FAQs and Myths About HIV and AIDS.

 

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The following questions and myths will be addressed in this section:

 

A There are many reasons why people may subscribe to myths or conspiracy theories about disease. AIDS, in particular, is a disease that lends itself to the perpetuation of myths and to different forms of denial. For example, myths that deny the existence of AIDS can respond to people's emotional needs or to a desire to reassure themselves that they can avoid changing their behaviour. HIV is often transmitted through behaviours that are essentially private. Also, visible symptoms of the disease only appear after many years, making it easier for people not to accept that HIV will eventually cause AIDS. Then again, the idea of re-examining the evidence regarding the causes of AIDS may provide hope that if a cause other than HIV is identified, a cure might more readily be found. Below is a list of deceptions.

1. HIV is harmless (or does not exist), and AIDS is not contagious - so sexual and other precautions are unnecessary.

2. The HIV test is unreliable - so don't get tested.

3. AIDS drugs are poisons, pushed by doctors corrupted by the pharmaceutical industry - so don't take any of them, no matter what your doctor says - or don't go to a doctor at all, especially if you feel well.

4. Viral load and CD4 tests are useless - so don't use them.

5. AIDS deaths would have gone down anyway, even without new treatments - so you don't need medical care.

6. AIDS is over, or never existed, or only affected small risk groups - so there is no important need for medical research on AIDS or HIV, or for AIDS services.

7. The free speech of dissenters has been suppressed - so you can't believe anything you hear.

HIV infects cells of the immune system, mainly CD4 cells and macrophages - key elements of the cellular immune system, and destroys or impairs their function in the process. Progressive HIV infection results in the progressive depletion of the immune system, leading to immune deficiency. The immune system is said to be deficient when it can no longer play its role: fighting off infections, and keeping cancers from developing. People with cellular immune deficiency are much more vulnerable to infections such as Pneumocystis carinii pneumonia, toxoplasmosis, systemic and oesophageal candidiasis, generalised herpes zoster, cryptococcal meningitis, and to cancers such as Kaposi's sarcoma. These diseases are very rare amongst people without immune deficiency. Some of these diseases, namely those that are strongly associated with severe immunodeficiency, are called “opportunistic”' diseases, because they use the opportunity of a weakened immune system to develop.

Immune deficiency can also be present as a consequence of rare inherited diseases, and be acquired through cancer chemotherapy or immunosuppressive therapy in transplant recipients. However, HIV infection is the most common cause of acquired immune deficiency. The symptom complex associated with acquired deficiency of the cellular immune system was called “AIDS” when people realised they were looking at an epidemic of acquired immunodeficiency for which an explanation was lacking. It was soon apparent that the syndrome was frequent in groups with certain behavioural characteristics, such as homosexuals or injecting drug users, and certain geographical groups. The missing link that explained why some people in these groups developed AIDS, and others with the same behavioural or ethnic backgrounds did not, was found in 1983-84, when HIV was discovered. In cohort studies of such groups, the presence of HIV infection predicted overwhelmingly who would develop AIDS.

HIV infection typically follows the following course:

a) primary acute infection with a characteristic clinical picture;

b) prolonged period without obvious, visible symptoms - although laboratory studies can demonstrate continuous disease progression; and

c) a severe immunodeficiency resulting in the development of secondary opportunistic infections and tumours that, in turn, represent the major causes of death in AIDS patients.

The spectrum of opportunistic infections may differ in different geographical locations, depending on the prevalence of certain pathogens (parasites, fungi, bacteria and viruses) to which immunocompromised individuals may be exposed.

The evidence that HIV causes AIDS is overwhelming. Numerous laboratory, clinical research and epidemiological studies have shown, for example, that:

· There is significant correlation between the level of viral production and viral load and disease prognosis. The onset of AIDS is greatly delayed in individuals who have low levels of viral replication, while patients with high amounts of the virus in the blood and lymph nodes have a much worse prognosis.

· When HIV infection is treated successfully with highly active antiretroviral therapy, the immune system recovers partially and the disease manifestations of HIV infection often disappear, even if the patient has already progressed to AIDS. What symptoms remain depend on how much irreversible damage was done to the immune system before therapy began. The clinical response to therapy can be monitored and predicted by measurement of the amount of HIV in blood and lymph nodes.

