Human immunodeficiency virus (HIV) was first reported in 1981 among gay men in Los Angeles. HIV caused a severe infection that weakened their immune system. It was the beginning of the acquired immunodeficiency syndrome (AIDS) pandemic (MHAF, 2019), which later in 2010 became the fifth leading cause of disability in all ages (Zulfiqar, 2017). Although these were the first incidents to be reported, many people have fallen victims of HIV and many have died before 1981. Although effective diagnosis, treatment and control have become available in higher income countries, this remains difficult for people living with HIV in disadvantaged countries in Africa. Throughout this essay, the disadvantaged circumstances of people living with HIV in Africa will be highlighted, and those of homosexual men in particular. Furthermore, the essay takes into account how shame and stigma act as barriers to effective treatment and control, and how education is crucial for HIV control.
What is HIV-1?
HIV-1 is the most common and virulent form of HIV, and it has spread worldwide. HIV-1 begins the assembly and the replication process by forming two different forms – mature and immature- vision of viral capsids (Ganser-Pornillos, 2008). These capsids are retroviral, meaning their genetic material consists of RNA molecules, which infect various immune system cells such as CD4+ T cells, dendritic cells, and macrophages (Zulfiqar, 2017). The virus first creates non-infectious and immature budding of the host’s immune cells, which are made out of a protein called Gag. The reason why the virus starts only with creating buddings is to prevent a strong immune reaction. The Gag protein molecules then assemble inside the plasma of the cells and the viral protease becomes activated, triggering the Gag to produce new layers of proteins and leading to the rearrangement of the immature visions in order to become mature and infectious (Ganser-Pornillos, 2008). This leads to the impairment of the immune cells function or in some cases to destroying them. Thus, making people with HIV more susceptible to infections as their immune cells cannot fight against infections anymore (Giamberardino, 2019).
What is the origin of HIV? Is it zoonotic?
HIV-1 is zoonotic, indeed. An evidence of animal reservoir was found in Africa, where one chimpanzees’ subspecies; the central P.t. troglodytes, had been commonly infected with a strain of virus called (SIVcpz), which is thought to be closely related to HIV (Gao, 1999). Based on this research, it was proven that this species is the primary reservoir for HIV-1. It is also thought that the transmission of SIV to humans initially occurred from Chimpanzees to African hunters through the delivery of Chimpanzees’ blood to the hunters’ cuts (Avert, 2019). Consequently, HIV-1 was primarily originated in Africa, and thus the African people were most likely the first to be infected with HIV-1. Hence, the spread of HIV-1 began through the migration of these African populations to the world – relocation and hierarchical diffusion; especially that HIV transmission only occurs through specific human-to-human interaction. Therefore, male African victims are expected to be in high numbers, especially that hunters are usually the males.
How is HIV transmitted to others? What are the unexpected ways of transmitting it?
HIV is transmitted through blood, semen and pre-seminal fluid, rectal fluid, vaginal fluid and breast milk. HIV transmission happens when any of these fluids comes into contact with the bloodstream or the mucous membranes of a HIV-negative. Yet, transmission does not occur very frequently since sexual acts, needles or razors sharing is required for transmission, and coughing or touching does not contribute to transmission. However, unfortunately acts like “not ejaculating semen” are unlikely to prevent the transmission of HIV and therefore, protective condoms must be used during intercourse with casual partners to lower HIV transmission (How Is HIV Transmitted, 2019). Yet, in countries with low SES, condoms are less available for people. A study was done in 1996 in Lusaka, Zambia, surveyed 806 participants showed that only 17% of women and 24% of men used a condom during their last intercourse with their casual partner. Surveyed men also revealed that condoms were used only when they are accessible, as sometimes they were unaffordable (Agha, 1998).
However, in some day-to-day life, using a condom is not seen as a necessity. This is due to developing unrealistic optimism; and it is when people, gay men in our case, believe they are less likely to be infected with HIV through sexual acts. In fact, two studies have shown that 89% and 77% of gay men think that HIV-1 infection is less likely to happen to them than their fellows (RS, 2006). Thus, these individuals are less likely to take actions to protect themselves, such as using condoms. The reason for this unrealistic optimism was predicted to be due to either of two models, the first is ‘motivational account’ where people attempt to encourage themselves and enhance their self-esteem. The second model is thought to be a by-product of ‘cognitive strategies’ which are done by employing cognitive heuristics. Often cognitive strategies do not have a good outcome as people tend to estimate how dangerous situations are based on how frequently they come to their mind. In the case of unrealistic optimism related to HIV, the model is different in different populations (RS, 2006). Additionally, in countries where homosexuality is socially and politically unaccepted and LGBT+ community and supporters might be jailed for 14 years (Bhalla, 2019) homosexual individuals are likely to marry a heterosexual partner but also have a secret homosexual partner. It is done to hide their homosexuality and to satisfy social norms (M.Fogel, 2018). Here lies the problem, when unrealistically optimistic gay men have sex with HIV-1 infected gay men in secret, not using condoms, and not using condoms with their female partner too. Thus, transmitting HIV-1 to their female partners, who could be breastfeeding, and thus infecting her infants. This creates an unaccounted-for cycle of HIV transmission. It was shown that even if women were aware of the HIV transmission and their partner’s homosexuality, they are unlikely to suggest safe sex practices to their partners, scared to be negatively viewed and stigmatised by them. This particularly happens when women are economically vulnerable which is more low SES countries. Yet, women who were more economically independent living in high SES countries were encouraged to do so. Therefore, African women at higher risk of infection compared to for example American women (Agha, 1998).
