The HIV epidemic becomes one of the most terrible events in the human history. HIV/AIDS is contagious and catastrophic. It is associated with lifestyles that may be considered deviant and behavior that may be illegal or, at the least, intensely personal. Therefore, the issues surrounding HIV are complex and involve conflicting rights, values and demands on scarce resources (Campbell, 2003). HIV is a progressively severe weakening of the immune system that renders a person highly susceptible to certain infections and types of cancer. In recent years, global community and World Health Organization (WHO) accept the view that HIV is a social and political problem caused by lack of preventive measures and education of people, poverty and inadequate healthcare services.
HIV/AIDS Background and Historical Information
Human immunodeficiency virus attacks particular white blood cells called “helper” T-cells, “helper” because they help other white blood cells produce antibodies to fight infection. It appears that HIV also directly attacks the brain. The virus concentrates in an infected person’s blood and semen (Emlet, 2004). It is transmitted when virus particles or infected cells gain access to another person’s bloodstream. This can occur during anal intercourse, vaginal intercourse and oral-genital contact. The other major routes of transmission are the sharing of needles among intravenous drug users (IVDUs), infusion with tainted blood supplies, and the prenatal passing to an unborn child or the postpartum passing to a breastfed child by an infected mother (Campbell, 2003).
The virus cannot be transmitted by a handshake or sneeze, or through food prepared by an infected person. It is not transmitted through casual contact or by activities related to living with or caring for an AIDS patient that does not involve direct exposure, such as unprotected sex (Gilbert & Wright 2004). Researchers suppose that HIV infection was originated in non-human primates lived in sub-Saharan Africa and transmitted to humans. Officially, epidemic of HIV was announced in 1981. The first cases of HIV were identified in 1950s when British soldiers traveled to Africa. It is supposed that to the USA HIV was brought from Haiti during the late 1960s (Greene et al 2003).
Yet most victims of HIV were exposed to the disease through behavior of their choosing–practicing unprotected sex or sharing hypodermic needles. However, many who engaged in such high-risk behavior did not knowingly accept the risk. AIDS was not discovered until 1981. By then HIV was well established in the gay community, yet no one was aware of it or of the danger it presented. Because of the high level of sexual activity among many gay men and their high frequency of anal intercourse (the sexual activity most conducive to HIV transmission as it more often involves tearing of the membranous lining), infection spread rapidly before transmission mechanisms were understood (Gilbert & Wright 2004). Persons are usually diagnosed with AIDS after suffering fever, weight loss, swollen lymph nodes, diarrhea and multiple long-lasting infections, usually of the skin and mouth. Diagnosis is also often triggered by the appearance of an opportunistic infection, one that rarely causes disease in a patient with a normal immune system but is life-threatening to an AIDS patient (Greene et al 2003).
The average length of time between diagnosis of AIDS and death, for all the cases reported since the disease (AIDS) was first identified in 1979, is 13 months, biased downward by the brief life expectancy of earlier victims. With earlier diagnosis and improved drug therapies, a victim’s life expectancy has been extended. It now averages 18 months. It is still dreadfully short. The number of AIDS cases has grown rapidly, both as the disease has spread and as diagnosis and reporting have improved (CDC 2006, HIV/AIDS fact sheet 2006). They may seriously undercount the actual number of AIDS cases. According to WHO statistical results, today there are 33.2 million people living with HIV/AIDS. There are 30.6-36.1 million adults living with HIV/AIDS. Newly infected with HIV in 2007 0 2.1 million 1.4-3.6 million (WHO 2008). The main regions that suffered from this epidemic are African countries and the South Asian countries. In the UK,
By the end of 2004, British authorities had reported a cumulative total of 68 556 HIV cases in the United Kingdom; they also reported that 21 010 of the infected individuals had developed AIDS, including 13 082 who had died. Among all the HIV cases that had been reported by the end of March 2005, approximately 6-7% of the infections with known transmission modes were transmitted through injecting drug use” (UK HIV/AIDS statistics, WHO 2006).
The number of HIV cases alone, even if accurately tabulated, does not describe the full scope of the epidemic.
- Male homosexuals: most of the estimates place HIV prevalence in the 20 to 50 percent range. The rate in San Francisco may be as high as 70 percent. Since blacks and Hispanics constitute a disproportionate percentage of homosexual and homosexual-IVDU AIDS cases, it is probable that their HIV infection rate also exceeds that of white homosexuals (Scott, 2003).