· The main risk factors for HIV transmission (unprotected heterosexual or homosexual intercourse; blood transfusions; and needle-sharing during injection-drug use) are not new, but never resulted in a massive increase of morbidity and mortality prior to the appearance of HIV.

· AIDS and HIV infection are invariably linked in time, place and population groups.

Additional evidence that HIV causes AIDS comes from unfortunate accidental infections such as the one in which three laboratory workers who had no other risk factors developed AIDS after accidental exposure to a pure, molecularly cloned strain of HIV. In all three cases, HIV was isolated from the infected individual, sequenced and shown to be the infecting strain of the virus.

The existence of immunodeficiency was documented long before the onset of the AIDS epidemic but was extremely rare in the absence of cancer chemotherapy. These immuno-deficiencies have a very specific pathogenesis and specific clinical manifestations. Some very rare types of immunodeficiency occasionally present with the clinical symptoms of AIDS. However, surveys conducted in many countries have shown the number of these cases to be insignificant compared to the numbers of HIV-induced immune deficiency cases.

Speculation that HIV does not cause AIDS has in part been fuelled by arguments that point to the existence of groups of individuals who have been HIV-positive for many years without progressing to AIDS.

The course of HIV infection and the development of AIDS vary significantly between different individuals, indicating the presence of multiple factors that may influence the outcome of infection. In the most reliable cohort studies conducted in different regions of the world on HIV-infected individuals who do not receive antiretroviral therapy, AIDS symptoms develop on average approximately 8 to 10 years after initial HIV infection. About 5-10% of HIV-positive individuals develop AIDS symptoms very rapidly during the first years of infection and about the same proportion may be infected with HIV for 15 or more years without progressing to AIDS. It follows that the overwhelming majority of people with HIV infection will develop AIDS unless treated with antiretroviral therapy in a timely manner.

Testing for the presence of infections often uses the detection of antibodies that the human body produces in response to the presence of a pathogen. These antibodies are specific to a given pathogen, similar to a security lock and its key. Diagnosis of infection using antibody testing is one of the best-established concepts in medicine. Examples include the diagnosis of viral hepatitis, rubella, and many other infectious diseases. Antibody testing for these diseases has never been questioned. HIV antibody tests exceed the performance of most other infectious disease tests in both sensitivity and specificity. Recent HIV antibody tests have sensitivity and specificity in excess of 98% and are therefore extremely reliable.

Progress in testing methodology has also enabled detection of viral genetic material, antigens and the virus itself in body fluids and cells. While not widely used for routine testing due to high cost and requirements in laboratory equipment, these direct testing techniques have confirmed the validity of the antibody tests.

Due to under-diagnosis, under-reporting, and reporting delays, surveillance based on cases with clinical manifestations of the acquired immune deficiency syndrome is unreliable in most countries - especially those with weak health care systems. Thus, epidemiological data on the spread of HIV are most commonly based on the measurement of HIV levels in various populations. Such studies use the antibody tests described above and are performed according to internationally accepted procedures, including measures to ensure quality control.

Over the past decade many countries have built up surveillance systems that include well-selected populations, such as women attending antenatal-care, which allow for extrapolation to larger populations in the countries. More recently, population based studies in a series of countries have proven the reliability of such systems. WHO and UNAIDS assist countries in their efforts to compile reliable estimates on prevalence and trends of HIV. Estimates resulting from these efforts are based on the best available data in all countries. Studies that are based on small or questionable samples are excluded.

Q Does HIV cause AIDS? How should we think about it? How do we answer people who do not believe that HIV causes AIDS?

A The human immunodeficiency virus (HIV) has been decisively established as the cause of AIDS. A small but vocal group, ignoring the evidence, has continued to question the link between HIV and AIDS. Periodically, this results in media attention and generates some renewed public interest in their views. Most recently, there has been controversy in the South African and international media over the South African government's announcement that it would convene an international panel to re-examine the scientific evidence surrounding AIDS, including evidence regarding the cause and diagnosis of the disease. The debate has also recently resurfaced in other countries.

