AIDS and HIV: epidemiology, transmission, and clinical outcomes

¶ … HIV and AIDS

Gallo, R. & Montagnier, L. (2003 Dec 11). The discovery of HIV as the cause of AIDS. The New England Journal of Medicine, 349(24). Retrieved November 17, 2006, from ProQuest database.

Gallo and Montagnier's (2003) article is a qualitative review of the research and history that led to the discovery of human immunodeficiency virus (HIV) as the cause of acquired immune deficiency syndrome (AIDS). The purpose of the article was to demonstrate how this discovery followed the typical twisting path of scientific research, comprised of "a mix of good and bad ideas, good and bad luck." The methodology was a qualitative review of research that both authors were heavily involved in.

The tale of scientific discovery begins in the late 1970s when many thought that industrialized nations were beyond the reach of epidemic diseases. Prevailing thought concluded that there was no such thing as a retrovirus that infected human beings. The authors, however, both worked for laboratories who continued the search for just such a retrovirus.

Their search paid off when they discovered human T-cell leukemia virus types 1 and 2. Many causes were considered at the time, however the authors realized that "(f)irst, the various manifestations of AIDS were unified by a biologic marker: a decrease in the levels of a specific subgroup of T cells that harbored the CD4 surface antigen. CD4 and other CDs had been identified only a few years earlier with the use of specific monoclonal antibodies, thanks to the work of Milstein and Kohler" (Gallo & Montagnier, 2003). As such the authors began a search for an HTLV-like virus in patients with AIDS.

The authors conclude that there are a variety of lessons that can be learned for the early intense period of research and note that great modesty is required for science. Basic research was critical for providing the technical and conceptual tools that lead to the discovery of HIV as the cause of AIDS. This was facilitated by the work of numerous researcher. And, although discovering the cause of an infectious disease, like AIDS, is an important step in medical research, allowing for development therapies and strategies for the elimination of transmission of the disease, it does not guarantee a cure (Gallo & Montagnier, 2003).

Critical Analysis of the Article:

This article was a comprehensive, yet brief, qualitative presentation of the early history of AIDS research and the discovery of HIV as the cause of AIDS.

It summed up the authors' personal experiences with the scientific discovery that led to this identification. Of particular interest was the notation that both authors had been working against prevailing thought at the time regarding retroviruses. It was this dedication to looking beyond the traditionally accepted that would ultimately lead to the new knowledge that it was indeed HIV that causes AIDS.

In addition to looking outside of the box, the process of scientific discovery was a twisting, turning path. It took both bad and good ideas, as Gallo & Montaganier (2003) note, as well as bad and good luck to eventually make the discovery possible. This demonstration of the struggle to come to new scientific knowledge was incredibly useful to fully appreciate the trials and tribulations that were experienced. Oftentimes scientific discovery is taken for granted as it seems advancement comes at leaps and bounds.

Future directions in research for this article would include the investigation of the pathway that has led to the various treatments offered. In addition, it would be interesting to learn more about other examples of collaborative processes that have yielded such significant results. Lastly, future research could provide a qualitative comprehensive literature review of all of the research, supportive and contradictory, that led to the discovery of HIV as the cause of AIDS, as opposed to this abbreviated, but thorough work.

Sabin, C., Pasi, J., Phillips, A., Lilley, P., Bofill, M., Lee, C., & Duesberg, P. (27 Jan 1996). Comparison of immunodeficiency and AIDS defining conditions in HIV negative and HIV positive men with haemophilia A. British Medical Journal, 312(7025). Retrieved November 17, 2006, from InfoTrac database.

Summary of the Article:

Sabin et al.'s (1996) article is a research findings report comparing the defining immunodeficiency and AIDS conditions in HIV negative and HIV positive hemophiliac males. Quantitative research was conducted on 263 hemophiliac males, over a six-year period. One hundred eleven of the subjects had become infected with HIV after treatment with contaminated factor VIII concentrate. One hundred fifty-two men remained HIV negative when infected batches of factor HIV started to be used, after regular testing.

The HIV positive patients were switched to monoclonally purified factor VIII concentrate which preserved the immune system of the patients. Since only the HIV positive patients received this treatment, the researchers focused on CD4 lyrnphocyte counts and clinical events that occurred before the end of 1990, when all received only intermediate purity factor VIII.

