The "small world" expression: evolution from personal connections to global ties

Global Health & HIV

Global Health Issue

It is a small World: HIV / AIDS and Global Health

It is a small World: HIV / AIDS and Global Health

The purpose of this essay is to discuss in detail the HIV / AIDS issue and its different aspects and impacts on global level. The author will describe its history and current situation as well as the difficulties of HIV / AIDS patients on cultural and social level.

HIV / AIDS prevalence

HIV / AIDS was discovered as a disease in 1983 when laboratories of Dr. Luc Montagnier of the Pasteur Institute, Paris and Dr. Robert Gallo of the National Cancer Institute, Washington, D.C found out that 'human immunodeficiency virus' (HIV) was the contributory cause of 'Acquired Immunodeficiency Syndrome' (AIDS) by the (Chermann, 1983; Barre-Sinoussi,868). On the discovery of this disease and its cause there were more than 4000 patients of HIV / AIDS in the United States and there was no effective treatment for this disease. By the year 1993 almost 332,468 patients were died from this disease.

It was in 1986 that the first antiretroviral compound that was proved to be effective was introduced and got approval from the food and drug administration (FDA). The compound, a thymidine analogue, azidothymidine, (AZT), inhibited HIV replication by terminating reverse transcription, an important step in the virus lifecycle. However, by 1989, it was recognized that benefits from single drug treatments were only transient due to the rapid emergence of drug resistant variants (Larder, 1731). The development of HIV inhibitors in the early 1990's targeting both reverse transcriptase and protease lead to the use of combination drug treatments that were more effective in the long-term control of HIV infection (Cheeseman, 141).

Three or more drug combinations became known as Highly Affective Antiretroviral Therapy (HAART). Due to the success of HAART, there was a sharp decline in the number of AIDS-related deaths in the U.S. However, the number of newly HIV-infected individuals continued to rise. Figures and facts show that almost 33.3 million people all over the world are living with HIV currently and 20 million deaths have occurred from this disease. The most affected area from AIDS is Africa where it is the main cause of death while all through the globe AIDS has been found to be the fourth largest killer (UNAIDS, 2).

Economical Impacts

Since many countries lack the funds needed to obtain sufficient quantities of antiretroviral and lack the patient care infrastructure necessary to administer these regimes and educate patients for HIV / AIDS prevention, their societies are most threatened by the disease pandemic. In more developed nations, the emergence and spread of combination drug resistant HIV variants has complicated control of the epidemic. Prevention of antiretroviral drug resistance in patients requires at least 90% adherence to HAART (King, 2046).

HIV / AIDS was a global epidemic by the mid-1980s. Medical and public health communities in different countries recognized the disease during 1981-1984. In the United States, the earliest cases of what would be identified later as HIV / AIDS emerged in 1981 when young gay men visited medical clinics exhibiting symptoms of Kaposi Sarcoma (KS) and pneumonias (PCP) (CDC, 1981). In the years following, the number of people with AIDS in the United States increased from 7,239 in 1984 to 160,969 in 1990 (amfAR.org, 1). Medical doctors in Kenya were among the first in the profession in Africa to describe HIV / AIDS. In their article, "Acquired Immunodeficiency in an African," Obel describe a case of one patient who presented AIDS-related symptoms in order "to alert medical practitioners to the possibility of AIDS occurring in Africans and to emphasize the point that no race may be exempted from this highly lethal syndrome." The Kenyan HIV prevalence rate reached 14% during the mid-1990s but has since stabilized to 6.3% prevalence (USAID, 2011). To address the global HIV / AIDS epidemic, new knowledge was needed during the mid-1980s and that new knowledge capacity had to be built through research and training. This essay describes global health capacity building to address HIV / AIDS

The Centers for Disease Control and Prevention (CDC) in the United States (U.S.) reported that at the end of 2003 between 1,039,000 and 1,185,000 adults and children were currently living with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), and that about 24-27% of these individuals were undiagnosed and unaware of their serostatus.1 By the end of 2005, it was estimated that 341,524 males, 126,964 females, and 6,726 children (

Research and Development

The AIDS International Research and Training Program was designed in response to the Institute of Medicine Report, Confronting Aids, published in 1986 (Bridbord, 2007). This report was designed to advise the U.S. federal government on a national HIV / AIDS response. In the report, the international aspects of the epidemic were outlined, including its impact on foreign policy and research (Institute of Medicine, 2). Also, the report outlined the need for international HIV / AIDS research collaborations with researchers from low-resource countries. It emphasized the importance of involving multiple disciplines, which generally fell into four fields: biostatistics, biomedical research, epidemiology, and socio-behavioral research. Consequently, the need for research expertise in these fields, both in the United States and abroad, required the engagement of higher education. AITRP was designed to facilitate this engagement. As the global health arm of the National Institute of Health, the Fogarty International Center (FIC) designed AIDS International Research and Training Program.

Calls for Action to Address the AIDS Epidemic in the U.S.

