The Changing Face of HIV/AIDS

CONTINUING EDUCATION

To earn CEUs, see current test at

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LEARNING OBJECTIVES

Upon completion of this article, the
reader will be able to:

1. describe statistics on HIV/AIDS to include the number of people affected in various geographic regions of U.S. and in other continents;
2. list various age groups, in particular at-risk groups, which should be tested for HIV;
3. discuss the rationale for comprehensive education on HIV/AIDS; and
4. discuss different available tools of communication that can be used to raise awareness and detection of HIV/AIDS.

Go to www.mlo-online.com to read the archived article from 1985, “What every laboratorian should know about AIDS.”

Key players in clinical labs hold starring roles

W

orld AIDS Day is celebrated on December 1st. “Act Aware” is this year’s theme. People around the world are encouraged to 1) take action to tackle HIV prejudice, and 2) protect themselves and others from HIV, the human immunodeficiency virus that causes the acquired immune-deficiency syndrome (AIDS). First observed in 1988, this special day has served to raise awareness about the AIDS epidemic, honor those who have died, focus attention on issues that are key to a successful response, and inspire positive action. Access to essential HIV information, prevention tools, treatments, and services are part of protecting people living with HIV and members of other vulnerable groups.¹

AIDS has been at the forefront of global health news from the earliest hints of a “dread disease” in 1981 to today’s successful solution for many patients — “cocktails” of effective antiretroviral drugs to treat that dread disease. Statistics — more accurately, estimates — from 2008 indicate that in developing and transitional countries, 9.5 million people are in immediate need of life-saving AIDS drugs; of these, only 4 million, or 42%, are receiving the drugs. By the end of 2008, an estimated 33.4 million people were living with HIV/AIDS. And despite ongoing improvements in access to antiretroviral treatment, 2008 saw another 2 million deaths from AIDS. AIDS has killed more than 25 million people worldwide since 1981. In Africa, more than 14 million children are labeled “AIDS orphans” (those under 18 who lost one or both parents to AIDS). And at the end of 2008, women accounted for 50% of all adults worldwide living with HIV.²

Increasingly, AIDS is seen as an “overseas” or an “African” problem, rather than something that directly affects American citizens. The President’s Emergency Plan for AIDS Relief, or PEPFAR, receives greater attention and attracts considerably more press than the work taking place within America. When AIDS is mentioned on a national level, it is often in relation to the chronic funding shortages for AIDS services or to the epidemic among African-Americans.³ To gain a realistic appreciation for the scope of the AIDS problem in America, three areas need to be examined: testing, education, and opportunity.

Why we must test everyone

Mandating the HIV/AIDS diagnostic test for all U.S. citizens is an idea for these times. While we focus here on four at-risk groups — youth, seniors, minorities, and the adult-entertainment workers — everyone is vulnerable to exposure. For example, the repercussions of an incident in a Las Vegas endoscopy center in early 2008 are still reverberating throughout that city’s population where as many as 40,000 patients were exposed to HIV through the reuse of needles at the point of anesthetic administration to save the clinic money.⁴ This incident serves as a reminder that even healthcare workers — knowingly and unknowingly — can expose patients to HIV. Other high-profile governmental and private healthcare providers also have been identified within the past year for various lapses of patient-safety requirements, exposing patients to HIV and other serious diseases.

After many years of public education since HIV/AIDS came on the scene, some are still naïve enough to believe that protection only applies to others: Two women testified in early October that they would not have engaged sexually with an airman if they had known he was HIV positive. One said she believed him when he denied he was HIV positive because “he was in the Air Force” [members of the U.S. military are tested for HIV regularly]. The airman’s wife participated in his “swinging” encounters but was concerned, she told military authorities, that he did not reveal his HIV status to his partners — but she never revealed this information to anyone with whom they were sexually involved.⁵

