Prognosis in HIV and Aids Essay

Abstract

The term HIV/Aids prognosis can be defined as the causes in connection to the outcomes of HIV/Aids. This include time or duration of Aids/HIV, probable outcomes, chance of complication, survival rates, recovery period for Aids/HIV as well as other effects in overall prospects of Aids/HIV (Welch, et, al, 2012).

Prognosis in HIV and Aids

HIV can be defined as human immune deficiency virus. The word Aids is derived from initials of acquired immune deficiency syndrome. Aids/HIV is acquired through contamination of body fluids that occur through sharing needles, unprotected sex and sharing intravenous drugs. Prognosis in HIV and Aids Essay. Testing, guidance, counseling and Aids education are the basic measures that can lower rate of HIV infection. It is also essential to notify the public that Aids does not spread through mosquitoes, casual contact or touching common items with people affected by HIV.

HIV

In the world, we have two different types of HIV. HIV 2 that is found in West Africa as well as HIV 1 which can be found in all parts of the world. The two strands start with infection. After infection, the patient enters into a period which has no symptom. This period is called asymptomatic HIV infection which is followed by another stage with early symptoms of HIV and later Aids. The symptoms occur after some few weeks, and they include fever, flu, fatigue and headache. This period can take months or even years. However, in this period a patient can spread the virus. HIV weakens a body CD4 cells as well as T4 cells, which fights infection in a human body leaving the person weak and unable to fight diseases. Symptoms of HIV infection complies of weight loss, fatigue, sweats and fever, memory loss, skin rashes and herpes infections.

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Aids

This is the last stage of HIV. Aids occur after a severe damage has been caused to the human immune system. Persons with Aids are in medical terms referred as those who have not as much as 200 CD4 cells/ ML of blood. Characteristics of Aids are extreme fatigue, weight loss, fever, severe headache, memory loss and confusion, neck stiffness, loss of coordination and coma.

Prognosis

Recovery prospect or the prognosis for HIV positive patients have improved in the past 20 years. However, this depends on a number of factors. The most essential involves the patient access to proper drugs and HIV specialists. Prognosis in HIV and Aids Essay. By today, the cure of Aids has not been discovered, but a combination of different drugs is proofed to slow down the effects of the virus (Morris, 2013). This enables patients to live healthier and longer. The time that a patient takes to develop from HIV to Aids infection, is determined by the person’s behavior, health status and time he take to seek for medical assistance. Anti-retroviral drugs are drugs that have proofed to treat retroviruses such as HIV. These are the most effective drugs in increasing the general fitness of a HIV positive serene.

Before 1996, development of HIV to Aids used to take a very short period and hence faced death within less than 10 years. Today, the help of anti-retroviral drug is helping patients to live for a long period if they stick to the medical prescriptions. For the drug to work in an effective way to a patient, therapy is also a basic requirement (Shen, et, al, 2010). Similar to other medicines every patient reacts in a different to the anti-retroviral drugs. However, every patient is supposed to consider the possibility of having no side effects from the drug. It is also essential to enlighten patients that in some patients, the virus many resist to the drug, medical specialists who have specialized in HIV/Aids treatment offers advice to patients on the right time to start the therapy and the drugs. This depends on the extent that the virus has set up itself in the resistant system of the patient.

References

Welch, K., et, al., (2012) Clinical Profile of End Stages of Aids New York Times
Shen, J., et, al., (2010) Predictors of Mortality for HIV Patients International Journal
Morris, A., (2013) Improved Survival: Anti-retroviral Therapy in HIV Treatment Milton Publisher

Although global commitment to control the HIV/AIDS pandemic has increased significantly in recent years, the virus continues to spread with alarming and increasing speed. By the end of 2005, an estimated 40 million people worldwide were living with HIV infection or disease, a notable rise from the 35 million infected with HIV in 2001 (UNAIDS 2005). In 2005, close to 5 million new HIV infections and 3 million AIDS deaths occurred, more of both than in any previous year. Sub-Saharan Africa remains the region most affected by HIV/AIDS; however, the virus is now spreading rapidly in Asia and parts of Eastern Europe. Prognosis in HIV and Aids Essay.