History of the controversy: The argument that HIV does not cause AIDS first attracted broad public attention in an article, published in Cancer Research in 1987, written by Professor Peter Duesberg of the University of California in Berkeley. Duesberg's contentions were rejected by scientists, but attracted attention in the mainstream press and also with specific groups outside the scientific community. For example, his attacks on the “AIDS establishment”, whom he accused of perpetuating the myth of AIDS for their own ends, were appealing to a public who already had a growing sense of disenchantment with the broad medical community. Similarly, his attribution of AIDS to specific lifestyle choices found favour with parts of society, especially those critical of the gay movement.

At the time that the controversy started, there were still some questions unanswered on the precise mechanisms of HIV disease. Ten years later there is a more complete understanding of how HIV causes AIDS.

Q What affect will AIDS have on fertility?

A According to Whiteside and Sunter the effect on fertility will be threefold. Firstly, the number of births may be reduced if women die before reaching the end of their child-bearing years. The second effect is that HIV infection and AIDS reduce fertility through physiological means. Finally, AIDS awareness, the use of condoms and increased empowerment of women will reduce fertility.

As the total fertility rate is already declining in South Africa on account of urbanisation and rising affluence, the epidemic and the programmes to fight it could cause the rate of decline to be steeper still.

A An AIDS vaccine is urgently needed in a world where over 5 million people are newly infected with HIV every year, but it will take time and a concerted international effort before we have one.

Given the complexity in implementing a vaccine development programme, it is essential that all countries affected actively participate in this process. Scientists around the world are working to understand the kind of immunity a vaccine would have to induce in order to protect someone against HIV infection. They are also looking into the genetic variability of the virus, which might affect the protection a vaccine could offer. The information that scientists generate is in turn being used by the pharmaceutical and biotechnology industry to develop "candidate vaccines" to be tested in HIV-negative human volunteers.

Most likely, the initial HIV vaccines will not be 100% effective (but then, few vaccines are) and they will have to be delivered as part of a comprehensive prevention package. What is important now is to ensure that countries where there is an urgent need for HIV vaccines participate in the global effort to ensure that a vaccine appropriate for their use is developed. Likewise, it is not too early to start planning now to ensure that a future vaccine is made available in the areas of the world where it is most needed.

In the long term, a safe, effective and affordable preventive vaccine against HIV is our best hope of bringing the global epidemic under control. However, it would be a mistake to think that the development of such a vaccine will be quick or easy or to expect that once a vaccine is available it will replace other preventive measures.

A The first human trial of an HIV-preventive vaccine was conducted in 1987 in the United States. Since then, more than 30 small-scale trials have been conducted, including 12 in developing countries (Brazil, China, Cuba, Thailand and Uganda). These trials, carried out with the participation of more than 5000 healthy volunteers have shown that the candidate vaccines are safe and that they induce immune responses that could potentially protect people against HIV infection.

The first large-scale HIV vaccine trials, designed to show whether the candidate vaccines actually protect against HIV infection or disease, were launched in 1998 in the United States and in 1999 in Thailand. The trials involve 8000 healthy volunteers who are given one of two different versions of gp120, a protein located on the outside of the virus, depending on the virus strains prevalent in the two countries. The initial results from these trials may be available within the next two years. Parallel to this, other candidate HIV vaccines are being developed through different experimental approaches. Some are based on the HIV strains prevalent in developing countries. Most of these newer candidate vaccines will be tested in small-scale trials in human volunteers, and the best will proceed to large-scale evaluation for efficacy.

Vaccine development is complicated not only by the range of virus subtypes circulating but by the wide variety of human populations who need protection and who differ, for example, in their genetic make-up and their routes of exposure to HIV. Inevitably, different types of candidate vaccines will have to be tested against various viral subtypes in multiple vaccine trials, conducted in both high-income and developing countries. It is vital for developing countries to build up their technical and human capability to conduct such trials with the highest ethical and scientific standards and with the full participation of the community.
 

Q How effective is the condom at preventing STD’s and sperm penetration?

