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HIV: A Public Health Crisis

Human Immunodeficiency Virus (HIV) is a global pandemic, with serious implications. Methods are needed to prevent the spread and control HIV.

HIV attacks immune cells, specifically, CD4 cells. As the CD4 cells die, the ability of the immune system to fight off infections decreases. This allows opportunistic infections to attack the body. A healthy person has a CD4 count between 500 – 1,600 cells/mm3 of blood. A person with HIV is considered to have  Acquired Immunodeficiency Syndrome (AIDS) when their CD4 count goes below 200 cells/mm3 of blood.

Infection of a cell by HIV begins with the HIV protein envelope binding to a primary cellular receptor on the CD4 cell. It is believed that the HIV must bind to a coreceptor to trigger the fusion of the cell membrane with the virus. The viral particle moves to the site of fusion by cellular transport mechanisms.1 HIV is a retrovirus, which means it uses RNA and converts it to DNA, reverse transcription, which then gets incorporated into the cell genome. RNA is converted to DNA by a reverse transcriptase enzyme. An integrase enzyme integrates the newly synthesized HIV DNA into the cell’s DNA. New HIV cells are produced in the cell starting with transcription of mRNA. The mRNA is translated into viral proteins. Finally, the virus is assembled, and is ready to attack more cells.

Both HIV and Simian Immunodeficiency Virus (SIV) are lentiviruses. SIV is similar to HIV in that it attacks the immune systems of monkeys and apes. HIV is related to SIV. The HIV-1 strain is almost identical to the chimpanzee SIV, SIVcpz, while the HIV-2 strain is most closely related to the sooty mangabeys SIV. HIV-1 is believed to have developed and crossed over to humans from SIVcpz. The chimpanzees also ate mangabeys, which is how the other strain of HIV could have passed over to humans. The prevailing theory of how HIV was passed to humans is by SIVcpz being transferred to humans when they ate chimpanzees. The SIVcpz adapted to the humans in the form of HIV-1. There are multiple forms of HIV, which suggest that SIV adapted to a few humans to form a few different forms of HIV. HIV-2 which comes from the sooty mangabey monkeys is believed to have entered the human genome in a similar manner.2  Studies show HIV first entered humans in Kinshasa, Democratic Republic of Congo around 1920.3  The earliest sample of blood of HIV is from 1959, from man who lived in Kinshasha, Democratic Republic of Congo.4 HIV spread from Kinshasa through the sex trade. By 1980 HIV was already and epidemic. HIV was first recognized in the United States in 19812 

HIV is a global pandemic, and can easily be spread from person to person via bodily fluids. HIV is spread when either blood, semen, rectal fluids, vaginal fluids, and breast milk of an infected person comes in contact with the blood or mucous membranes of a HIV negative person. Most commonly HIV in the U.S. is spread though vaginal or anal sex or through sharing needles for drugs. HIV can also spread between a mother and baby, and from sharp related injuries, other less common methods of HIV transmission also exist.5  1.1 million People are living in the U.S. with HIV, approximately 157,000 of those people don’t even know they have HIV. It is more common for young people to be unaware that they have HIV. There are approximately 38,000 new cases of HIV diagnosed each year in the United States. Gay and bisexual men make up 69% of new cases of HIV diagnoses in the United States. Injection drug users make up 7% of people diagnosed with HIV.6 In 2018 42% of new HIV diagnoses were given to Blacks/African Americans. 27% of new cases were diagnosed to Hispanics/Latinos.7

25% of new HIV infections happen in people aged 13 – 24.8 As such I would propose targeting the youth.  An additional issue with the youth is that they often don’t know they have HIV. I would make it an education requirement to teach middle school and high school students about HIV. I would also incorporate mandatory testing of the information taught into government exams. It is especially important to start with middle age students, this way they can learn it before they are likely to come across a situation in which they may get infected. Also, since some students drop out of high school, this would ensure they learn about it at some point. I would recommend that it is incorporated into the curriculum for each grade, which would allow them to learn about it multiple times. Additionally, since many young people don’t know they have HIV, I would add confidential HIV testing to more locations. Every school should offer HIV testing. I would like to increase the accessibility of HIV testing to the public. I would propose doing this by having the government reimburse clinics for testing uninsured people. This would allow people to get HIV testing at any clinic which performs it.

Needle exchange programs are a form of harm reduction. The needle exchange programs, which give sterile needles for free to drug users, have been controversial. Critics of the needle exchange program state giving out free needles enables drug use, and may increase drug use. Supporters understand this offers an opportunity to decrease the spread of infectious diseases such as HIV. The needle exchange sites also have the added benefit of providing a location where drug users can seek help. Both sides are valid. The benefits outweigh the risks in this case, as such the needle exchange programs should be continued. I would also recommend adding free condoms at the needle exchange sites. Additionally, I would add more needle exchange sites. Increasing the accessibility will increase the use of these programs. I would recommend adding needle exchange programs to pharmacies, clinics and hospitals. These programs are cost effective, prevention of HIV is cheaper than treating the disease.

The classic HIV treatment is Antiretroviral Therapy (ART). ART consist of a combination of drugs that work to prevent HIV from spreading within the body. A study in Uganda showed that the combination of ART and male circumcision to prevent HIV had a population -level effect.9 The foreskin has Langerhans’ Cells. These cells have HIV receptors, which provide an entry point for the virus to enter.10 Circumcision men have a significantly lower chance of getting HIV compared to uncircumcised men.10 I would suggest educating new mothers of males in the hospital about the benefit of circumcision, and offering new mothers to have their child circumcised.  

The methods stated above offer ways to decrease the number of cases of HIV on the population level. The methods stated above will cost the public money, however, they are cost effective because HIV treatment cost more money. People may argue HIV treatment cost the individual money, while these methods cost the public money. This is not the case, because HIV treatment paid for by Medicare and Medicaid cost everyone money. Many of the methods suggested above involve education. Education is a relatively feasible method to implement.

References:

  1. Wilen, C. B., Tilton, J. C., & Doms, R. W. (2012). HIV: cell binding and entry. Cold Spring Harbor perspectives in medicine, 2(8), a006866.
  2. Avert (updated 2019, October): Origin of HIV and AIDS, Retrieved https://www.avert.org/professionals/history-hiv-aids/origin
  3. Faria, N.R. et al (2014, October): The early spread and epidemic ignition of HIV-1 in human population
  4. Science (1998, February) Oldest Surviving HIV Virus Tells All, Retrieved https://www.sciencemag.org/news/1998/02/oldest-surviving-hiv-virus-tells-all
  5. HIV.gov (updated 2019, June ) How is HIV Transmitted?, Retrieved https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/how-is-hiv-transmitted
  6. HIV.gov (updated 2020, January) U.S. Statistics, Retrieved https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
  7. CDC.gov (updated 2019, November) HIV Basic Statistics: Retrieved https://www.cdc.gov/hiv/basics/statistics.html
  8. CDC.gov (Updated 2012, November) HIV Among Youth in the US: Retrieved https://www.cdc.gov/vitalsigns/hivamongyouth/index.html
  9. Grabowski, M. K., Serwadda, D. M., Gray, R. H., Nakigozi, G., Kigozi, G., Kagaayi, J., … & Galiwango, R. M. (2017). HIV prevention efforts and incidence of HIV in Uganda. New England Journal of Medicine, 377(22), 2154-2166.
  10. Szabo, R., & Short, R. V. (2000). How does male circumcision protect against HIV infection?. Bmj, 320(7249), 1592-1594.