By Marissa Arzate
What if a ketchup package could save the life of a child? In developing countries, where 33% of infants are born to HIV seropostive mothers, studies show that administering anti-retroviral drugs (ARVs) within 24 hours of birth can prevent transmission (1). Unfortunately, it is difficult to deliver these drugs outside a hospital setting.
In the summer of 2015 engineering students at Duke University created the Pratt Pouch, a pre-measured dose of ARVs in a squeeze package similar to the ketchup pouches at fast food restaurants. Clinical trials were implemented in Ecuador, a country with a high rate of at-home births, and results showed that the pouches were effective in preventing transmission.
Yet too many families in Ecuador don’t obtain the ARVs because they are unaware that they are even at risk of HIV. The history of HIV and AIDS is riddled with examples of misinformation, denial, and social stigma, but nowhere is this more prevalent than Ecuador. Even today, 35 years after the discovery of the virus and the beginning of a pandemic, 40% of people in Ecuador believe that AIDS is transmitted by mosquitoes (1). This is a level of misinformation that must be addressed.
I. History and Origin
A mysterious virus, possibly contracted from chimpanzees baffled people from the start. After years of research, studies identified the origins of HIV in the ‘Pan troglodytes troglodytes’ chimpanzee of Central Africa (2). This species of chimpanzees carries a virus identified as simian immunodeficiency virus (SIV cpz ), while the human species carries human immunodeficiency virus (HIV). If this virus stems from two different species, how was this virus successfully transmitted? Studies reveal that HIV was transmitted from apes to the human species hundreds of years ago. This cross-species transmission was successfully spread to the human species through exposed cutaneous or mucous membranes coming into contact with infected ape blood or ape bodily fluids (3).
There are two forms of HIV that infect humans, HIV-1 and HIV-2, although the focus in this paper will be HIV-1. There are four groups of this specific virus: M, N, O, and P, which have each independently been transmitted from the chimpanzee to the human species (3). Through time and evolution, the M group of HIV-1 has been identified as the ‘pandemic’ strain due to its prevalence among 69 million people around the world (2). The other HIV-1 strains are less prevalent and restricted to smaller communities, with Group O representing less than 1% of global pandemic cases, Group N documented in just 13 cases, and Group P representing only two individuals worldwide (2).
In 1981, HIV-1 surfaced in the United States (4). Five formerly healthy, gay men in Los Angeles, California were reported to have characteristic symptoms of opportunistic infections such as Pneumocystis carinii pneumonia (4). In addition to opportunistic infections, these patients suffered from cellular-immune dysfunction and transmission seemed to come from sexual contact (4). After initial reports in Los Angeles, medical cases also appeared in San Francisco and New York with similar patient symptoms (4). Then, cases that did not involve men having sex with men started to appear. In December of 1982, an infant was infected from a blood transfusion with contaminated blood from a man who was later diagnosed with Acquired Immune Deficiency Syndrome (AIDS), the last stage of HIV (5). This case of an HIV-infected infant totally altered the public’s understanding of HIV transmission, which had been limited to homosexual contact. As the virus began to spread on a global level so did fear.
Epidemiology of HIV
Transmission of HIV occurs through blood, body fluids, or breast milk. The first mode of transmission was recognized in 1981 when gay men were believed to have contracted HIV through promiscuous sexual activities (7). Today, we now understand that the virus is not only spread in sexual activities between men having sex with men, but the virus is also transmitted between individuals involved in heterosexual activities (7). By 2006 heterosexual transmission accounted for 80% of HIV infections (10). Risks are increased when patients have other sexually transmitted infections, unprotected sex, multiple partners, and anal sex (7).
HIV is also transmitted through infected blood. Before 1985, blood donations were not screened which led to a huge increase of HIV infections among transfusion patients (7). With screening, by1992 transmission via transfusion was eliminated, though patients continue to contract HIV from other blood sources (7). Today about one-third of major AIDS cases have been attributed to direct or indirect intravenous drug abuse (7).
Finally, mother to child transmission can occur during pregnancy, labor, delivery, or breast-feeding and this accounts for up to 45% of infections (1). Anti-retroviral therapy within the first24 hours after birth can greatly reduce infections (1).
When HIV was first discovered in 1981 in the United States by the Centers for Disease Control (CDC), the nation was unaware of the pandemic ahead. Twenty-five years after the initial discovery of the virus, more than 65 million people have been infected by HIV (13).