Despite the rapid spread of HIV, several countries have achieved important success in curbing its transmission. The extraordinary potential of HIV prevention is exemplified by such diverse efforts as Thailand’s 100 percent condom program, Uganda’s remarkable decrease in HIV prevalence, and the community-based syndromic management of sexually transmitted infections (STIs) in Mwanza, Tanzania. Box 18.1 describes characteristics common to these programs.

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Box 18.1
Successful HIV Prevention Strategies. The HIV prevention success stories highlighted in this chapter stem in part from each country’s unique cultural, historical, and infrastructural elements. Nevertheless, these successes share several common features, (more…)

Successes also include the development and effective use of highly sensitive and specific HIV screening tests, which have virtually eliminated infection from the blood supply in the developed world and in most parts of the developing world (WHO 2002a). In addition, the administration of a short course of nevirapine to mothers during labor and to newborns post-partum reduces the risk of mother-to-child transmission (MTCT) by as much as 47 percent (Guay and others 1999). However, recent data suggest that such short-term successes may be at the expense of resistance and viral failure once treatment is introduced after delivery (Eshleman and others 2001).

Enormous advances in HIV/AIDS treatment regimens have fundamentally altered the natural history of the disease and sharply reduced HIV-related morbidity and mortality in countries where such treatments are accessible. The advent of anti-retroviral drugs in the late 1980s began a revolution in the management of HIV, which can be seen as analogous to the use of penicillin for treating bacterial infections in the 1940s. The most notable advance on the treatment front is the use of combination antiretroviral therapy, which is far more effective than monotherapy (zidovudine or AZT), the standard of care when the first edition of this volume was published. Recent declines in the price of combination antiretroviral therapy in developing countries from US$15,000 per year to less than US$150 in some countries have prompted numerous developing countries to introduce antiretroviral therapy through the public sector. These declines also pose difficult questions regarding the optimal allocation of limited resources for HIV/AIDS, as well as the potential impact on already strained health care infrastructures.

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Obstacles to HIV Control
Obstacles to effective HIV control include lack of prevention and care coverage and lack of rigorous evaluations. Both are discussed below.

Lack of Coverage and Access to Prevention Services
Notwithstanding these treatment strides, global efforts have not proved sufficient to control the spread of the pandemic or to extend the lives of the majority of those infected. The desired level of success has not yet been achieved for several reasons. Most people who could benefit from available control strategies, including treatment, do not have access to them. Modelers commissioned by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) determined that existing interventions could prevent 63 percent of all infections projected to occur between 2002 and 2010 (Stover and others 2002). Nonetheless, a 2003 survey of coverage revealed that fewer than one in five people at high risk of infection had access to the most basic prevention services, including condoms, AIDS education, MTCT prevention, voluntary counseling and testing (VCT), and harm reduction programs (Global HIV Prevention Working Group 2003). WHO and UNAIDS estimate that only about 7 percent of the nearly 6 million people in need of treatment receive it and that the number of people who require antiretroviral therapy increases by 8,000 each day (UNAIDS 2004).

Current coverage shortfalls, combined with the relentless expansion of the epidemic, underscore the acute need for rapid scale-up of prevention and treatment interventions—an imperative that the international community has acknowledged but that remains to be realized after more than 15 years. However, the activities of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the U.S. President’s Emergency Plan for AIDS Relief (a five-year, US$15 billion initiative) suggest a growing commitment to tackle these issues. The latter aims to provide antiretroviral drugs for 2 million HIV-infected people, to prevent 7 million new infections, to provide care for 10 million individuals, and to develop health system capacity in Vietnam and in Africa and the Caribbean. Even though 15 countries are currently slated to receive support from the President’s Emergency Plan, many of the countries most affected by HIV/AIDS—including Lesotho, Malawi, Swaziland, and Zimbabwe—are not included in the list of beneficiary countries.

Because antiretroviral therapy has historically been unavailable in most developing countries, national programs have lacked the means to undertake a comprehensive approach to HIV/AIDS (notable exceptions are Argentina, Brazil, and Mexico, which provide universal coverage for antiretroviral therapy). As discussed in chapter 8, control of the pandemic demands a two-front battle that emphasizes both prevention and care. Even though the prospect of greater access to treatment increases the feasibility of integrating prevention and care in resource-limited settings, it also raises new questions regarding the selection of optimal prevention programs to pair with treatment programs.

