What is discouraging HIV testing among at-risk populations?
At present, around 35.3 million people worldwide are living with HIV or AIDS. Each day, almost 6,300 people are infected with HIV - the equivalent to 262 every hour. There is not yet a cure for the virus, although there are treatments that can help manage and slow its progression. But not everyone with HIV knows they have it.
Of the 1.1 million who are living with HIV (human immunodeficiency virus) in the US, almost 16% do not even realize they have the infection, meaning 1 in every 6 are at increased risk of death due to lack of treatment.
And the lack of HIV awareness and testing is even more of a concern among low- and middle-income countries, where the disease is most prevalent. In 2012, only 35% of infants living in these countries who were born to mothers with HIV received an HIV test in the first 2 months of life, indicating that more needs to be done on a global scale to ensure people with the virus receive diagnosis and treatment.
This Friday, June 27th, is National HIV Testing Day - an annual campaign launched in 1995 to promote the importance of HIV testing. In line with this campaign, this feature looks at the signs and symptoms of HIV, the testing procedures available and discusses what is preventing at-risk individuals from being tested for HIV.
The signs and symptoms of HIV
HIV is a virus that weakens the human immune system by destroying T cells or CD4 cells that normally fight infection and disease. The virus uses these cells to make copies of itself, enabling it to spread.
HIV weakens the human immune system by destroying T cells or CD4 cells that normally fight infection and disease.
Once the virus has destroyed a large number of these immune cells, this can lead to AIDS (acquired immunodeficiency syndrome) - the final stage of the HIV infection - in which the body is no longer able to stave off life-threatening infection.
Although not all people experience symptoms in the early stages of HIV infection, many people can experience flu-like symptoms within the first 2-4 weeks, such as fever, swollen glands, sore throat, headache, fatigue, rash and aches and pains in the muscles or joints. This is referred to as acute retroviral syndrome (ARS) or primary HIV infection.
Following the early stages of HIV infection is what is referred to as the "clinical latency" stage, or chronic HIV infection. During this stage, the infection may not cause any symptoms at all or very mild ones.
During the later stages of infection - as it is progressing toward AIDS - symptoms may include rapid weight loss, chronic fatigue, prolonged diarrhea, pneumonia, sores of the mouth, anus or genitals, memory loss, depression and blotches under the skin or inside the mouth, nose or eyelids. However, antiretroviral therapy (ART) - a combination of at least three antiretroviral drugs - may slow the development of such symptoms.
Many people with HIV can live with infection for more than 10 years without any symptoms developing and only experience symptoms - such as sickness - when they are progressing toward AIDS. Therefore, it is important to know the risk factors for HIV and undergo testing for the infection as early as possible.
How can HIV be transmitted?
A person who is infected with HIV can transmit the virus through certain bodily fluids, such as blood, semen, rectal fluids, vaginal fluids and breast milk. In order to transmit infection, the fluids must come into contact with a mucous membrane (found inside the vagina, rectum, mouth and opening of the penis), damaged tissue or receive an injection directly through the blood stream from a needle or syringe.
In the US, the virus is most commonly contracted through unprotected sex with an HIV-infected partner, and sharing needles, syringes or other injection-drug tools with a person infected with HIV.
HIV may also be transmitted to a child by an infected mother through pregnancy, birth or breastfeeding, or a person may become infected through receiving blood products or organ/tissue transplants contaminated with HIV, though such incidences are rare.
As stated previously, many people with HIV may not experience any symptoms, or the symptoms may even be mistaken for other illnesses. If a person believes they are at risk of HIV, the best way to find out is to undergo an HIV test.
The US Centers for Disease Control and Prevention (CDC) recommend that every individual between the ages of 13 and 64 undergo an HIV test as part of routine medical care. People at high risk of HIV infection - such as those who have had unprotected sex, or who have sex in exchange for money or drugs - are recommended to have an HIV test at least once a year.
There are three main tests that can detect HIV: the HIV antibody test, the HIV RNA test and the Western blot test.
There are three main tests that can detect HIV. The most common is the HIV antibody test, which can detect HIV antibodies - proteins produced in response to HIV infection - in urine, blood or mouth fluids. This test is not usually carried out until 3-6 months after potential HIV infection, as it can take this long for antibodies to be produced.
The HIV RNA test, however, may detect whether HIV is present in a person's blood within 9-11 days of infection, and test results can be available within a few days to weeks.
The Western blot test is usually carried out if results from the HIV RNA or HIV antibody tests are positive. It is used to confirm whether HIV is present in the blood.
There are also two home tests available that have been approved by the US Food and Drug Administration (FDA). One of these involves taking a blood sample and sending it to a laboratory for testing, while the other involves taking a swab of the gums with a device to obtain a sample of oral fluids before inserting the sample into a test solution. If the results of these tests are positive, they must be followed up with a Western blot test.