This crisis called for a global response, engaging political leaders and resources from every country. The developed countries needed to take the lead and lend support to developing countries (13). Because HIV spread quickly between countries the pandemic became a global crisis and the response needed to transcend politics and focus on the medical emergency at hand. According to Merson, policymakers of this initial global response needed to confront stigmas associated with “sexual behavior, drug use, power relations between the sexes, poverty and death”(13). Addressing these taboos related to HIV resulted in a largely negative response around the world. Eventually, this negative response led to an increase in the stigma, discrimination, and denial of AIDS (13).
The scope of this pandemic was finally realized in 1987 when the World Health Organization (WHO) announced the Global Program on AIDS (13). This program ignited response, increased support for those living with HIV, raised funds for research, and built awareness of the HIV crisis (13).
Unfortunately, the Global Program on AIDS was not successful among policymakers, which led to the formation of Joint United Nations Programme on HIV/AIDS (UNAIDS) (13). Support for UNAIDS was initially very difficult to attain. The threat of destabilized global security, the need for cheaper antiretroviral drugs, and the increase in financial contributions finally led to the collective, grounded support that allowed UNAIDS to succeed (13). These global responses helped to provide a foundation for current efforts to fight against the stigma that the disease still engendered in the world.
The initial reaction was simply silence. In the 1990s throughout sub-Saharan Africa, this silence meant people were not getting tested, not recognizing the risks of promiscuous sexual behaviors, and not educating themselves on prevention (14). This silence on a cultural level meant that information on the virus was not available. Thus, on a public policy level, African political leaders were unaware of the crisis at hand (14). Cultural and religious taboos suppressed open communication about an infection that spread primarily through sexual contact (14). This problem was not limited to Africa, but was mirrored in many countries where taboos limited awareness because sexuality could not be discussed.
Education on Sexual Activity and Reproductive Health in Ecuador
In Ecuador, policy makers attribute HIV transmission solely to homosexuals and sex workers. Deeply-rooted Roman Catholic religious beliefs, taboos about sexuality, low education levels, and lack of government infrastructure in medicine combine to perpetuate this information. Until honest communication is improved, infections will continue to rise.
As confirmed by the World Health Organization (WHO) and United Nations Population Fund, Ecuadorians generally do not have the information to educate themselves about the reality of HIV and AIDS (15). Adolescents, parents and teachers are universally uninformed about reproductive and sexual health. In a survey produced by a community health clinic, 552 high school students were interviewed about reproductive and sexual health (RSH), family planning, and sexually transmitted infections (15). This study verified that 57% of children and adolescents between the ages of 10-17 are lacking accurate information on the transmission of HIV (15). Many students believed that information on sexual health and reproduction should be provided by parents, yet only about half of these students (48.6%) claimed to have received any information on family planning (15). As seen in figure 5, the main reason children do not discuss their reproductive and sexual health with their parents is due to lack of trust, followed shortly thereafter by embarrassment (15).
On the topic of contraceptives, the majority of students (96%) were informed about birth control methods, yet only about 81.5% of these students actually use, or would use, some form of contraceptive (15) When discussing contraceptives, gender played a large role in whether or not a student would use birth control. As shown in figure 6, among the students who claimed they would use contraceptives or a birth control method, condoms were the most common choice (15). The study showed that female students were discouraged from using contraceptives due to fear of side effects or a desire to have children in the future (15). As recently as 1980, the cultural norm in Ecuador resulted in a fertility rate of up to six children per woman. Fertility rates today have dropped to about two children per household, yet among the students interviewed almost a quarter of students wanted three children (15).
Fig. 5: Graph explains why children and parents do not discuss reproductive and sexual health in Ecuador (15) Of the students interviewed, sexually transmitted infections (STI’s) had been discussed by 17.8% of sexually active teens (17). Of these students, 10% believed oral contraceptives could prevent them from getting STI’s and HIV/AIDs. Additionally, 24.8% assumed HIV/AIDS is actually transmitted through saliva or sweat (17). Clearly with this level of misinformation on HIV infections, transmission rates will continue to increase.
Fig 6: Preferred Contraceptive Method among the 552 teens surveyed in Ecuador (15) This study indicates that many parents are unable to answer their adolescents’ questions about sexual health and reproduction because they themselves do not have accurate information (17). To reassess the way that sexual education is addressed in schools, it would be most beneficial to include parents so adolescents can have open communication about reproductive and sexual health in their home environments. With clarity and confidence, knowledge in these areas can greatly reduce the risk of sexually transmitted infections including HIV.