Lack of Rigorous Evaluations
In addition to poor coverage of key interventions, perhaps the greatest challenge to effective global control is the lack of reliable evidence to guide the selection of interventions for specific areas or populations. In the same way that global policy makers are increasingly recognizing the need for rigorous evaluation of development programs to ensure their success and eliminate waste, the need for reliable scientific evaluations of AIDS control programs is equally paramount for the same reasons. There are simply not enough resources to do everything everywhere; choices must be made and priorities set. In the HIV/AIDS field, this information deficit is especially pronounced with respect to HIV prevention in general and prevention implemented on a population level in particular. Currently, the allocation of resources for HIV/AIDS prevention is seldom evidence based, primarily because of a lack of data on both the effectiveness and the cost of interventions (Feachem 2004).

Few evaluations have collected data specifically on HIV infection as an outcome (Fleming and DeMets 1996). In the case of care and treatment, success and failure are more readily and rapidly apparent, leading to a substantial degree of auto-correction of ineffective policies. In contrast, with respect to HIV prevention, it is unlikely that those infections that might have occurred in the absence of a prevention program would be monitored, thus reducing the meaningfulness of the auto-feedback cycle for prevention. This underscores the importance of proactive, rigorous evaluation to differentiate success from failure in a timely manner. Sound evidence on the effectiveness of HIV prevention measures is especially important in light of the tendency of many governments and international aid agencies to avoid programs that address sexual behaviors, drug use, and highly stigmatized and vulnerable populations.

In addition, prevention studies have rarely incorporated the well-defined control or comparison groups necessary to identify contextual factors that are essential for appropriately tailoring interventions to the diverse regional settings and the myriad of microenvironments in which HIV transmission occurs (Grassly and others 2001). Contextual data are similarly critical for developing strategies to combat HIV/AIDS-related stigma and restrictive social and gender norms, which often frustrate attempts to address sexual and addictive behaviors associated with HIV transmission. Even where national efforts have succeeded in curbing the spread of the epidemic, as in Senegal and Uganda, evidence often does not clearly indicate the specific, well-defined, contextual features that account for success.

The lack of both contextual data and sound evidence regarding the effectiveness of HIV interventions hinders policy makers’ ability to tailor HIV interventions to the nature and stage of national epidemics, something that the authors argue is necessary to address HIV/AIDS effectively. In the absence of such data, HIV/AIDS expenditures undoubtedly incorporate an unacceptable degree of waste, people are unnecessarily becoming infected with HIV, and HIV-infected individuals are dying prematurely.

Why has this type of research not been more forthcoming? In part it is because, by definition, such research is less innovative scientifically and also typically less experimental than research to develop new interventions. It is handicapped both in competing for traditional research funding and in receiving academic recognition. The only way to redress the imbalance is through specific earmarking of significant research funds.

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Action under Uncertainty
Even though the current deficit in evaluation research is glaring, the magnitude and seriousness of the global pandemic means that action is nevertheless required. Moreover, despite such gaps in knowledge, we can still improve control strategies by tailoring interventions to the nature and scope of the epidemic. Summarized below is what is known with regard to the burden of disease, the determinants of transmission, and the effectiveness and cost-effectiveness of existing prevention interventions.

Burden of Disease
As a result of large-scale implementation of data collection methods for surveillance worldwide and enhanced methods for validating and interpreting HIV-related data, the HIV/AIDS epidemic is probably one of the best documented epidemics in history. An increasing number of data sources contribute to reasonably accurate estimates and a more nuanced understanding of the epidemic’s trends. Unfortunately, this relatively accurate picture of where the epidemic is and has been is not matched by similarly convincing maps of the factors that explain its spread.

Although no single country has been spared the virus, the epidemic has affected certain regions of the world disproportionately, and Sub-Saharan Africa remains by far the hardest hit region (table 18.1). With only 10 percent of the world’s population, it accounts for more than 75 percent of all HIV infections worldwide and more than 75 percent of AIDS-related deaths estimated for 2003. Asia and the Pacific, with several large and populous countries, account for 7.4 million infections, or 19.5 percent of the current burden of disease. Prevention and treatment efforts in Sub-Saharan Africa and Asia—regions that together represent 85 percent of all current infections—have dictated, and will continue to dictate, global trends in the burden of HIV- and AIDS-related mortality.

