2 курс / Микробиология 1 кафедра / Доп. материалы / Kartikeyan_HIV and AIDS-Basic Elements and Properties

23.8 HIV testing and reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 23.9 Issues pertaining to treatment . . . . . . . . . . . . . . . . . . . . . . . . . 346 23.10 Issues pertaining to dying . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346 23.11 HIV and marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 23.12 Ethical issues in HIV/AIDS research . . . . . . . . . . . . . . . . . . . 348

24.1 Expectations from health care providers . . . . . . . . . . . . . . . . . 355 24.2 Continuing HIV education . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 24.3 Role in public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358 24.4 Peer support organisations . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

25.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362 25.2 Study of immune responses . . . . . . . . . . . . . . . . . . . . . . . . . . 363 25.3 Scientific obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 25.4 Programme-related obstacles . . . . . . . . . . . . . . . . . . . . . . . . . 365 25.5 Various approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 25.6 Ethical issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 25.7 India’s role in HIV vaccine trials . . . . . . . . . . . . . . . . . . . . . . . 369 25.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

26 Response to the HIV Epidemic in India . . . . . . . . . . . . . . . . . . . . . . . 373

26.1 Government’s response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 26.2 National level programme management . . . . . . . . . . . . . . . . . 374 26.3 State-level programme management . . . . . . . . . . . . . . . . . . . . 375 26.4 First phase of NACP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 26.5 Second phase of NACP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 26.6 National HIV policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 26.7 Community response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 26.8 Private sector’s response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 26.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381

27 Response to the HIV/AIDS Epidemic in Thailand . . . . . . . . . . . . . . . 383

27.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 27.2 Response to the epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 27.3 Current situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 27.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

28.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 28.2 Phases of China’s epidemic and response . . . . . . . . . . . . . . . . 388

PREFACE

In June 1981, the Centers for Disease Control and Prevention reported the first evidence of a new disease that would later become known as acquired immunodeficiency syndrome (AIDS). Since then, there has been an explosion of information, and volumes have been written on the clinical aspects, virology, immunology, pharmacology, therapeutics, and epidemiology of this new plague.

In the minds of the public, HIV infection is associated with sexual “minorities”, “deviant” sexual behaviour, sexual promiscuity, and injecting drug users. Due to these associations, individuals who are infected with HIV face social humiliation and discrimination, which is somewhat similar to that faced by leprosy patients since biblical times. So far, HIV/AIDS is neither curable nor vaccine-preventable. Ignorance about various aspects of HIV/AIDS exists in all sections of society, irrespective of educational status. Consequently, sociology, psychology, ethics, and human rights have assumed a dominant role. HIV medicine has blossomed into a multidimensional medical specialty. Though young doctors and medical students cannot be expected to know all details, they need to be conversant with several dimensions of HIV/AIDS. As compared to their teachers, today’s medical students are highly skilled in accessing electronic information. However, sources of electronic information are multiple, unregulated, and subject to perplexing malfunctions. Access to electronic sources depends on availability of electric power and functioning Internet connections. Some websites are poorly maintained.

The authors feel that a book continues to function as a dependable source of information even in the 21st century. Non-specialist doctors who are unable to undertake a detailed study due to pressures of busy medical practice may prefer a concise book with sequential arrangement of information. There are already many authoritative books on the various aspects of HIV/AIDS. Although most medical textbooks contain exhaustive details about epidemiological, diagnostic, clinical, and therapeutic aspects, the psychological, ethical, and legal aspects are either briefly touched upon or are completely ignored. Consequently, the average medical student or non-specialist doctor may remain ignorant about these dimensions. Techniques for counselling have been included because doctors have to take up the task of counselling if trained counsellors are not available in the peripheral settings.

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SECTION ONE

FUNDAMENTALS

Soon after the New England Journal of Medicine published articles on a disease with acquired cellular immune deficiency in December 1981, the scientific community soon realised that the cases reported in 1981 were not the first. In 1979, doctors in the United States had reported undiagnosed illnesses that were most likely cases of AIDS (Gottlieb, 2001), and studies showed that HIV was present in some US plasma donors as early as 1977 (Madhok et al., 1985; Gottlieb, 2001). Anti-HIV antibodies were reported in a serum specimen collected in 1959 in the Belgian Congo (Nahmias et al., 1986). RNA from this 1959 serum specimen was sequenced and identified as a group M strain of HIV (Zhu et al., 1998). The genomic divergence of group M serotypes began sometime between 1910 and 1950 (Korber et al., 2000). Comparisons of HIV-1 with SIVs isolated from chimpanzees (SIVcpz) indicate that its ancestors crossed over to humans on at least three separate occasions (Hahn et al., 2000). However, it is not known when that cross-over to humans occurred (Gottlieb, 2001).