Youth: Almost one in 10 New York City high school students is sexually active; males with both same-sex and opposite-sex partners reported the lowest levels of condom use, according to an analysis of the New York City (NYC) Youth Risk Behavior Surveys from 2005-2007, which was administered to a representative sample of the city’s high schools. Of 17,220 students surveyed, 7,261 reported having had sexual intercourse. Fewer males (3.7%) than females (8.7%) reported partners of both genders. Participants reporting partners of both genders indicated higher-than-average rates of risky sex, such as not using a condom and higher rates of forced sex. Condom use during most recent sex was reported by 79.8% of males with only female partners, compared with 62.3% of males with only male partners and 44.1% of males with partners of both sexes. “It has been shown in the literature that students who have both male and female partners have a lot of adverse health problems,” says Susan Blank, MD, MPH, assistant commissioner of the NYC’s health department and head of its STD-prevention efforts. The data are a reminder that “our public-health prevention messages really need to look at behavior, not identity.” ⁶

Seniors: People rarely consider the threat of HIV/AIDS to seniors. Now, medical research studies show that seniors are at risk. In Florida, the 2008 statistics from the state’s reported cases showed the total of STDs as 96,957, with 1,594 of those registering HIV positive. According to the Centers for Disease Control and Prevention (CDC), people over 60 now make up 19% of all newly diagnosed AIDS cases. In 2007, heterosexual transmission in men over 50 was up 94% since 1991, and the rate had doubled in women.⁷

In the over-60 category, several reasons impact the explosion of seniors’ STDs. Among them is the fact that the growing widow population re-enters the social scene, becoming sexually active with the limited population of male partners. In retirement communities, there could be one man for every 10 or 12 women.⁸ Those male sex partners, having access to impotence drugs, are able to engage well into their 70s and 80s in more frequent sexual activity with more partners. West Palm Beach gynecologist and sexual-health expert Maureen Whelihan, MD, says that many of her patients maintain active sex lives well into their 80s; some are having sex in their 90s.⁹ Additionally, in men over 60, not only was condom use considered “unmanly” when this age group was initially introduced to sex but also those who practiced homosexuality often hid that behavior by marrying and having families — sometimes spreading AIDS to their wives and male sex partners, with neither of whom did they use protection.¹⁰

Minorities: By race/ethnicity, African-Americans face the most severe burden of HIV in the U.S. At the end of 2007, blacks accounted for almost half (46%) of people living with a diagnosis of HIV infection in the 37 states and five U.S. dependent areas with long-term, confidential, name-based HIV reporting. In 2006, the rate of new HIV infection for black women was nearly 15 times as high as that of white women and nearly four times that of Hispanic/Latina women. In 2010, the CDC announced a second three-year expanded HIV-testing program that supplements a 2007 initiative to increase HIV testing among African-Americans.¹¹

The adult-entertainment industry: Among taboo topics in the U.S. are those of the adult-entertainment industry and Nevada’s legalized prostitution. In Nevada, licensed brothels are required to have their sex workers tested weekly for several STDs and monthly for HIV; condoms in Nevada brothels are mandatory for all sexual activities.4 Adult-film actors do not generally use protection and, thus, can also place their personal sexual contacts at risk. In October 2010, a producer of pornographic films says production was halted in Southern California’s multibillion-dollar industry after an actor tested by the Adult Industry Medical Healthcare Foundation (AIM clinic) was found positive for HIV. At least five companies shut down production as a precaution to protect actors as the industry awaited more news and testing. More companies were expected to follow suit. While Los Angeles and California public-health and occupational-health officials have said widespread lack of condom use on porn sets puts performers at risk for contracting HIV and other diseases, major adult-film producers have spoken out against their use because viewers find them to be a “turnoff.” ¹²

The death of a 25-year-old pornographic actor earlier this year from HIV is the latest chapter in an ongoing debate about unprotected sex in adult films. Observers note that the issue is a sensitive one among practitioners of what is known as “bareback sex” who believe that safer-sex advocates are intrusive with their message of the importance of condom use.13 There were 22 known cases of HIV between 2004 and 2009 in the adult film industry.¹² Numerous adult-film actors have died of AIDS-related illnesses.¹⁵

Why we must educate everyone
Youth:

In our constantly upgraded technological world, Yahoo reports that three of the five top health searches using cell phones are “pregnancy,” “herpes,” and “STDs.”16 And while statistics show that young people use popular social networking media, the federal government, as well as local governments, continue to support youth education in pre-kindergarten through grade 12. The CDC’s Division of Adolescent and School Health (CDC/DASH) funds allow school systems to provide educational resources, staff-development opportunities, and technical assistance for the development and promotion of youth prevention-education programs, with an emphasis on preventing HIV and other sexually transmitted infections. Additionally, the National Health Education Standards (NHES) were developed to establish, promote, and support health-enhancing behaviors for students in all these grade levels. The NHES provides a framework for teachers, administrators, and policy makers in designing or selecting curricula, allocating instructional resources, and assessing student achievement and progress. Importantly, these standards also provide students, families, and communities with concrete expectations for health education.¹⁷