A Due to sperm’s relatively large size, blocking it is the least demanding of the two. Evidence shows that a natural rubber condom, free from defects, provides a complete barrier to sperm. There are many effective means of preventing or reducing the incidence of pregnancy arising from intercourse, but there are far fewer reliable options for avoiding transmission of STD’s. Studies have shown that condoms protect against a wide range of STD’s, including syphilis, gonorrhoea, chlamydia, herpes, and hepatitis B. (source: http://www.durex.com/; scientific articles)

Q There have been rumours of naturally occurring holes in latex that are big enough for HIV to pass through. Is this true?

A The reports of holes in latex appear to have originated from an article in Science Magazine about latex gloves, not condoms. Holes as large as 5 microns in diameter were evidently identified in latex used in gloves. However, gloves are only dipped in latex once when they are made, condoms are dipped twice in latex. Gloves are allowed to fail the water leak test at a rate of 40 per thousand, while condoms are only allowed 4 failures of the water leak test per thousand condoms before the entire batch is rejected. While holes large enough for HIV to pass through have been found in natural membrane condoms, latex condoms do not allow the HIV to pass through the condom unless the condom has been damaged or torn. Used properly, latex condoms are effective in reducing the risk of HIV infection. (Source: CDC)
 

Q I want to use a condom, but my partner does not. How do I negotiate for safer sex?

A Many women may have contemplated using condoms but may be uncomfortable suggesting condom use to their partners. Developing condom negotiation skills may help women in this situation.

Here are some sample responses women can practice and then use when a partner objects to condoms:

· Sensation objection: "I won't feel as much if I have a condom on."
Response: "You won't feel anything if you don't have a condom on."

· Sensation objection: "It doesn't feel good."
Responses: "I think it's really sexy when a guy uses a condom. It shows he cares. What if I put it on for you?" OR "I'd feel better."

· Availability objection: "I don't have one."
Response: "I do, and it's ribbed inside for your pleasure."

· Disease prevention objection: "If you trusted me, you wouldn't ask me to use one."
Response: "I trust that you're telling me the truth, the best you can. But with some STD’s, you can't tell if you have them just by looking. Let's be safe and use condoms."

· Disease prevention objection: "You won't catch anything from me."
Response: "If you love me, respect my health."

· Spontaneity objection: "It will interrupt sex."
Responses: "Let me put it on you. You'll love it." OR "I'll wait."

· Spontaneity objection: "It spoils the mood."
Responses: "It puts me in the mood." OR "Not if I help." OR "We could always just go to a movie."
· Traditional objection: "I don’t shower with a rain coat on” OR “I don’t eat sweets with the papers on."
Response: "You will not be eating any sweets without your raincoat on.”

A The female condom is a strong, soft sheath that is inserted into the vagina before sexual intercourse. It has two plastic rings:

· one at the closed end, which helps insert the condom and keep it in place, and

· the other at the open end, which remains outside the vagina.

 

It is made of polyurethane plastic, which requires no special storage and can be inserted quite a while before having sex. It does not require immediate withdrawal after ejaculation and it can be used with both oil-based and water-based lubricants. Because it is usually visible during sex, a woman cannot easily use a female condom without her partner knowing about it, but women do have more control over use of this method than they do over use of a male condom. The female condom is not meant to replace the male condom. Rather, it is meant to increase the options available to fight HIV and other sexually transmitted infections.

 

A According to a Thai study among sex workers in brothels, when a female condom was provided as an extra option to the male condom, the women experienced a 34% decrease in the number of new sexually transmitted infections. The same study also found that sex workers who had access to both the female and the male condom were less likely to have unprotected sex than women who had access only to male condoms.

Use of the product is not expected to reach the high levels recorded in many countries for the male condom. Research in Zambia and Zimbabwe reveals that after a year of mass marketing, awareness of the female condom is high but use remains extremely low. Some studies show, however, that once women try the female condom, they like it. For example, among female drug users in Brazil, 75% who used the female condom reported being comfortable with it. Follow-up interviews three months later showed that 43% reported continued use, although women living in poor areas (favelas) were less likely to continue using the condom. The biggest problem is that female condoms are several times more expensive than male condoms and therefore not readily available to all. Efforts to expand access, increase global volume and further reduce the price continue. (UNAIDS global report – June 2000)

Q Is there a difference in the rate of HIV transmission between circumcised and uncircumcised men?