HIV positive patients were matched to HIV negative patients in two stages. Firstly, each HIV positive patient was matched for his median yearly usage of concentrate to an HIV negative patient whose usage was closest to and within 5% of that of the HIV positive patient. Secondly, the mean yearly amounts of concentrate received were compared in cases and controls and considered a good match if they were within at most 30-000 units. All matching was blind to patient outcome. Matching on the basis of both median and mean usage ensured that patients were treated similarly in terms of the number of years of treatment with concentrate and the overall amount of concentrate received. As most patients with severe haemophilia -- and therefore the highest users of clotting factor concentrate -- were seropositive to HIV, only a few matches could be identified. However, the patients who could be matched in this manner were comparable in their usage of concentrate. (...) Paired comparisons between HIV negative and HIV positive patients were tested for significance with McNemar's test for the development of AIDS and the sign rank test for the mean CD4 count during follow up. (Sabin et al., 1996).

It was concluded that HIV infection led to progressive immune deterioration and AIDS irrespective of clotting factor usage.

Critical Analysis of the Article:

The article concisely described the testing performed as a comparison of immunodeficiency and AIDS defining conditions in HIV negative and HIV positive hemophiliac men. However, more information could have been presented regarding the contaminated factor VIII concentrate. As it was presented, it was very confusing. No background information was given regarding this important factor. Therefore more information that would clarify this even would have added value to the report.

The authors' conclusion that HIV infection led to progressive immune deterioration and AIDS irrespective of clotting factor usage is rebutted at the end. It is this contrary information that enhances the usefulness of this research report and help with the clarification process noted above. In the rebuttal, it is noted that hemophilia specific AIDS may be explained non-infectiously via the long-term use of immunosuppressive foreign proteins containing contaminating commercial factor VIII and zidovudine. This rebuttal further goes on to note that Sabin et al. "reject the foreign protein-zidovudine hypothesis. However, their data and those of others actually support the hypothesis" (cited in Sabin et al., 1996). This clearly demonstrates an inaccuracy in the researchers' work and the need for continued research.

Their own findings that most severe hemophiliac patients, and therefore highest users of clotting factor concentrate, were seropositive to HIV, which would support the foreign protein hypothesis. As the rebuttal notes, "An appropriate test of the foreign protein hypothesis would compare HIV positive patients with HIV negative patients matched for the lifetime dosage of factor VIII" (cited in Sabin et al., 1996). In this way, the pathogenicity of the foreign protein zidovudine can be investigated.

Mitchell, C., DeLange, N., Moletsane, R., Stuart, J., & Buthelezi, T. (2005 July). Giving a face to HIV and AIDS on the uses of photo-voice by teachers and community health care workers working with youth in rural South Africa. Qualitative Research in Psychology, 2(3). Retrieved November 17, 2006, from ProQuest database.

Summary of the Article:

Mitchell et al.'s (2005) article discusses the teachers and community health workers, in rural South Africa, that work with youth and HIV and AIDS. The goal of the paper was to determine how university researchers could "draw on the voices of the people who most crucially must be heard in debates about curriculum and care in addressing HIV and AIDS, and how can the research itself do more than just draw on the voices, but make sure that those voices are heard?" Both teachers and community health care workers have a significant amount to contribute to the challenges and solutions regarding working with young people. The goal of the paper was to determine how visual methodologies, particularly photo-voice, could assist in this work.

The first phase of the study involved working with health care workers, over the course of four sessions. The first session involved a drawing activity to begin dialogue and begin the process of working visually.

The second session had camera instruction. The third session had each participant given a camera and they were instructed to "(t)ake pictures of the challenges and solution in addressing HIV and AIDS" (Mitchell et al., 2005). The fourth session saw the photos developed and asked small groups to compare and contrast their pictures by creating posters. The authors draw on previous research on photo-voice techniques, as well as memory and photography and self-representation through photography.

In the end, the authors' qualitative research concluded that although many projects use photography to give voice to participants, it is especially significant in the giving a voice to community health workers and teachers in rural South African communities. In these remote areas, the communities do not have to wait for researchers to provide them answers, instead they are able to take action themselves and give a visible face to the HIV and AIDS plight (Mitchell et al., 2005). Through the creative use of photography, these communities can express themselves in entirely new ways.