Lack of early HIV testing 'diminishes the benefits of ART'
There is no doubt that levels of HIV testing have improved in recent years. A 2013 analysis from the CDC found that the percentage of Americans getting tested for HIV increased from 37% in 2000 to 45% in 2010.
This is reflective worldwide, even in low- and middle-income countries where almost 97% of HIV cases occur. The World Health Organization (WHO) state that in 2012, more than 118 million people over 124 low- and middle-income countries received HIV testing and counseling.
But although such statistics look promising, WHO state that the majority of individuals with HIV are still unaware they are infected. They note that HIV testing coverage is particularly low among adolescents and populations with a high burden of HIV infection, adding:
"As a consequence, in all regions, large numbers of people test and present late for HIV treatment, usually once their health is failing, which diminishes the benefits of ART."
The effect of health care facilities on HIV testing
In low- and middle-income countries - particularly sub-Saharan Africa - lack of health care facilities and health care professionals remain a problem.
Between 2009-10, the number of health care facilities in low- and middle-income countries that provide HIV testing increased from 107,000 to 131,000.
According to AVERT - an international HIV and AIDS charity - scarcity of information and education about HIV contributes to the lack of testing in these countries.
In order to tackle this problem, the number of health care facilities in developing countries that provide HIV testing has been increased in recent years. Between 2009-10, the number of health care facilities in low- and middle-income countries increased from 107,000 to 131,000.
Voluntary counseling and testing programs have also been launched in these countries, whereby individuals are provided with information before and after the testing process. In addition, home-based voluntary testing and mobile testing have been provided in certain regions.
But still, the percentage of HIV testing in some developing countries is as low as 7%, suggesting that more needs to be done to encourage populations in developing countries to undergo HIV testing.
Last year, Medical News Today reported on a study published in PLOS Medicine, which detailed how a universal test and treat (UTT) approach could eradicate HIV in South Africa.
This would involve annual screening of all individuals aged 15 and over, alongside immediate ART for adults infected with HIV from 2012 and increasing the therapy to 90% coverage by 2019. Using this approach, the team says HIV could be eradicated after 17 years.
But it seems the shortage of HIV information and education and health care facilities in developing countries is not the only barrier to improved testing.
Is the stigma attached to HIV discouraging testing?
A recent study, led by Dr. Rashida Ferrand of the London School of Hygiene and Tropical Medicine in the UK, suggests that a stigma attached to HIV infection may be discouraging HIV testing in low- and middle-income countries.
According to AVERT, HIV- and AIDS-related stigma stems from the fact that HIV infection is associated with certain behaviors - such as homosexuality, prostitution and drug addiction - that are already frowned upon in many societies. Many religious or moral beliefs also cause some individuals to believe that HIV infection is a result of moral negligence and that the infected person should be punished.
From the study, Dr. Ferrand and his team found that of 2,831 children eligible for HIV testing, 75% were offered it and 54% consented. However, they discovered that one of the main reasons health care workers did not offer testing to the children was that they felt the child's caregiver would not consent on behalf of the child, as it could blemish the reputation of the child or family.
"The fear of the stigma faced by the child and their family seems to be discouraging caregivers from testing children for HIV," says Dr. Ferrand.
"However, with improved clarity of guidelines, engagement with staff and organizational adjustments within clinics, it should be possible to harness the commitment of health care workers and properly implement HIV testing and counseling."
But it is not only individuals in developing countries who are affected by stigma and discrimination related to HIV and AIDS. The infection is stigmatized globally, and many health care professionals believe it is stopping people from receiving treatment.
Commenting on the issue in The Washington Times, Ban Ki-Moon, Secretary-General of the United Nations, said:
"Stigma remains the single most important barrier to public action. It is a main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so.
It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. Stigma is a chief reason why the AIDS epidemic continues to devastate societies around the world."
Although an issue such as stigma is difficult to tackle on a global scale, it is something that is being addressed in the fight against HIV.
Many individuals believe it comes down to the issue of education, not just about the infection itself but about the laws and policies that may protect an HIV-infected individual from being discriminated against.
AVERT explain that many people living with HIV are unaware of their rights in society. Therefore they need to be educated in how to challenge any stigma or discrimination they may come across.
"We can fight stigma," said Ki-Moon. "Enlightened laws and policies are key. But it begins with openness, the courage to speak out. Schools should teach respect and understanding. Religious leaders should preach tolerance. The media should condemn prejudice and use its influence to advance social change, from securing legal protections to ensuring access to health care."
But of course, tackling the stigma associated with HIV relies on changing people's attitudes about the condition - something of a challenge. But Ki-Moon remains positive that it can be done.
"Above all," he said, "we must recognize that those who bear the stigma of HIV should not be those who live with the disease. It is those who allow it."
Written by Honor Whiteman
Copyright: Medical News Today
Not to be reproduced without the permission of Medical News Today.