Despite how much has changed since the dark days of AIDS, when both the agent and its transmission paths were unknown, HIV infection today remains an incredibly important problem. Despite the advances made to medicine and public health in the last three decades, we continue to face great public health and social challenges.
The history of HIV over the last 38 years has marked and defined human history beyond how it marked Biomedicine and Medicine. At a time when human beings were thought to be able to do anything, a communicable disease appeared that was defined by opportunistic infections that mercilessly attacked the body as a result of a fundamental shortage of defenses. Quickly, a shocked society that had not had time to absorb the impact blamed the victims and associated the disease with homosexuality, hemophilia, and heroin use. That is how the stigma arose and began to follow patients around as a second illness (albeit a social one) for the last four decades.
In 1983 the virus was isolated; it was found to be transmitted by blood, unprotected sex, and vertically (from mother to child during pregnancy, childbirth, and breastfeeding). In 1996, after the discovery of highly active antiretroviral therapy (HAART) the virus began to be effectively controlled; the 10 years prior served to define the medicines to be used and how they should be combined, while patients fell by the wayside. That year we also learned that AIDS can be prevented, awakening new hope for patients and society, which had seen how treatments gradually became less toxic and less invasive. Now, with simple HAART and no significant side effects, the main challenges are preventing transmission and putting an end to the stigma. Both require social changes, which always take longer than biomedical advancements.
According to UNAIDS (2017), there are 36.9 million HIV positive people in the world, 35 million are adults and 18 million are women. In 2017 there were 1.8 million new infections and 940,000 people lost their battle with AIDS. The largest part of the global pandemic is concentrated in Sub-Saharan Africa. In Spain, an estimated 140,000-170,000 people are HIV positive, with 3,381 new cases in 2017, according to ministry sources. 15% of newly diagnosed patients are women. Transmission in 54% of cases was from sexual relations between men and 28% in heterosexual relations.
The inflection resulting from the virus interacting with the body (and with the immune system) has three phases: primary HIV infection, asymptomatic latency period, and an AIDS stage characterized by the appearance of “AIDS events”: opportunistic infections and well-defined cancers which may develop after the loss of CD4 lymphocytes. Although everyone responds to the virus differently, without treatment full-blown AIDS is reached after an average of 8-10 years, depending on the morbidity and mortality arising form the infection at the time when HAART begins. If HAART begins early, the immune system is maintained without deteriorating, the patient’s quality of life remains normal, and the patient’s life expectancy is similar to the life expectancy of someone who is not HIV positive. However, if HAART begins late, the individual is at risk of contracting opportunistic diseases and infections, experiencing lower quality of life, becoming dependent, and ultimately dying from the infection.
It is a challenge for modern society to fight against the consequences of the disease and until we can fully prevent or eradicate infection, early use of HAART is obligatory. Early use of HAART, in turn, requires an early diagnosis; i.e., avoiding a late diagnosis, which involves diagnosing the infection with less than 350 CD4/mm3, which is associated with higher morbidity and mortality, higher (direct and indirect) healthcare costs, and more transmissions due to lack of awareness. The fact that in 2017 48% of diagnoses were late in Spain indicates the vast room for improvement in this regard.
Preventing transmission requires a multifaceted approach in which healthcare workers, institutions, society, and patients work together as parts of a joint plan with biomedical, behavioral, and structural measures. Primary prevention today requires including the use of barrier methods against sexual transmission, universal hygiene measures against intravenous transmission, and specific measures against vertical transmission.
When considering the long list of preventive measures, undoubtedly the most important is antiretroviral therapy: it has been known for a long time that control and suppression of the virus prevents transmission in all ways, with the most evidence for sex lives thanks to the publication of the PARTNER I and PARTNER II studies in the last two years. From these studies arose a key prevention slogan for today: “Undetectable equals untransmittable.” i.e., someone who has the virus under control (undetectable) cannot transmit the infection sexually. This evidence is currently considered the main tool to fight against the stigma, as it has been scientifically proven that a person who is being treated properly cannot transmit the infection.
The second part of prevention in the field of HIV is the infection filter, i.e., an HIV test. The test is currently recommended in certain circumstances and obligatory in others (e.g., donation of biological material). The situations in which the test is recommended include at least once for anyone sexual active. This has been proven to be cost-effective. Early diagnosis allows HAART to be initiated before the immune system deteriorates, ensuring better quality of life and life expectancy as well as breaking the transmission chain when the plasma becomes undetectable. Stigma also has a profoundly negative effect on prevention: multiple studies have shown that one of the main causes for which people decide not to get themselves tested is fear and lack of knowledge, i.e., stigma.
Regardless of the curriculum, knowledge of HIV is essential within university education as a cross-cutting public health measure. First, because knowledge of the disease is the first instrument a person has to fight against transmission: knowledge empowers people to protect themselves and others. Second, because knowledge is the main arm to fight against stigma and against the discrimination of people who are HIV positive.
Given the amount of preventive measures available today, disinformation works as a barrier to prevention and information is the best tool to reduce transmission and eradicate stigma. Therefore, information is the way to control the epidemic and improve the quality of life for people who live with HIV. This appeals to the responsibility of all healthcare workers, in the broadest sense of the term, i.e., not just physicians and nurses, but also agents of healthcare professions who must participate in a joint public health initiative.