therapy represents an important prevention strategy. Research has indicated that pre-exposure prophylaxis, in which uninfected persons take an antiretroviral pill daily, can effectively prevent infection.

Vaginal antimicrobial gels also have been investigated for the prevention of HIV infection, designed to prevent the binding of HIV to cells in the vagina. Consistent condom use reduces the risk of HIV transmission by approximately 80 percent over the long term.

Circumcision “reduces the acquisition of HIV by heterosexual men between 38 and 66 percent over 24 months”. The World Health Organisation and UNAIDS recommended male circumcision in 2007 as a method of preventing female-to-male HIV transmission in areas with high rates of HIV. Comprehensive sexual education provided at school may decrease high-risk behaviour.

A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV-positive blood or genital secretions is referred to as post-exposure prophylaxis. PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV-positive. The duration of treatment is usually four weeks.

Currently, there is no licensed vaccine for HIV or AIDS. In 2010, scientists reported the discovery of naturally occurring antibodies that neutralise (inactivate) about 90 percent of HIV strains and hence, have considerable potential for facilitating the generation of vaccines for HIV prevention.

There is currently no cure. Treatment consists of highly active antiretroviral therapy (HAART), which slows the progression of the disease. Treatment also includes preventive and active treatment of opportunistic infections. Rapid initiation of antiretroviral therapy (within one week of diagnosis) appears to improve treatment outcomes. Once treatment is begun, it is recommended that it is continued without a break.

The WHO has recommended that all people living with HIV be provided with lifelong ART. This included children, adolescents, adults and pregnant and breastfeeding women, regardless of clinical status or CD4 cell count.

The benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death. Treatment also improves physical and mental health. With treatment, there is a 70 percent reduced risk of acquiring tuberculosis. Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission. Treatment recommendations for children are somewhat different from those for adults. The World Health Organisation recommends treating all children less than five years of age; children above five are treated like adults.

A generally healthy diet is recommended. High intakes of vitamin A, zinc and iron can produce adverse effects in HIV-positive adults and are not recommended unless there is documented deficiency.

For pregnant and lactating women with HIV, a multivitamin supplement improves outcomes for both mothers and children. There is some evidence that vitamin A supplementation in children with an HIV infection reduces mortality and improves growth.

The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system. The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person’s susceptibility and immune function; their access to health care, the presence of co-infections; and the particular strain (or strains) of the virus involved.

Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV-infected people and causing 25 percent of HIV-related deaths. HIV is also one of the most important risk factors for tuberculosis. Hepatitis C is another very common co-infection where each disease increases the progression of the other. The two most common cancers associated with HIV/AIDS are Kaposi’s sarcoma and AIDS-related non-Hodgkin’s lymphoma.

AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV-infected people including the quarantine of HIV-infected individuals. Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.

There are many misconceptions about HIV and AIDS. Three of the most common are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS and that HIV can infect only gay men and drug users. Also, that one could get HIV from sharing a glass, spitting, a public toilet seat and coughing or sneezing.

The writer is a physician of long standing

Fighting stigma