In another study of self-reporting HIV status among men who have sex with men (MSM) or transgender women who have sex with men in Africa, it was observed that HIV-infected African men may deny or choose not to disclose their HIV status. In fact, when 183 infected individuals were tested for antiretroviral drugs, 116 individuals reported themselves negative! This is connected to anxiety of shame of carrying HIV. Additionally, these individuals may think they will discriminated against or may feel stigmatised if ever this information is to be shared with society, particularly if their partners were not aware of their homosexual behaviour (M.Fogel, 2018). Another study based in the UK suggests that heterosexual carriers of HIV are more likely to disclose their HIV status to family and friends than a homosexual carrier. Furthermore, it also highlighted that individuals from a non-white ethnicity are less likely to disclose their HIV status and less likely to be on ART (Daskalopoulou, 2017). This could be due to lack of peer-support and fanatic religious views. This was demonstrated particularly when the US government funded campaigns in Africa, providing packs of condoms for free. Yet, when this was reported to media, public and religious organisation voiced reservation against condom promotion (Zulfiqar, 2017) and some people followed their views, countering the purpose of these campaigns.
Due to criminalization of homosexuality in countries of Africa, stigma and laws against LGBT, less testing for HIV is done among these populations (M.Fogel, 2018). This leads to latent detection of HIV, that if ever detected before these individuals die from infections, particularly gay African men as they are less likely disclose their HIV status. Moreover, due to this later intervention, the development of AIDS (most advanced level of HIV) is made possible, which may have been totally preventable if treatment for HIV was available. Since the development of HIV to AIDS could take 5-10 years, unknowingly infected African men are contributing to spreading and the re-emerging of HIV.
Furthermore, disadvantage occurs as hospitals in Africa may not be provided with the technology to properly sterile their equipment, or their lack of funding to purchase disposable equipment. According to a study, transmission of HIV due to using unproperly sterile equipment in Africa’s hospitals is 10-20% (Gisselquist, 2006). Thus, transmission could also occur from HIV positive to HIV negative patients when being treated at a hospital. This is unlikely to occur in high income countries, as regulations in hospitals are very strict.
Education plays a huge role in controlling HIV. HIV-related content is now integrated in the education system of the first world countries and is accessible for everyone, but not in Africa’s. The unawareness of flu-like symptoms that occur in the first stage of HIV is a contributor for its spread. Thus, educating African populations is a vital. This is further advocated when younger and more educated gay men were more likely to use condoms (Agha, 1998) showing that access to education made prevention possible. Thus, in order to be close to eliminating HIV, HIV-related and sexual education must be taught from a young age. Unfortunately, despite all the campaigns done around the world to eliminate HIV, 770 000 people around the world have died from HIV in 2018, according to WHO, and the majority of deaths happen in Africa (WHO, 2019). New strategies are being tested to lower infection rates, for example, it was suggested that male circumcision could reduce the chance of HIV transmission (Lawal, 2017) and implying this practice lower Africa’s cases.
HIV is a chronic and infectious virus, yet, no natural immunity against HIV is found, and no vaccines were discovered, thus herd immunity cannot be reached at this stage, and HIV-free environment may be hard to reach. HIV is severe, and most likely results in mortality, it is also spread world-wide, and can be transmitted to others through body fluids. It is found that individuals living in Africa are less likely to pursue methods for HIV prevention, detection and treatment, especially gay men. Actions are taken to lower mortality cases to less than 400 00 by 2030 worldwide. Still African populations are clearly disadvantaged, with 470 000 HIV deaths in Africa compared 49 000 in America in 2018 (WHO, 2019), so does where you live determines whether you live?
- Agha, S. (1998). Sexual Activity and Condom Use in Lusaka, Zambia. The Alan Guttmacher Institute.
- Avert. (2019). Retrieved from origin of HIV and AIDS: https://www.avert.org/professionals/history-hiv-aids/origin
- Bhalla, N. (2019). gay men seen dying from AIDS due to Africa’s homophobic laws. Retrieved from Reuters: https://www.reuters.com/article/africa-lgbt-aids/gay-men-seen-dying-from-aids-due-to-africas-homophobic-laws-idUSL3N26S1WX
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