Critical Analysis of the Article:

This article was incredibly moving and illustrated a non-conventional approach to communicating. The premise of the research, how best to give healthcare workers and teachers a voice in the plight against AIDS and HIV reaches beyond the medical and scientific issues involved in this topic and touches on the psychological and sociological issues as well. The authors effectively call attention to the need for putting faces with the HIV and AIDS epidemic, as well as the need to give critical people involved in the community a way to express their own unique opinions on the topic. For this alone, the article was useful.

However, further research needs to be conducted. The methodological premise of the value of photo-voice is sound, but it would be interesting to see this article followed up with the effectiveness specifically in rural South African communities, and specifically regarding the HIV and AIDS plight. Although healthcare workers and teachers may have found photography useful in expressing their thoughts and feelings about the challenges and solutions surrounding the epidemic, it would be interesting to learn if their voices were heard by the greater community.

Yoshikawa, H., Wilson, P., Hsueh, J., Rosman, E., et al. (2003 Sept) What front-line CBO staff can tell us about culturally anchored theories of behavior change in HIV prevention for Asian/Pacific islanders. American Journal of Community Psychology, 32(1/2). Retrieved November 17, 2006, from ProQuest database.

Summary of the Article:

Yoshikawa et al.'s (2003) qualitative research was reported in this article. The researchers noted that there are "(f)ew rigorously tested primary prevention programs (that) have been developed to prevent HIV infection among immigrant communities in the United States (due to) the lack of culturally specific behavioral theories that can inform HIV prevention for immigrant communities in the United States." The researchers' goal was to develop these behavioral theories for specifically the Asian/Pacific Islanders (A/PIs) immigrant communities.

Although A/PIs in general appear to be at a lower risk of contracting HIV, certain A/PIs subgroups are at an increased risk.

These include young gay A/PI males, who have a higher incidence of HIV infection than White gay males. In addition, the authors cited a recent study that found that between 21 and 53% of AP/I males that have sex with men self-reported having unprotected anal intercourse within the last 6 months (Yoshikawa et al., 2003).

Since the purpose of the study was to inform both researchers and practitioner audiences, the researchers chose a methodology that not only allowed for assessment and description of theories of change, but also one that would create practical and immediately useful information for those at CBOs. An empowerment evaluation approach was undertaken and with the assistance of a CBO participant staff, the study was conceptualized, and the measures to be used and data analysis procedures were developed. In the end, it was discovered that one way to address a taboo topic, with A/PIs, such as HIV and AIDS< was to pair it with a positive cultural symbol. They also determined that "diffusion of innovation processes are more efficient under conditions that address the particular meanings of sex and HIV / AIDS in A/PI cultures" (Yoshikawa et al., 2003). In addition, the researchers presented risk factors that were inherent to the contraction of HIV. These included: retention of cultural values from their home country that stigmatized protected sex, perceived low levels of risk for contracting the disease, length of U.S. residence, and education levels. Lastly, Yoshikawa at al. surmised that processes at the social network, behavior setting, and community levels, that are directed towards cultural preferences and attitudes, specifically for A/PI populations, are currently lacking in the American HIV prevention programs.

Critical Analysis of the Article:

Yoshikawa et al.'s (2003) research is instrumental in helping correct the severely lacking amount of culturally specific behavioral theory regarding immigrant communities and HIV prevention in the United States.

Their findings were contrary to mainstream practice of one-size-fits-all prevention programs. Their qualitative research helps fill that void. In addition, they brought to light the fact that American HIV prevention programs are not geared towards the cultural preferences and attitudes of immigrant populations, specifically A/PIs.

Future qualitative and quantitative research is needed to explore the predictors of HIV risk among A/PI populations, in order "to expand the data base on culturally anchored theories suitable for HIV prevention. In addition, quasiexperimental and experimental evaluation of culturally anchored strategies such as the ones reported by the peer educators in this study is urgently needed" (Yoshikawa et al., 2003).

