The Human Immunodeficiency Virus

The Human Immunodeficiency Virus (HIV) attacks the CD4 cells of the body's immune system and weakens the defense mechanism from protecting against infections and diseases. As the number of CD4 cells decreases the body becomes more vulnerable to all opportunistic diseases and cancers. AIDS is the most advanced stage of HIV infection with severe immune deficiency i.e. least CD4 count (less than 200 cells/ cubic meter), it takes nearly 2 15 years for the virus to develop into this stage. At this stage, the body becomes vulnerable to serious infections and cancers.

About two-thirds of the world population living with HIV are in Africa, of which Sub-Saharan Africa (SSA) accounts for 70% of this disease rate (Kharsany & Karim, 2016). There was a slight decline in the incidence of HIV/AIDS in past few years nearly 1.3 million in this country yet persistently remains in the top 5 countries that are infected with HIV (see fig.1). According to 2013 census Sub-Saharan Africa (SSA) had 24.7 million people who are infected with HIV, and in 2016 there are 25.98 million people living with HIV (see fig.2).

Undisputedly SSA harbors 60% of HIV cases, of which 28 million are living with HIV, more than 14000 people are getting an infection every day and nearly 11000 are dying with AIDS-related complications (Dzimnenani Mbirimtengerenji,2007). Factors contributing to the spread of HIV/AIDS in SSA social stigma, ancient and traditional practices, poverty, multiple sex partners, heterosexual transmission, and lack of male circumcision(Chen et al., 2007) ( see fig 5). As a matter of fact, HIV infection has played a considerable role in decreasing the life expectancy, health status, education, employment and country's economy. The pandemic has reduced the national economy by 2-4% a year on an average across Africa (Dixon, 2002). Also, the death rates are so high due to HIV related diseases and cancers. Fig 3: Map: Share of the population infected with HIV, 2016 Source: IHME, Global Burden of Disease Fig 4: Disparately High HIV Prevalence among Young Women Compared to Young Men Source: UNAIDS, 2014 Fig 5: Distribution of new HIV infections among population groups, 2017 Source: UNAIDS special analysis, 2018 What has been done so far? With more than 30 years of continuous efforts made on this HIV epidemic, there is still no proper cure or an effective vaccine, however, due to advanced treating methods by using Antiretroviral therapy (ART) has made the deadly disease into more chronic disease and manageable condition and also by increasing the life expectancy (Kharsany & Karim, 2016).

Moreover, behavioral modifications also helped in reducing the prevalence rate of HIV in some tropical countries. The strategic goals for behavioral change involve stigma reduction, reduce the number of sex partners, avoid sharing of needles and injections that are contaminated, reduce the age of first intercourse, increase the use of condom and its sales, and also by encouraging regular screening and health education counselling services (Coates, Richter, & Caceres, 2008). Not only behavioral interventions but also the combination of biomedical and structural interventions have a holistic approach to prevent HIV infection. Fig 6: Effective HIV Prevention require a combination intervention. At intrapersonal level, the PLWHA (Persons Living With HIV/AIDS) in SSA have been educating all the high-risk group individuals about the methods of transmission, preventive measures, and how to protect their human rights based on the resources. Moreover, the national government of Sub-Saharan Africa has released funds for the campaigns on disease awareness and reducing stigma related to the HIV. These are the massive campaigns which are promoted targetting families and communities, in spite of all these efforts there is still gender inequality, lack of knowledge and high level of stigma in SSA (Dahlui et al., 2015). At the interpersonal level, the combination strategy includes health education for sex workers and men who have sex with men to have access to male and female condoms, lubricant and PrEP (pre-exposure prophylaxis).

At Community and Organization level, the NSPs (Needle and Syringe Programmes) focused on people who inject drugs and have been effective in reducing the usage of contaminated needles, and Opioid Substitution Therapy (OST). UNAIDS in collaboration with World bank has launched several successful health education programs for teenage girls, women, and homosexuals focusing on social discrimination, reducing stigma, awareness. The biomedical interventions at schools and multimedia organization level included VMMC (Voluntary Medical Male Circumcision, free HIV testing and condom supply. Examples of such successful large-scale programmes were Love Life multi-media campaign in South Africa, the National Behaviour Change Programme in Zimbabwe and Multi-Country one love campaign in southern Africa. In 2003, UNAIDS and WHO launched the '3 by 5' initiative which is reducing the incidence rate of HIV by 3 million in 2005 with ART( Antiretroviral therapy). The programs did not achieve the target population by the expected deadline and instead the number tripled which lead to the initiative of many challenging and great momentums. WHO and UNAIDS set up ambitious global targets (90-90-90) by 2020.

In 2013 Health and education ministers addressed the barriers that are preventing girls and women from accessing the services. They have also focused on sex education in schools (CSE- comprehensive sexual education), eliminating gender barrios. Between 2010- 2015 the PMTCT (Prevention of Mother-to-child transmission) in East and southern Africa was successful in preventing the vertical transmission of this virus from a positive mother to child by 66%. The recent report shows that there has been an improvement from 61% in 2010 to 89% in 2016.

