Student guest post by Francis Mawanda.
HIV/AIDS is a major public health problem worldwide. To date, it is estimated that more than 60 million people have been infected with HIV and more than 25 million people have died as a result of HIV/AIDS worldwide1. Despite the high prevalence and mortality rates that are associated with HIV/AIDS, and after more than 29 years of aggressive research efforts, there is still no cure or vaccine to prevent against HIV/AIDS. And although the introduction of antiretroviral (ARV) drugs in the mid 1990s greatly improved the outlook, health and quality of life of people living with HIV/AIDS, ARV drugs are associated with issues of viral resistance, serious side effects and high costs which render them unavailable in developing countries with the greatest HIV/AIDS burden. Therefore, prevention remains the key in the fight against HIV/AIDS.
Since the beginning of the HIV/AIDS epidemic, prevention has always been recognized as the major method for controlling the spread of HIV/AIDS. As a result, numerous HIV/AIDS prevention programs have been implemented in countries and communities all over the world. While these programs initially succeeded in reducing the prevalence of HIV/AIDS, current trends suggest that after an initial decline HIV/AIDS prevalence in most countries has plateaued over the last decade1 with new infections still being diagnosed every day. According to UNAIDS & WHO, in 2008 alone there were more than 2.7 million new cases of HIV/AIDS worldwide1 representing an average of 7000 new cases per day.
The continued spread of HIV/AIDS despite aggressive prevention programs and widespread public awareness presents a public health dilemma. This is true not only for HIV/AIDS, but for most health conditions that are associated with behavioral and or lifestyle risk factors such as smoking and lung cancer. This is because the reasons why people continue to engage in high risk behavior despite awareness of the possible negative health consequences are multiple, complex, and not only vary from individual to individual, but even for each individual, the reasons may vary from situation to situation or from one environment to another.
However, given that HIV can only be transmitted to an uninfected person from an infected person, then the continued spread of HIV/AIDS could be attributed in part to the fact that majority of current HIV/AIDS prevention programs are aimed at increasing awareness and reducing high risk sexual behavior among HIV negative individuals. These programs not only ignore the role people living with HIV/AIDS play in the HIV transmission equation, but also assume that people living with HIV/AIDS do not engage in high risk sexual behavior. However, recent studies have shown that a significant proportion of people living with HIV/AIDS continue to engage in high risk sexual behavior even after diagnosis of HIV/AIDS2,3,4. Therefore, there is a need for prevention programs aimed at increasing awareness and reducing high risk sexual behavior among people living with HIV/AIDS as well.
However, in developing and implementing HIV/AIDS prevention programs that target people living with HIV/AIDS, the fact that the population of people living with HIV/AIDS consists of individuals with HIV/AIDS and are aware of their HIV serostatus and individuals with HIV/AIDS but are unaware of their HIV serostatus should be considered since both groups require different approaches and yet both groups should be targeted concurrently in order for prevention efforts to succeed.
A large number of people living with HIV/AIDS, especially in developing countries are unaware of their HIV serostatus. These individuals continue to spread HIV/AIDS to their partners unknowingly. The huge role this group of individuals plays in the spread of HIV/AIDS has recently been recognized and as a result some countries have implemented programs to encourage people to test for HIV/AIDS and in some countries such as Botswana, by making HIV testing part of routine medical care. However these efforts alone without efforts targeted at people living with HIV/AIDS who are aware of their serostatus would be ineffective not only because routine testing does not involve proper HIV/AIDS counseling but also because as noted above some individuals will continue to engage in high risk sexual behavior after receipt of a positive HIV serology test . In addition, because HIV prevention is one of the major factors motivating individuals from engaging in high risk sexual behavior, after an HIV diagnosis there is no longer motivation not to engage in high risk sexual behavior except as an act of altruism.
In terms of people living with HIV/AIDS and who are aware of their HIV/AIDS serostatus, some governments have also recognized the role of this group of people living with HIV/AIDS in the continued spread of HIV/AIDS and as a result some countries have taken steps to prevent these individuals from spreading HIV/AIDS. These include laws and sentences for people living with HIV/AIDS and are aware of their serostatus who transmit HIV to an uninfected individual. However such efforts alone are also ineffective as they may instead discourage individuals from testing for HIV/AIDS to prevent prosecution and yet these programs depend on well documented and widespread HIV serostatus awareness. In addition, these programs are not practical in developing countries with the highest HIV/AIDS burden, simply because medical record keeping is inadequate making it very difficult to determine an individuals’ serostatus prior to any alleged contact.
However a combination of programs aimed at people living with HIV/AIDS who are unaware of their serostatus such as routine HIV/AIDS testing and proper counseling with programs aimed at people living with HIV/AIDS who are aware of their serostatus such laws and prosecution would address most of the issues that arise from targeting only one group.
Therefore there is not only a need for increased programs aimed at HIV/AIDS prevention through people living with HIV/AIDS but these programs should target both people living with HIV/AIDS and are aware of their HIV serostatus and people living with HIV/AIDS who are unaware of their HIV serostatus in addition to the programs aimed at people without HIV/AIDS. This would ensure that everyone regardless of their serostatus is involved in stopping the continued spread of HIV/AIDS.
1. UNAIDS, WHO (2009). 2008 report on the global HIV/AIDS epidemic. Available from http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp
2. Heckman T, Kelly J, Somiai A. Predictors of continued high-risk sexual behavior in a community sample of persons living with HIV/AIDS. AIDS and Behavior. 1998; 2: 127-135.
3. Kalichman S. Psychological and social correlates of high risk sexual behavior among men and women living with HIV/AIDS. AIDS Care. 1999; 11: 415-428.
4. Reilly T, Woo G. Predictors of high-risk sexual behavior among people living with HIV/AIDS. AIDS and Behavior. 2001; 5(3): 205-217.