In addition, this research should be repeated but with a greater diversity of participants. The researchers sample was based on a group of peer educators from a community-based AIDS service organizations serving A/PI communities in a Northeastern city. A more geographical diverse study would either confirm or draw question to this research. In addition, the current study was a small sample size of only 35 participants. A greater sample size would again provide more validity to the findings.

Weitz, A., Reddy, P., Van Den Borne, H., Kok, G., & Pietersen, J. (2003 May). Determinants of multi-partner behaviour of male patients with sexually transmitted diseases in South Africa: Implications for interventions. International Journal of Men's Health, 2(2). Retrieved November 17, 2006, from Academic OneFile database.

Summary of the Article:

The article presents quantitative research results regarding multi-partner behavior among patients with STDs in Cape Town, South Africa. Two thousand two-hundred thirty-three male patients with STDs were given a structured interviewer-administered questionnaire. The questions that were asked centered on personal determinants such as: biodemographics, the patient's general knowledge regarding STDs, their beliefs and attitudes about STDs, and perceptions regarding HIV risk. In addition, normative determinants were explored "including social norms regarding gender role beliefs about refusing sex and condom use behaviour as well as perceptions of self-efficacy in using condoms" (Weitz, Van Den Borne, Kok, & Pietersen, 2003).

A logistic regression analysis was utilized to identify the significant predictors of multiple partner behavior. The data identified a strong linkage between mult-partner behavior and male gender constructs that value sexual prowess and the belief that men cannot refuse sex because their sexual desire is uncontrollable. Previous experience with an STD was also found to be linked to multi-partner behavior, centered on the belief that having an STD is synonymous with sexual prowess. Disturbingly, there was no significant relationship discovered between the number of sexual partners and condom use behaviors, which would help prevent the spread of STDs and specifically HIV and AIDS.

Negative attitudes about condom use was a factor in this. In the end, "(t)he findings suggest that the real challenge for preventive behavioural change lies in addressing gendered beliefs that emerged as significant predictors of multiple sex partner behaviour. These deep-seated beliefs touch the very core of what it constitutes to be a man and a woman within the Southern African context" (Weitz, Van Den Borne, Kok, & Pietersen, 2003).

Critical Analysis of the Article:

The article explored a significant facet of the struggle against HIV and AIDS.

Multi-partner behavior is a critical issue concerning the spread of the disease.

Their research sampling, although geographically specific, included such a large participant group that produced great insight into the prevailing belief system amongst the participants. One of the more interesting findings was the specific beliefs behind the negative attitudes towards condom use. It was discovered that many of the participants expressed negative attitudes due to cultural beliefs that believed condom use to be a waste of sperm as it limited the continuation of the clan name, and that it was bad because it was 'like masturbation' and not 'flesh to flesh'. In addition some believed that condom use would cause a man to lose his virility (Weitz, Van Den Borne, Kok, & Pietersen, 2003). These unique insights into the cultural biases of South African males are critical to developing behavioral change intervention programs.

Future research, on this topic, should include other regions of South Africa to ensure that these same beliefs hold true in other South African communities. In addition, for behavioral change strategies to take effect, it is important that the social environment support these changes. More research is needed on the general community's understanding of how the existing gender constructions are not only facilitating the spread of STDs, including HIV and AIDS, but also if the community is willing/able to develop and support strategies that effectively address these gender constructions. Only in this way could an effective strategy be developed and implemented successfully for correcting HIV and AIDS preventative behaviors and thus become part of the change process.

Rosenfeld, B., Brietbart, W., Gibson, C., Kramer, M., et al. (2006 Nov/Dec). Desire for hastened death among patients with advanced AIDS. Psychosomatics, 47(6). Retrieved November 17, 2006, from ProQuest database.

Summary of the Article:

This quantitative analysis of research results explored the prevalence and predictors that were associated with a patient's desire for a hastened death, when faced with advanced AIDS, in light of recent controversy over assisted suicide. The study involved 372 patients with advanced AIDS who had been recently admitted to a palliative-care facility, one of either two skilled nursing facilities or one medical center. "Clinician-rated and self-report measures of desire for hastened death, depression, hopelessness, spiritual well-being, social support, pain, and physical symptom burden were administered to assess the factors that correspond to a high desire for death" (Rosenfeld et al., 2006).