Table 18.1. Deaths and Disability-Adjusted Life Years Attributed to AIDS by Region, Age, and Gender, 2001.
Table 18.1
Deaths and Disability-Adjusted Life Years Attributed to AIDS by Region, Age, and Gender, 2001.

Between 1997 and 2001, the percentage of women living with HIV/AIDS increased from 41 to 50 percent. This trend is most apparent in Sub-Saharan Africa, where women represent 57 percent of adults living with HIV and 75 percent of HIV-infected young people. Even though women account for a smaller share of infections in Asia (28 percent), the disease burden among women and girls is likely to rise as the epidemic becomes generalized. More detailed information about the global burden of HIV/AIDS, regional differences, and trends over time is available in the UNAIDS (2005) report on the global AIDS epidemic.

Determinants of Infection
HIV transmission predominantly occurs through three mechanisms: sexual transmission, exposure to infected blood or blood products, or perinatal transmission (including breast-feeding). The likelihood of transmission is heavily affected by social, cultural, and environmental factors that often differ markedly between and within regions and countries. There is also some indication that molecular, viral, immunological, or other host factors might influence the likelihood of HIV transmission. For a more detailed discussion of sexual behaviors and the contextual determinants of infection, see chapter 17.

Sexual Transmission
Worldwide, sexual intercourse is the predominant mode of transmission, accounting for approximately 80 percent of infections (Askew and Berer 2003). Sexual intercourse accounts for more than 90 percent of infections in Sub-Saharan Africa. Although many people who know they are infected reduce their risk behaviors, studies in developed countries suggest that a substantial percentage nevertheless continue to engage in unprotected sex (Marks, Burris, and Peterman 1999). The risk of sexual transmission is determined by behaviors that influence the likelihood of exposure to an infected individual and by infectivity in the event of exposure. This also includes factors related to the infectiousness of the infected partner and the susceptibility of the uninfected partner.

Infectivity
The per contact infectivity of HIV from sexual transmission varies depending on sexual activity (Royce and others 1997). Anal intercourse carries a higher transmission probability than penile-vaginal intercourse, and male-to-female transmission is more likely than female-to-male transmission. Data on infectivity by transmission mode are shown in table 18.2.

Table 18.2. Estimated HIV Transmission Risk per Exposure.
Table 18.2
Estimated HIV Transmission Risk per Exposure.

Biological Mediators of Infectivity
Untreated STIs increase the risk of sexual HIV transmission several-fold (Institute of Medicine 1997). Numerous epidemiological studies have supported the association of genital ulcers in general and of genital herpes (herpes simplex virus 2, or HSV-2) in particular with HIV infection (Hook and others 1992). Not only does the biological interaction between HSV-2 and HIV enhance the transmission and acquisition of HIV, but HIV infection is also associated with more frequent reactivation of HSV-2. The presence of herpetic ulcers and lesions allows an entry point for HIV in the uninfected individual, and the presence of high copy numbers of HIV ribonucleic acid (RNA) in HSV-2 lesions in HIV-infected individuals underscores the importance for HIV prevention of controlling HSV-2 infections (Mbopi Keou and others 1999).

Vaginal infections are also emerging as important risk factors for HIV. For example, infection with trichomonas increases the risk for HIV seroconversion (Buve 2002). In addition, higher trichomonas rates have been detected in regions of Sub-Saharan Africa that have higher HIV rates, and investigators working throughout Sub-Saharan Africa report similar results, with odds ratios from 1.5 to 56.8 (Gregson and others 2001). In addition, studies have shown an increased risk of HIV acquisition in patients who have bacterial vaginosis (Martin and others 1999).