Seniors: Prevention and education dollars are concentrated toward the young-adult population; however, seniors are not using the tips from safer-sex education and continue to get HIV infected. The Senior HIV Prevention Project in South Florida reports that many seniors still believe that HIV is transmitted only by blood transfusion and casual contact. This lack of HIV knowledge — combined with the belief among this group that safer sex (condom use) is only for young women wanting to prevent pregnancy — leads to risky behavior among the community’s elder citizens. Without intensive education, post-menopausal adult women are less likely to discuss condom use now that the risk of pregnancy is removed.⁷

In 2005, the so-called “prophylactic prophet,” Miriam Schuler of Fort Lauderdale, was doing volunteer work in her community at the age of 87. She gained the nickname “Condom Grandma” when she joined up with the Senior HIV Intervention Program there. “I am a grandmother and when I was raised, sex was very private,” she told a reporter back then. She spread the word about the dangers of HIV and AIDS among older people by visiting retirement homes, assisted living centers, condominium complexes, and even to meetings of Kiwanis service clubs — wherever she was invited to talk to older people about safe sex. When a man asked her if one size condom fit all because he needed an XL, the once-shy Schuler rolled a condom down her arm to her elbow to demonstrate its capacity. While people may have laughed at her demonstration, Schuler was dead serious about her mission.¹⁸

Minorities: In 2010, one of the most hard-hit areas in the United States — Washington, DC — reported a 26% rise in the number of people tested for in the last 12 months following the implementation of routine HIV testing and a marketing campaign among D.C. residents to educate them about the new testing measures.3 About a year ago, the mayor of the District of Columbia, Adrian M. Fenty, announced the campaign, “D.C. Takes On HIV,” encouraging all citizens to ask their doctors for an HIV test when they go for a visit. “Everybody is at risk,” he explains. Statistics show that gay black men lead the percentage of people who contract the disease in the District. Latinos are the second most threatened minority group, and risky heterosexual sex threatens to expand infection to pandemic levels if it is not checked, officials say.¹⁹ In early October, D.C. brought free HIV testing to its Department of Motor Vehicles (DMV) where participants in the testing project received up to $15 to help defray their DMV costs.20 In June in Atlanta, a city with the eighth highest rate of AIDS cases in the nation (with blacks representing the biggest group impacted), Mayor Kasim Reed hosted a National HIV Testing Day event at City Hall where a rapid HIV test provided results within 20 minutes.²¹

The adult-entertainment industry: Currently, porn actors are required by law to test negative for HIV and other sexually transmitted diseases within 30 days of going to work on a film. The AIM clinic, founded by a former porn star who earned a doctorate in human sexuality, maintains a computer database that film producers can check to determine that actors have passed their tests. This has reduced the forging of test certificates, something more common during the 1990s when tests were required only every 90 days. State workplace safety officials at Cal/OSHA are considering strengthening rules designed to prevent transmission of disease through bodily fluids to specify the use of condoms in the adult-entertainment industry. Currently, the same laws that call on healthcare professionals to wear gloves and other protective barriers when dealing with patients applies to the adult film business, but the laws do not make provisions specifically for pornographic actors.¹²

“Neither monogamy nor heterosexuality is a protection. The virus likes mucous membranes. Unprotected penetrative sex puts one at risk,” says Carol Queen, PhD, a San Francisco sex educator and founding director of the Center for Sex and Culture, a sex education nonprofit.²²

Opportunity is knocking
According to William Haseltine in his commentary in The Atlantic on Oct. 15, “What cannot and should not be ignored is HIV/AIDS, an ongoing epidemic … is as severe in the nation’s capital and nearby Baltimore as it is in many countries of sub-Saharan Africa.” ²³ The Washington Post reported in early October that DC’s “2008 epidemiology update concluded that 3% of the city’s population had HIV/AIDS, well above the 1% considered to be a general epidemic.” ²⁴ Haseltine goes on to say that Washington, DC, together with Miami, New Orleans, and New York City, bears the highest HIV/AIDS burden in the country. In DC, sexual transmission is the dominant cause, followed by intravenous drug use; however, heterosexual sex is the most common mode of transmission in both black men and women, while sex between men is the most prevalent means of transmission among white men.²³