There were several important findings discovered during this research. First, was the relatively low rate of desire for a hastened death among the participants. Less than 10% of the participants indicated elevated levels on either one of the two measures of a desire for a hastened death. This figure was in stark contrast to previous research conducted on cancer patients, how exhibited rates ranging from 8.5% to 16% of patients with a desire for a hastened death. In addition, there was also a significantly higher rate of clinical depression indicated in patients with AIDS than previous research involving cancer patients, despite the fact that fewer desired a hastened death. Twenty-seven percent of participants demonstrated a major depressive disorder, in comparison to 12 to 17% of cancer patients. Interestingly there was a higher magnitude of association between symptoms of clinical depression and hopelessness and the desire for a hastened death in AIDS patients, when compared to those with cancer. Eighty percent of the studied patients with a high desire for hastened death also met the criteria for a major depressive disorder, in comparison to on 47 to 58% of cancer patients in previous studies (Rosenfeld et al., 2006).

Critical Analysis of the Article:

The usefulness of the article lies in a further understanding of the psychological factors that affect patients with advanced AIDS. Clearly there is a significant relationship between depression and a sense of hopelessness and the desire for a hastened death.

Less clear were the associations between a desire for hastened death and adequate social support, physical symptom distress, and a patient's physical functioning. What the study was not able to determine also was a connection between hopelessness, depression and a desire for a hastened death and the appropriateness of assisted -suicide policies.

The emergence of assisted-suicide debate recently was the driving force behind this research originally, yet their findings did not uncover a rationality for the desire for a hastened death. In fact, many times opponents of legalized assisted suicide premise their position partly on the fact that depression and hopelessness are treatable, although this is not explored in this research, if true one would have to take into consideration that depression could negatively affect an individual's ability to make decisions. Therefore, further research is indicated in these areas. First, whether or not depression and hopelessness are treatable, even in patients with advanced stages of illness. And, second, further research needs to be performed to determine whether or not depression does negatively affect one's decision making. Further research needs to be conducted also on how most effectively to treat patients with a desire for a hastened death. And, lastly, future research could include a similar study of prevalence and predictors of the desire for a hastened death in other groups of patients with less advanced forms of AIDS, all as a means of finding more effective ways to improve the quality of life for these patients both physically and psychologically.

Meija, N., Vasquez, E., & Sanchez, M. (2006 Summer). Community-based participatory research: HIV prevention for Latinas. Hispanic Health Care International, 4(2). Retrieved November 17, 2006, from ProQuest database.

Summary of the Article:

Meija, Vasquez and Sanchez (2006) highlight the importance of community-based participatory research (CBPR) as a means of HIV prevention in the Latina community. The impetus of this research was the fact that the changing demographics in the United States means that the Hispanic population is a vital target group when addressing health issues, such as the prevention of HIV. Thirteen percent of the population in America in Hispanic. However, startlingly 20% of the new HIV infections are Hispanic. The HIV incidence for Hispanics, in 2000, was nearly four times that of Whites in the United States (30.4 cases per 100,000 versus 7.9 cases per 100,000). In addition, only 61% of Latinos are alive at 9 years after an AIDS diagnosis, versus 64% of Whites and 69% of Asians. According to the researchers, HIV / AIDS is the third leading cause of death among Latinas between the ages of 35 and 44, clearly indicating a need for HIV prevention for the Latina community.

Meija, Vasquez and Sanchez (2006) cite previous research to define CBPR.

CBPR differs from simple community-based research in that community-based research centers on conducting research in a community, but does not give community member involvement in the research. In contrast, CBPR seeks participation from the community to combine their unique knowledge and facilitate social change that will ultimately improve the community's health. This qualitative review of CBPR also includes the identification of nine key elements to the process, provided in past research. These include:

recognizing the community as a unit of identity; (2) building on the strengths and resources within the community; (3) facilitating collaborative, equitable involvement of all partners in all phases of the research; (4) integrating knowledge and intervention for mutual benefit of all partners; (5) promoting a co-learning and empowering process that attends to social inequalities; (6) involving a cyclical and iterative process; (7) addressing health from both positive and ecological perspectives; (8) disseminating findings and knowledge gained to all partners; and (9) involving a long-term commitment by all partners (Meija, Vasquez & Sanchez, 2006).