In 2007 WHO and UNAIDS promoted VMMC (voluntary medical male circumcision) as one of the key components for preventing HIV. In 2015, South Africa took the first initiative to fully approve the PrEP (Pre-exposure prophylaxis with antiretroviral drugs. Next steps: A. Gaps or shortcomings in what has been done so far Although many attempts were made to prevent the prevalence and incidence rate of HIV in Africa and SSA specifically, the disease still remains a serious problem. This is because of all the current interventions and strategies are not specific to a particular region, which is in fact, globally formulated policies (Hanson & Hanson, 2008). Despite considering all the specific factors in each setting such as regional, cultural, traditional and high-risk population in combination interventions yet have drawbacks.

Gaps in the Behavioral intervention: - This intervention was not effectively practiced and discontinued in many countries. As a result, many young people had inadequate knowledge (36% young men, 30% of young women) according to the survey in 2015. - Very minimal efforts are made to bring a change in social norms that are negatively impacting HIV (Hanson & Hanson, 2008). Gaps in Biomedical interventions: - VMMC has been rapidly expanded in 14 countries, out of which 8 countries declined the use of this programme in 2015. So, in order to reach the Fast track target, the voluntary male circumcision number has to double in 2020. - UNAIDS 2020 target on PrEP coverage is 5% at present. - According to the 2015 survey, 62% of individuals were not virally suppressed and 42% were unaware of their HIV status. So, there is a limitation is TasP ( Treatment-as- prevention) and PrEP. - Thus the campaigns ""AIDS kills, ""Abstinence, Be faithful and use a condom approach was introduced by indulging fear among people. But this approach had failures in promoting safe sex (Hanson & Hanson, 2008)

Gaps in Structural interventions: - These are difficult to implement in poor countries like SSA as they deal with deep-rooted socio-economic issues such as gender discrimination, poverty, and human rights. As South Africa is the first to widely approve the ART (antiretroviral therapy) treatment, SSA is likely to benefit from future interventions that would concentrate on early access to ART, large-scale HIV screening promotions, health educations on HIV/AIDS. B- Future Intervention: There has to be a realistic target in setting up future interventions to prevent HIV/AIDS in low-income tropical countries that have the highest burden of this disease. The goal of my intervention is to bring a change in risky behaviors among the targeted population in SSA. (i)Development: - Aim for reducing the high-risk sexual behavior patterns by half in a span of 3 years. - This intervention will be targeting homosexuals, substance abusers, and sex workers. - Assessment is done in two ways -Identifying and analyzing the data on the number of sex workers, LGBTs. -By conducting surveys of knowledge, practices, and attitudes towards the stigma of HIV/AIDS. - Develop trust, strength, and empathy in the population. - Hiring well-trained health care providers. (ii) Implementation: - Distributing pamphlets, advertising, mass media communications. - Awareness campaigns- includes disposal of contaminated needles, use of condoms, safe sex education, screenings, sex education in schools. - Health education programs in rural areas and providing them with free condoms. - Conduct free screenings for all the high-risk population. (iii)Evaluation: - Conducting pre and post surveys to assess their knowledge and beliefs. - Assess the syringes and condom supply and sales in hospitals and pharmacies. - Evaluate the hospital records for the incidence and prevalence rate of HIV infection.

Web resources: https://www.avert.org/professionals/hiv-programming/treatment/overview

https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview

https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics https://www.prb.org/thestatusofthehivaidsepidemicinsubsaharanafrica/

References:

Coates, T. J., Richter, L., & Caceres, C. (2008). Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet, 372(9639), 669-684. doi:10.1016/S0140-6736(08)60886-7 Chen, L., Jha, P., Stirling, B., Sgaier, S., Daid, T., Kaul, R. and Nagelkerke, N. (2007).

Sexual Risk Factors for HIV Infection in Early and Advanced HIV Epidemics in Sub-Saharan Africa: Systematic Overview of 68 Epidemiological Studies. PLoS ONE, 2(10), p.e1001. Dahlui, M., Azahar, N., Bulgiba, A., Zaki, R., Oche, O. M., Adekunjo, F. O., & Chinna, K. (2015).

HIV/AIDS Related Stigma and Discrimination against PLWHA in Nigerian Population. PLoS ONE, 10(12), e0143749. doi:10.1371/journal.pone.0143749 Dzimnenani Mbirimtengerenji, N. (2007). Is HIV/AIDS Epidemic Outcome of Poverty in Sub-Saharan Africa? Croatian medical journal, 48(5), 605-617 Dixon, S. (2002). The impact of HIV and AIDS on Africa's economic development.

BMJ, 324(7331), pp.232-234. Hanson, S., & Hanson, C. (2008). HIV control in low-income countries in sub-Saharan Africa: are the right things done? Global Health Action, 1, 10.3402/gha.v3401i3400.1837. doi:10.3402/gha.v1i0.1837 Kharsany, A. B. M., & Karim, Q. A. (2016). HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities. The Open AIDS Journal, 10, 34-48

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