Circumcision also affects HIV transmission. In a meta-analysis of 27 studies (Weiss, Quigley, and Hayes 2000), uncircumcised men were almost twice as likely to be infected with HIV as those who were circumcised. Studies that controlled adequately for other risks and studies that separately assessed risk in high-risk populations, such as STI clinic attendees or truck drivers, found an even stronger protective effect of circumcision. Similarly, an ecological study comparing two high-prevalence Sub-Saharan African cities with two low-prevalence cities found that circumcised individuals were substantially less likely to be infected with HIV (Auvert and others 2001). Two recent studies conducted in Kenya and India (Donnelly 2004; Reynolds and others 2004) found that uncircumcised men had an HIV rate 7 to 11 times greater than circumcised men. More recently, results from a randomized controlled trial conducted in South Africa indicated that the risk of HIV acquisition was reduced by more than 60 percent of men randomized for circumcision (controlling for sexual behavior, including condom use and health seeking behavior) in a community where more than 30 percent of the women were infected (Auvert and others 2005).

Before circumcision among adult males becomes a widespread policy recommendation, results are still pending in two similar trials. Obviously one issue is the acceptability of such a procedure as well as the fact that some increase in high risk sexual activity was noted among the men who were circumcised, although this did not offset the results of the intervention.

The risk of sexual transmission is also strongly correlated with the plasma level of virus in the infected individual (Quinn and others 2000); thus, infectivity varies over the natural progression of the disease. Individuals are most infectious subsequent to infection and again during the late stage of the disease. Antiretroviral therapy significantly reduces the level of virus, often to the point that standard tests cannot detect HIV in the patient’s blood (Palella and others 1998). Available data suggest that viral load reductions induced by antiretroviral therapy will lower infectiousness. Studies have shown a close relationship between the amount of viral suppression and the risk of vertical transmission (Garcia and others 1999). Quinn and others (2002) show that the risk of sexual transmission between couples in Africa was strongly related to the level of viral load in the infected partner.

Exposure to Infected Blood or Blood Products
Injection drug use and blood transfusion are two mechanisms of HIV exposure to infected blood. Determinants of each are discussed below.

Injection
Because of the efficiency of HIV transmission through needle sharing, the introduction of HIV into an urban network of injecting drugs users can quickly lead to extraordinarily high HIV prevalence in this population. Sharing of injection equipment and frequency of injection are both important correlates of HIV infection (Chaisson and others 1989). Attendance at shooting galleries, where sharing with anonymous injecting partners is likely to occur, is also an independent risk factor across many studies (Vlahov and others 1990). Injecting cocaine (associated with “booting” or “kicking,” where blood is drawn into the syringe and then injected) and having a number of needle-sharing partners are also associated with HIV infection (Anthony and others 1991).

Blood Transfusion
The probability of becoming infected through an HIV-contaminated transfusion is estimated at more than 90 percent (UNAIDS 1997), and the amount of HIV in a single contaminated blood transfusion is so large that individuals infected in this manner may rapidly develop AIDS. Currently, between 5 and 10 percent of HIV infections worldwide are transmitted through the transfusion of contaminated blood products (WHO 2002a). Setting up and maintaining a safe blood supply will virtually eliminate HIV transmission through transfusions.

Perinatal Transmission
Perinatal HIV transmission includes both vertical transmission and transmission during breastfeeding. Determinants of each are discussed below.

Vertical Transmission
Perhaps the most compelling evidence of the significance of viral load and transmission risk has been documented with respect to MTCT. Maternal viral load, as quantified by RNA polymerase chain reaction, is associated with increased risk in each mode of vertical transmission. A recent randomized clinical trial in Kenya found that maternal plasma HIV RNA levels higher than 43,000 copies per milliliter were associated with a fourfold increase in vertical transmission (John and others 2001).

Independent of HIV RNA levels in maternal plasma, additional risk factors include cervical HIV deoxyribonucleic acid (DNA), vaginal HIV DNA, and cervical or vaginal ulcers. Chorioamnionitis has also been documented as a risk factor for MTCT among African mothers (Ladner and others 1998), as has exposure to maternal blood during labor and delivery. Newell (2003) estimates that for every hour an infant is exposed to ruptured membranes, the risk of transmission increases by 2 percent.