Haseltine points out that, untreated, HIV infection is almost uniformly fatal, and the annual cost per HIV+ patient, including costs of diagnostic tests and drugs, is estimated to be approximately $25,000.23 In the current American economy, many people are out of work and without insurance; thus, the Georgia state program that provides medication for low-income citizens with HIV and AIDS closed its enrollment in July, after creating an enrollment waiting list this past year that increased 17%.²⁵

What Haseltine does not point out is what U.N. Secretary-General Ban Ki Moon suggests: “Stigma remains the single most important barrier to public action … it helps make AIDS the silent killer, because people fear to social disgrace of speaking about it or taking easily available precautions.”²⁶ Perhaps innovative new media — cell phones, social networking sites, and interactive games — could be a more successful path to youth education and prevention than the traditional classroom lectures, films, and reports. Already, condom use is routine for American teenagers, who are much more likely to use them than people over 40.²⁷

As an example of the potential impact of the mobile phone as a health device for young and old worldwide, more than 1.1 billion women in low- and moderate-income countries already own a mobile phone.²⁸ Additionally, television can make an impact almost anywhere as well. Debuting last year, an MTV soap opera set and filmed in Nairobi, Kenya, follows a group of students in the era of AIDS. The cutting-edge style of “Shuga” distinguishes it from many other TV shows in Africa, and its non-preachy reflections of modern life have won it a young following across the continent. Shuga” came about when UNICEF joined with MTV to create a campaign to draw youth to health and social issues. Part of MTV’s “Staying Alive” campaign, the drama’s drive is an emphasis on protected sex and HIV testing. Of young Kenyans polled by Johns Hopkins University, 60% said they had seen the show. Of these viewers, 90% said the show would change their behavior.²⁹

“The goal of early-detection campaigns is to raise public awareness but also to prepare the healthcare system to follow through with screening tests,” says Brad Hesse, PhD, chief of the Health Communication and Informatics Research Branch at the National Cancer Institute. Health-promotion messages should focus on what can be gained by changing behavior, while behavior detection messages should focus on what could be lost if people do not go through with the screening. Another type of campaign aimed at raising public awareness (e.g., yellow-band and pink-ribbon campaigns) might be a possibility for HIV/AIDS.³⁰

Mass media are good for short, persuasive messages that can be squeezed into a 30-second television ad, says Hesse, but “it gets a little bit more complicated when you are talking about screening stuff because there is so much more involved in interacting with the healthcare system. It is good for raising awareness, but it is not as good as a follow-up. You need to connect that with some other channels.” He recommends brochures and computer media for tailoring and presenting more complex information, and says a mass media commercial should include a website or toll-free number for people to get more information.³⁰

Throughout our national history, environmental awareness campaigns seemingly have worked well:

• Smokey Bear reminded us only we can stop forest fires;
• Iron Eyes Cody shed a tear for our environment in a Keep America Beautiful public-service advertisement in the 1970s imploring us to stop pollution³¹; and
• The Don’t Be a Litterbug campaign in the 1950s reminded us not to throw trash along the then-new national highway system.

An ongoing campaign — World AIDS Day everyday — to raise awareness of the necessity of protection against HIV/AIDS perhaps could begin to put in a dent in the soaring rates of the virus/disease in American’s largest cities and among its most vulnerable populations, as well as those worldwide. According to the website Act Against AIDS (www.nineandahalfminutes.org) every 9.5 minutes, someone in the United States is infected with HIV; and of the 1 million Americans living with HIV, one out of every five does not know it. On World AIDS Day’s this year, we are all reminded to put personal awareness into action by sharing its slogan, “Act Aware,” with family, friends, and neighbors — everyone with whom there is an opportunity for dialogue — and reminding them that HIV and AIDS have not gone away. They are deadlier than ever unless we all are aware.

Note: To understand how far our understanding of HIV/AIDS has come, read MLO’s November 1985 cover story, “What every laboratorian should know about AIDS,” at www.mlo-online.com.

References

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