- Intravenous drug users: Studies of heroin addicts in drug rehabilitation programs have found infection rates of up to 65 percent ( Hahn et al.). There is evidence that seroprevalence among the 85 percent of IVDUs not in treatment is greater. Hahn and colleagues estimate that one-third of the country’s 1.3 million IVDUs are HIV-infected, with prevalence 5 to 14 times greater among black IVDUs and 3 to 4 times greater among Hispanic IVDUs than among whites. IVDUs who are also homosexual males have somewhat higher rates but, overall, the seroprevalence rates for male and female IVDUs are about equal. Seroprevalence is greatest in New York City, northern New Jersey and Puerto Rico ( Hahn et al.). A study of IVDUs in San Francisco found seropositive rates among IV (intravenous) cocaine users to be more than three times greater than among heroin users. Also, since a cocaine high is of relatively short duration, cocaine IVDUs inject with far greater frequency than do heroin users, increasing their risk of HIV infection yet more. Blacks, and to a lesser extent Hispanics, not only were more likely to inject cocaine than white drug abusers, but, among cocaine IVDUs, had two to ten times higher seropositive rates (Scott, 2003).
- Prostitutes: Up to 45 percent of prostitutes are estimated to carry the AIDS virus. Rates are highest in large inner cities in which drug use is common, such as New York, Miami and Detroit. Wallace found 50 percent of the IV-drug-using prostitutes in Harlem in 1997 to be seropositive. Infection is three to four times higher in prostitutes who are also IVDUS. It is twice as high in black and Hispanic prostitutes as in whites (Scott, 2003).
- College students: A study of almost 17,000 college students across the country found that 0.2 percent tested positive for HIV. Most were older (over 24); almost all were men.
- Runaway and homeless adolescents: Clients of Covenant House, a New York City shelter for troubled adolescents, averaged seropositivity rates of 5.3 percent in 2004. Other than male homosexual activity, the strongest risk factors were crack use, engaged in by 38 percent of the teens interviewed, and prostitution, practiced by 29 percent) (Stanton, 2004).
- Disadvantaged adolescents: HIV students, primarily high school dropouts from inner-city communities, found extremely high seroprevalence rates. The highest rates were found among black and Hispanic youths from large northeastern cities, where up to 1 in 40 21-year-olds were infected. Since these youths are considered a sentinel population, more representative of inner-city youth than either military recruits or runaways, their high infection rates are alarming (Stanton, 2004).
- Homeless persons: An estimated 20 to 30 percent of the homeless in New York City are HIV positive. Most are IVDUs. Although increasing, seroprevalence is estimated to be lower among the homeless elsewhere (Stanton, 2004).
For this and a variety of other reasons, including restrictive testing requirements, failure to diagnose and failure to report, the WHO estimates that a full one-third of all AIDS cases were not tabulated by the WHO.
Distribution and Social Factors of HIV
The distribution of AIDS cases has changed and is expected to continue changing in a similar fashion. Homosexuals and whites comprise a smaller proportion of cases; IVDUs, blacks and Hispanics comprise a larger proportion. But the greatest change has been the shift to cases involving heterosexual transmission and, consequently, to women and infants. Minority women, accounting for 72 percent of the female cases today are at greater risk for They or their sex partners are more likely to use intravenous drugs (UNAIDS 2008, Fast facts about HIV/AIDS) They are far less likely than white women to use condoms even when aware of the risk of HIV infection (Stanton, 2004).
The number and proportion of female and IVDU cases will continue to increase as crack addicts turn to injectable cocaine for its longer-lived high. Women (and teenagers) comprise a greater proportion of cocaine users than heroin users. Here too, minorities will be disproportionately affected, as they comprise the majority of crack users. The results of the screening of students indicate that AIDS cases among minority women will be increasing rapidly. Seroprevalence rates among black and Hispanic adolescent women who were high school dropouts, the population hardest to reach, were almost as great or greater than those among males with similar characteristics from their communities. The primary mode of transmission appeared to be heterosexual transmission (Emlet, 2004). If current trends prevail, HIV cases will continue to increase as those currently seropositive develop the full-blown disease and many more people become infected. People all make behavioral choices intended to promote utility maximization.