A For several years, researchers have been debating the relationship between male circumcision and HIV. Several studies have indicated that circumcised men are less likely to become infected with HIV than uncircumcised men. However, because circumcision is usually linked to culture or religion, it has been argued that the apparent protective effect of the procedure is likely to be related not to removal of the foreskin but to the behaviours prevalent in the ethnic or religious groups in which male circumcision is practised. In addition, some researchers have assumed that any association between circumcision and HIV may be complicated by the presence of other sexually transmitted infections, which have been found to be more common among uncircumcised men.

Clearly, the correlations are not straightforward. In the higher-income countries, the rates of HIV infection among men who have sex with men do not vary greatly even though the circumcision rates do: few men in Europe and Japan but four-fifths of men in the United States are circumcised. In Africa, however, circumcision seems to confer some protection. A study in Nyanza Province, Kenya, among men from the same ethnic group (the Luo), found that one-quarter of uncircumcised men were infected with HIV, compared with just under one-tenth of circumcised men. The protective effect remained even after other factors, such as sexual behaviour and sexually transmitted infections, had been taken into account. A study of over 6800 men in rural Uganda has suggested that the timing of circumcision is important: HIV infection was found in 16% of men who were circumcised after the age of 21 and in only 7% of those circumcised before puberty. A recent review of 27 published studies on the association between HIV and male circumcision in Africa found that, on average, circumcised men were half as likely to be infected with HIV as uncircumcised men.

When African men with similar socio-demographic, behavioural and other factors were compared, circumcised men were nearly 60% less likely than uncircumcised men to be infected with HIV.

Even though the weight of evidence increasingly suggests that circumcising men before they become sexually active does provide some protection against HIV, the practical implications for AIDS prevention are not obvious. Circumcision, where it is practised, usually has links to religious or ethnic identities and life-cycle ceremonies, and may customarily be done after puberty. If the same scalpel were used without sterilisation on a number of boys, this could actually contribute to the transmission of HIV. Finally, if circumcision were promoted as a way of preventing HIV infection, people might abandon other safe sexual practices, such as condom use. This risk is far from negligible – already, rumours abound in some communities that circumcision acts as a "natural condom". A sex worker interviewed in the city of Kisumu in Kenya summed up this misconception, saying: "I can sleep with circumcised men without a condom because they don’t carry a lot of dirt on their penis". While circumcision may reduce the likelihood of HIV infection, it does not eliminate it. In one study in South Africa, for example, two out of five circumcised men were infected with HIV, compared with three out of five uncircumcised men. Relying on circumcision for protection is, in these circumstances, a bit like playing Russian roulette with two bullets in the gun rather than three (UNAIDS report June 2000).

Q What is the risk of HIV transmission from oral sex?

A The likelihood of transmission of HIV from an infected person to an uninfected person varies significantly, depending on the type of exposure or contact involved. The risk of becoming infected with HIV through unprotected (without a condom) oral sex is lower than that of unprotected anal or vaginal sex. However, a lower-risk activity will increase in risk when it is repeated enough.

The Options Project found that 7.8% (8 out of 102) of recently infected men who had sex with men in San Francisco were probably infected through oral sex. Most of these men believed that the risk was minimal or non-existent. Nearly half (3 out of 8) of these cases reported oral problems, including occasional bleeding gums. Almost all (7 out of 8) of these men reported having had oral contact with pre-semen or semen.

The study results emphasise that any type of sexual activity with an infected person poses a risk of HIV transmission. (7th National Conference on Retroviruses and Opportunistic Infections, January 2000) Oral sex with someone who is infected with HIV is certainly not risk-free.

This is why scientists divide the risk of contracting HIV into four categories:

No risk	Social contact
Low risk	French Kissing (kissing with an open mouth), sharing toothbrushes and razors, etc.
Medium risk	Oral sex
High risk	Any form of unprotected sex, of which receptive anal sex has the highest risk incidence

Without question, the greater risk of contracting HIV rests with the performer of oral sex. Having ejaculating take place outside the mouth, not swallowing ejaculate, and/or reducing the frequency of these sex acts, lowers the risk. If one receives oral sex from a partner with a cold sore or herpes, the chances of contracting this sexually transmitted disease are higher, as compared to HIV infection.