Breastfeeding
Transmission through breastfeeding is likely associated with an elevated viral load in the breast milk, which in turn is associated with maternal plasma viral load and CD4 T cell levels. Mastitis has also been associated with increased risk of vertical transmission. Meta-analyses suggest that the cumulative probability of HIV infection increases from 0.6 percent at age 6 months to 9.2 percent at age 3 (Read 2003). A study in Malawi, however, indicates that most transmission occurs in the early breastfeeding months, with an incidence per month of 0.7 percent at age 1 to 5 months, 0.6 percent at age 6 to 11 months, and 0.3 percent at age 12 to 17 months (Miotti and others 1999). In one study, infants who were breastfed in combination with receiving other supplementary foods were twice as likely to be infected at age 6 months than infants fed exclusively on breast milk or on formula (Coutsoudis and others 2001). The hypothesis is that antigens and bacterial contaminants present in supplemental fluids and foods consumed by infants who are not exclusively breastfed may cause inflammation and microtrauma to the infant’s intestinal gut, thereby facilitating viral transmission. Another hypothesis is that mixed feeding increases the risk of subclinical or clinical mastitis in the mother, which could increase milk viral load (Semba and others 1999).

Decisions about breastfeeding are further complicated by recent data indicating possible increased mortality among breastfeeding mothers (Nduati and others 2001) and by the stigma associated with not breastfeeding in countries where abstaining from breastfeeding is tantamount to disclosing a woman’s HIV status.

Effectiveness and Cost-Effectiveness of Prevention Interventions
Below we discuss the need for ongoing surveillance and contextual data to determine the effectiveness of HIV interventions and how best to implement those interventions. We then discuss the existing effectiveness and cost-effectiveness data.

Essential Background Data for Any Intervention
Because the prioritization of prevention strategies for any epidemic requires accurately identifying the epidemiological profile (discussed below), maintaining a sound and reliable public health surveillance system is a prerequisite for an effective prevention response. An understanding of HIV and STI prevalence and trends, as well as the prevalence and distribution of behaviors that contribute to the epidemic’s spread, should be supplemented by national monitoring systems that track sources and uses of funding to promote greater accountability. In addition, data are needed to identify and characterize key contextual issues that affect the selection of interventions.

Although surveillance is essential for an optimally strategic public health response, its utility depends on the degree to which the information it yields is effectively deployed. As noted below, countries with concentrated epidemics should prioritize interventions that are targeted to the populations at highest risk. In Latin America, however, where information on national AIDS funding is strongest, the proportion of limited prevention resources that is not targeted to the populations at highest risk of infection varies from less than 5 percent to more than 50 percent (Saavedra 2000). This range strongly suggests that resource allocation is frequently not based on available epidemiological and effectiveness data.

Table 18.3 summarizes information about the effectiveness of the interventions discussed below.

Table 18.3. Effectiveness of HIV Interventions.
Table 18.3
Effectiveness of HIV Interventions.

Cost-Effectiveness Estimates for Prevention Interventions
How countries spend funds and which interventions they prioritize should be guided by estimates of the relative cost-effectiveness of such interventions. Unfortunately, reliable estimates of cost-effectiveness are largely lacking, for a number of reasons. The main reason is that HIV prevention interventions are difficult to force into a typology that clearly distinguishes one intervention from another. For example, the counseling component of VCT has a strong information-sharing element that overlaps with (a) information, education, and communication (IEC) through the media; (b) peer interventions; and (c) the counseling component of STI treatment. Similarly, the psychological support offered through counseling is comparable to support provided through support groups or to interventions designed to increase social support. Such overlap and duplication among components of different interventions complicate efforts to estimate both the effectiveness and the cost-effectiveness of different interventions.

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Several authors have recently reviewed estimates of cost-effectiveness for the prevention interventions described here (Creese and others 2002; Jha and others 2001; Marseille and others 2002; Walker 2003). These reviews address a number of methodological issues that will not be repeated here. The reviews agree that the availability of cost and cost-effectiveness analyses for HIV/AIDS prevention strategies is limited and that the need for such knowledge for planning and decision-making purposes is urgent.

Table 18.4 summarizes available cost-effectiveness estimates for the four UNAIDS epidemic profiles that are described later in table 18.5. The estimates of cost per disability-adjusted life year (DALY) saved assume a uniform 20 DALYs lost per infected adult (Murray and Lopez 1996) and 25 DALYs lost per infected child (Marseille and others 1999) and do not account for the increasing proportion of people living with HIV/AIDS in developing countries who will have access to antiretroviral therapy over the coming years.Prognosis in HIV and Aids Essay.