Some of those choices, like drug abuse, are misguided. They provide only fleeting gratification, bear considerable risk and generate significant costs. Those risks and costs may be greater than anticipated. No one chooses to contract HIV. It is a terribly painful and invariably fatal illness. This, combined with the median latency period of eight to ten years, means that the majority of the cases among homosexual men probably resulted from behavior that was not known to bear risk. Intravenous drug users also played a critical role in spreading HIV infection before the mechanics of transmission were known. They not only spread the virus among themselves through sharing injection equipment that carried HIV-contaminated blood, but also infected their sexual partners and their offspring. Now that AIDS and its transmission are better understood, many people strive to avoid risk-bearing activity. But all too often, those at greatest risk still take the greatest risks (Greene et al 2003).
Teenagers are a high-risk group, vulnerable because of their high rates of unprotected intercourse and use of drugs and alcohol, which leads to riskier sexual behavior in all populations. Although the incidence of HIV among adolescents is low, many patients in their twenties contracted the virus as teenagers. As with gay men, teen sexual practices vary, and those at greatest risk of exposure to AIDS are often least likely to practice safe sex (Emlet, 2004). The survey reviewed found that 66 percent of the young men categorized as low-risk used a condom at last intercourse, but only 51 percent of the high-risk group did. Most of the high-risk condom users were bisexuals (Greene et al 2003).
Costs of HIV
Population measures seek to contain contagious disease to those already infected, usually by physical isolation. Although often ineffective in controlling epidemics, the population measure historically favored has been quarantine. A quarantine guarding against AIDS would have to include every HIV-infected person as well as those with full-blown cases. Fidel Castro is attempting just such a massive screening and quarantine in Cuba today (Greene et al 2003). In this country healthy prison inmates have filed suits demanding HIV screening and isolation of all seropositive inmates. Judges have occasionally jailed HIV-infected prostitutes who refused to stop soliciting. Parents of healthy children, failing to realize that their children face greater danger riding in motor vehicles, exposed to tobacco smoke or simply at play than through casual contact with an infected person, have clamored to have children with AIDS kept out of the schools. All applicants for permanent admission must submit to HIV screening; applicants for temporary admission may be tested at immigration officials’ discretion. Quarantine on a national scale in this country would be extremely unwieldy and expensive and entail massive violations of civil rights (Greene et al 2003).
Attempts to isolate HIV victims have been fraught with contention and have sparked legitimate disagreement even among sympathetic persons. The courts have frequently been called upon when HIV victims have been denied housing, have been refused admission to schools, or have had their employment terminated. New legislation, similar to that which protects the handicapped, has been passed (Gilbert & Wright 2003). Behavioral remedies are more efficacious than population remedies. Population measures have serious limitations and are basically unnecessary, as HIV is not spread by casual contact. People need only be aware of and avoid the avenues of transmission. The first step in changing behavior is education. Only two-thirds of the nation’s school districts provide HIV education. Many do not offer it in the upper grades, where students are more sexually active. Teacher training is often insufficient. Yet surveys indicate that our overall efforts have been effective, that most people know a good deal about HIV how to avoid it (Gilbert & Wright 2003).
This is especially true of low-risk groups; they have been most responsive in changing their behavior to reduce their risk yet more. The society must expand these efforts, close the gaps and strengthen programs targeted to high-risk groups. A great variety of culturally sensitive techniques have been designed to reach our various subpopulations, but implementation has been limited. These programs must be more widely employed. A second step is also necessary, as many people have failed to translate knowledge into less risky behavior. This involves encouraging and enabling people to reduce their risk-bearing activities. It is here that the greatest controversies have arisen and the diversity of American values have been shown in sharpest relief. The controversy raises unsettling issues of racism, class bias, and the value of human life. The question is partly one of money, partly one of equality versus equity and partly, perhaps, one of social self-protection. Drug therapies are expensive and, while they extend life, they do not save it. Nor do they prevent HIV transmission. They extend life expectancy but also extend costly treatment time and increase the opportunities for spreading the disease.
HIV is a social problem caused by complex social and economic, political and cultural issues. Many people are at greatest risk but have been least influenced by current behavior modification efforts. Those that effectively reduce drug use effectively reduce HIV transmission. The task of the state is to promote realistic HIV risk reduction strategies, recognizing the fact that people do not always act in accordance with their own best interests. People have a taste for drugs and people are sexually active, sometimes promiscuously so.