In the end it was determined that the Latina population is a population at high risk for contracting HIV and that CBPR is a potentially effective research tool.

Critical Analysis of the Article:

The article was useful in demonstrating the significantly higher risk that the Latina population is at when considering the contraction of HIV. The data presented on this facet was both surprising and compelling. In addition, the authors did an excellent job in defining CBPR and its components. And, they do note the importance of culturally specific prevention programs in the effectiveness of preventing HIV.

However, the relationship between CBPR and this need for culturally specific prevention programs is not clear, especially in consideration of the Latina community specifically. Very little evidence is given, in the first place, to support the need for a culturally specific preventative programs, further qualitative review of literature on this subject would be of value to support the authors' conclusion.

In addition, research concerning the effectiveness of CBPR specifically on minority communities and the development and implementation of preventative health care programs, and their effectiveness in creating culturally specific preventative programs, is warranted. In this way, the article would have been improved from a series of loosely related facets into a fully integrated and heavily supported proven theory.

Cheemeh, P., Montoya, I., Essien, E., & Ogungbade, G. (2006 July). HIV / AIDS in the Middle East: A guide to a proactive response. Royal Society for the Promotion of Health, 126(4). Retrieved November 17, 2006, from ProQuest database.

Summary of the Article:

Cheeman, Montoya, Essien, and Ogungbade (2006) present a qualitative review of previous literature to identify the "numerous gaps and shortfalls in the existing programs, (and to) elucidate the reasons behind the lack of information, and provides suggestions for taking actions." More than two decades following the declaration that HIV / AIDS is an epidemic it has now spread to even remote parts of the Middle East. Five hundred forty thousand people are currently living with HIV in the Middle East and North Africa. Approximately 92,000 people were newly infected in 2004 and 28,000 died during that same year.

This region is especially vulnerable to the spread of the disease due to the increases of sexually transmitted infections, injection drug users, increased numbers of unemployed youth, and a low awareness of HIV.

This article identifies several gaps in the existing programs and reasons for this lack of information.

The authors not the need for culturally competent care that understands the beliefs and practices of this culture and how care should differ from western medicine practices. There is also a need for more treatment facilities for women, especially pregnant women. Sexual behavior education programs that are culturally appropriate are lacking. And, there is a great need for reliable and comprehensive epidemic data.

In the end, the authors note that it is through behavioral change that the most effective results in reducing HIV transmission is seen. This would involve study of high risk groups and the development and implementation of intervention strategies. Yet, these programs have not begun in the Middle East. It is noted that there is not only the obvious benefit of reduced human suffering and death when preventative measures are put into place, but that there is also "vast dividends in future savings to the healthcare system and the public sector at large. (However), without information on the sexual behavior of a population as a whole and its subgroups, it is impossible to design, implement or monitor effective intervention programs" (Cheeman, Montoya, Essien, & Ogungbade, 2006).

Critical Analysis of the Article:

The authors provide valuable information on a geographic region that has been somewhat ignored by researchers. HIV and AIDS in the Middle East is typically overshadowed by their geographic neighbor South Africa and its epidemic challenges over the last two decades.

Just because there is a lower prevalence of the disease in this region, does not mean that the potential for the spread of the disease and loss of life isn't there. The authors clearly explain the socio-economic conditions that make the Middle East vulnerable to a rampant spread of the disease.

In addition, the authors also bring to light some significantly lacking areas of programs for this region, in the prevention and treatment of HIV and AIDS.

They bring to light very good points about the need for medical care that is culturally sensitive. More treatment facilities, especially for pregnant women, education programs and more data on the epidemic are all significant areas that are lacking in the Middle East region. The authors effectively compile previous literature to support these areas of need.

More comprehensive data on HIV and AIDS in the Middle East region is clearly called for after review of this article. The authors make this point very clearly. In addition, future research could involve investigation into other lower prevalence of HIV / AIDS regions.

It would be interesting to see if these same areas of programs and comprehensive data are also overlooked, as a compare and contrast against the Middle East region. In addition, it would encourage more attention to be given to prevention programs in areas other than geographic regions where the epidemic has already taken a fast hold.