1.2 – GLOBAL SITUATION

AIDS ranks fourth among the world’s top killers of mankind. Tuberculosis, respiratory tract infections, and malaria are among the top three killers. AIDS has killed more than 25 million people since it was first recognised in 1981, making it one of the most destructive epidemics in recorded history (UNAIDS/WHO, 2005). Of the HIV-infected persons, 90 per cent live in developing countries and over 40 per cent of those infected are women. Youth (15–24 years) is the fastest growing segment among the newly infected population. About half of the newly infected persons belong to the age group of 15–24 years. Each day, about 16,000 persons are newly infected, and every minute six persons below 24 years are infected. The number of AIDS orphans is expected to swell up to 25 million by 2010.

The number of people living with HIV worldwide as of December 2005 was 40.3 million (36.7–45.3 million). Of these, the estimated number of infected adults and children under 15 years was 38.0 million (34.5–40.6 million) and 2.3 million (2.1–2.8 million), respectively. The proportion of women infected with HIV is steadily rising. In 2005, 17.5 million (16.2–19.3 million) women were infected, one million more than in 2003. The number of people newly infected with HIV worldwide in the year 2005 was 4.9 million (4.3–6.6 million). This included 4.2 million (3.6–5.8 million) adults and 700,000 (630,000–820,000) children less than 15 years. Despite improved access to antiretroviral (ARV) treatment and care in many regions of the world, the AIDS epidemic claimed the lives of 3.1 million (2.8–3.5 million) persons in the year 2005, of whom 570,000 (510,000–670,000) were children less than 15 years. HIV/AIDS statistics pertaining to various regions of the world as of December 2005 is given below. The figures in brackets indicate range estimates (UNAIDS/WHO, 2005). Unlike a point estimate, the range estimate reflects the actual situation in the field. The upper limit of the range is usually about 20 per cent higher than the lower limit in order to take care of unaccounted number of HIV-positive persons in high-risk and other age groups.

In 2002, the Pan Caribbean Partnership against HIV/AIDS signed an agreement with six drug manufacturers to provide access to cheaper ARV drugs. Partly due to wide differences in drug prices, access to ARV treatment is unequal in this region. ARV therapy is made available to all those in need in Cuba, and the Bahamas and Barbados are progressing towards this objective. However at the end of 2005, just about one-third of those in need of ARV treatment were receiving it in Trinidad and Tobago. The rates were even lower in Haiti and the Dominican Republic (Noble, 2006).

1.5 – SOUTH AND SOUTH-EAST ASIA

The epicentre of the global HIV pandemic is moving from Africa to Asia. The total number of HIV-infected persons was estimated at 7.4 million (4.5–11.0 million) at the end of December 2005. Of the infected adults, 26 per cent (aged 15–49) were women. During 2005, 990,000 (480,000–2.4 million) adults and children were newly infected with the virus and an estimated 480,000 (290,000–740,000) died due to AIDS-related conditions.

Across Asia, the epidemic is fuelled by a combination of injecting drug use and commercial sex. The HIV infection prevalence rates in Asia are low in comparison with that in some continents, especially Africa. However, the populations of many Asian countries are so large that even a mere 1 per cent rise in prevalence implies addition of millions of people living with HIV. The initial driver of the HIV epidemic in most Asian countries is injecting drug use. Since large proportions of drug users are also involved in commercial sex, HIVinfected drug injectors can help build a “critical mass” of infections in sexual networks. As HIV enters commercial sex networks, its wider sexual transmission is almost certain to follow (UNAIDS/WHO, 2005).

The epidemic continues to spread in Papua New Guinea and Vietnam. Countries like Pakistan and Indonesia could be on the verge of serious epidemics (UNAIDS/WHO, 2005). Myanmar (formerly Burma) has been described as the epicentre of the Asian epidemic. As per current projections, the number of HIVinfected persons in the Asia-Pacific region will overtake that in sub-Saharan Africa by early 21st century (Chin, 1995). Many countries in the Asia-Pacific region have not initiated the strategies for prevention and control of the epidemic. Blood supply remains unsafe in many countries of the region. Cross-border trade and international migration of the workforce (particularly single migrants from Philippines, India, Sri Lanka, and Bangladesh to Middle Eastern countries) may create a favourable environment for the spread of HIV (Dwyer et al., 1997).

1.5.1 – Afghanistan

Though there are only 49 reported HIV-infected persons in the country, these statistics could be misleading because HIV screening is limited to blood donors. There are only two voluntary counselling and testing centres in the entire country – at Kabul,