HIV/AIDS in Ecuador
In 1984, the first case of HIV/AIDS was reported in Ecuador by the Ministry of Public Health (17). The government realized that HIV had spread throughout Africa and the United States, and the pandemic was about to hit Ecuador and the rest of South America. By August of 2006 the HIV pandemic was proclaimed globally (17).
Ecuador is the target focus of this paper because this middle-income country suffers from poverty-driven health problems, low education levels, gender inequality, religious restrictions and discrimination (17). These problems are the driving force behind the spread of HIV/AIDS here.
Lacking financial resources, many patients do not seek regular medical attention. When patients do not get tested regularly for sexually transmitted infections like HIV, they are more likely to transmit the infection to other partners. Eventually, not getting tested can lead to more rapid progression into AIDS. If patients begin taking the medication and lose a job or financial support, stopping the medication can result in creating a resistant strain of the virus. This strain could then be transmitted to others. Although HIV testing is essential to reduce these risks of transmission, Ecuador is a country that has limited research and funding for HIV/AIDS. High poverty levels reduce patients’ ability to access expensive medications or to get tested regularly, therefore increasing the spread of diseases such as HIV/AIDS (17).
Lack of education means people do not fully understand how the disease is transmitted or how it can be prevented. With little to no sexual education in schools, children do not understand how to protect themselves.
Fig. 7: Distribution of HIV/AIDS cases by age group in Ecuador, 2009 (17) how to protect themselves.
As seen in figure 7, the age range most affected by HIV is between 20-35 years old (17). If teenagers do not enroll in college after they complete high school then they are encouraged by their culture to start their families, so this is the age when many people are most sexually active. In Ecuador, 99% of infections in this age group are due to sexual activity (17). If education alone could promote condom use, sexual abstinence, and safe sex practices more effectively, these statistics could be greatly reduced (17).
Disclosing HIV serostatus in Ecuador leads to financial constraints, regret, and material instability. One study reports that for 24% of respondents revealing disclosing HIV serostatus claimed that revealing their seropositive status was a mistake (18). Upon disclosure, workers experienced rejection and discrimination in the workplace (18). When men or women face discrimination in the work place, they risk losing their jobs. Often women experienced higher rates of rejection than men. For women, revealing a seropositive status meant facing barriers built by the ongoing stigma of HIV: fear of rejection from their spouses, losing their children, or even facing domestic violence. The stigma attached to HIV can be more damaging then the infection.
HIV seropositive individuals without independent financial support cannot afford anti- retroviral therapy. Financial support from the Ecuadorian government is minimal. As a result, many HIV patients must pay for the first-line treatment regimens out of pocket. For most, this means a prohibitive cost of $673 a year towards viral therapy with no alternative option (19). As a result, when risk of disclosure among HIV positive patients lingers in the workplace an economic crisis can emerge. A cost this large creates moral dilemmas for the family when faced with the decision to pay for their medication or put food on the table.
Mother-to- child transmission is another route of HIV transmission that is elevated due to high at-home birth rates (1). If a child is administered ARV treatment within the first 24 hours of birth, the risk of transmission can be dramatically reduced. Unfortunately, many mothers lack access to pre-dosed anti-retroviral medications for their newborns (1). Though many ARVs are available in clinics and hospitals, women who deliver at home often cannot or will not bring a newborn baby to a clinic right after birth because of the social stigmas that are attached to bringing a potential HIV-infected newborn to the clinic.
One way to overcome this challenge is the Pratt Pouch was invented. After trials in 2015 in Guayaquil, this premeasured liquid dose of anti-retroviral medication proved to be the easiest and most effective way to deliver treatment to HIV-exposed infants (1). Still the problem remains. If mothers are unaware of their seropositive status, they won’t seek treatment. With such high levels of misinformation and such low levels of medical support, women are unlikely to get tested. The stubborn stigmas and cultural resistance compound the problem.
To conquer these challenges, the citizens of Ecuador must work together to improve levels of education and access to information. If people still believe myths about transmission by mosquitoes and kissing, this pandemic will never diminish. Together, political leaders, educators and the entire community must work towards UNAIDS’ vision of creating a country with zero discrimination, zero new infections, and zero deaths.
In conclusion, while scientists continue to learn more about how HIV replicates in the body, there is hope that they can create an effective vaccine against this virus. Until then there are three actions that can reduce transmission: enhancing sexual education among adolescents, parents, and teachers, reducing stigma in the workplace and community settings; and increasing access to support for the HIV patient community. In Ecuador and other developing countries around the world, united progressive actions can begin to make a difference.
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