Calls for combating the deleterious effects of HIV / AIDS-related stigma and discrimination have been made since the mid-1980s. In a statement given to the United Nations General Assembly in 1987, the Founding Director of the World Health Organization's Global Programme on AIDS (known today as the Joint United Nations Programme on HIV / AIDS or UNAIDS), Jonathan Mann, identified three phases of the AIDS epidemic3 in any community. According to Mann, the first phase is characterized by the silent and unnoticeable spread of HIV throughout communities over many years without being widely perceived or understood. The second phase includes, after some unspecified amount of time, the development of AIDS related illnesses (i.e., Kaposi's sarcoma and pneumocystis carinii pneumonia) that arises as a direct result of HIV infection. The third and final phase is marked by the social, cultural, economic, and political responses to AIDS, including the stigmatization and discrimination of PLWHA (Mann, 6).

Although this proclamation by Mann was an early identification of the potential harmful consequences of HIV / AIDS-related stigma and discrimination, very little was done to address this problem over the next decade. In fact, it took approximately 13 years before public health officials and researchers attempted to contend with this enduring predicament and for it to be seen as a continuing challenge to fighting the AIDS pandemic. In 2000, the Executive Director of UNAIDS, Peter Piot stated in an address to the agency's Programme Coordinating Board that, "effectively addressing stigma removes what still stands as a roadblock to concerted action, whether at the local community, national or global level" (Piot, p. 2) A couple of years later, the theme for the 2002-2003 World AIDS Campaign focused solely on that of HIV / AIDS related stigma and discrimination, demonstrating the resurgence and urgency of this topic. Secretary General of the United Nations, Kofi Annan in his message on World AIDS Day in 2003 captured the importance of contending with HIV / AIDS-related stigma and discrimination by proclaiming that,

"…No progress will be achieved by being timid, refusing to face unpleasant facts, or prejudging our fellow human beings -- still less by stigmatizing people living with HIV / AIDS. Let no one imagine that we can protect ourselves by building barriers between 'us' and 'them.' In the ruthless world of AIDS, there is no us and them. And in that world, silence is death…Join me in tearing down the walls of silence, stigma and discrimination that surround the epidemic. Join me, because the fight against HIV / AIDS begins with you" (Annan, p. 1).

Stigma Attached to AIDS

It is gradually more approved veracity today that all over the world individual who are most intensely affected by the HIV epidemic are also the most sternly deprived, whether on the basis of race, economic status, age, sexual orientation or gender. Bharat noted that

"As in the case of most other stigmatized health conditions such as tuberculosis, cholera and plague, fundamental structural inequalities, social prejudices and social exclusion explain why women, children, sexual minorities and people of color are disproportionately impacted by AIDS and the accompanying stigma and discrimination. The stigmatization of the African-American identity in relation to diseases in the early twentieth century shows a remarkable continuity today in the context of HIV / AIDS at the turn of the century." (p. 1)

Bharat also described that stigma related to AIDS and discrimination is multifaceted social practice. They are neither exclusive and nor arbitrarily patterned. They generally are constructed upon and strengthen pre-existing doubts, chauvinisms and social disparities pertaining to poverty, gender, race, sex and sexuality, and so on. In this way, racist behaviors and racial inequity associated to HIV / AIDS status are only playing into, and reinforcing, previously active racial stereotypes and disparities about people of color in general. "There is a four part process of stigmatization on the part of a society: first, by identifying and defining the disease; second by assigning responsibility for its appearance to some person, group or thing; third, by determining whether those affected by the disease are to be viewed as innocent or guilty; and fourth, by assigning responsibility for identifying a cure or solution to another segment of society." (pp. 4-5)

Impact of HIV / AIDS-Related Stigma on Psychological Distress

Psychological distress typically refers to the experience of negative affective states, such as depression, anxiety, and loss of emotional and behavioral control (Manning & Wells, 6). In the U.S., several research studies involving PLWHA have documented the association between at least one of the three different dimensions of HIV / AIDS-related stigma (e.g., enacted, perceived, and internalized) and depression, as well as anxiety, alienation, and poor psychological functioning. In addition, previous U.S. empirical studies among PLWHA have found a significant positive relationship between one of the dimensions of HIV / AIDS-related stigma and psychological distress (Silver, Bauman, Camacho, & Hudis, 431).

In one of the earliest studies on AIDS-related stigmatization, Crandall and Coleman (163) found in sample of 48 U.S. men and women who were either diagnosed with AIDS or AIDS related complex, 2 or were diagnosed as being HIV-positive that those participants who felt stigmatized by others also experienced higher levels of depression, anxiety, and alienation. Moreover, these authors showed that feelings of depression, anxiety, and alienation were independent of HIV diagnostic severity but were associated with disruptions in social relationships. Lichtenstein and colleagues study on chronic sorrow with a diverse sample of 21 HIV-positive men and women living in Birmingham, Alabama showed that half of their participants were clinically depressed. In particular, these authors noted that stigma and the social isolation that results from having a "discredited identity" were especially challenging for the African-American infected mothers in the study, who reported greater levels of depression. Clark (2003) also found that higher perceptions of AIDS-related stigma among their sample of 98 HIV-infected African-American women with children were associated with poorer psychological functioning. These authors operational zed psychological functioning as the extent to which the experience of AIDS-related stigma was perceived to cause psychological distress.

Impact of HIV / AIDS-Related Stigma on Health-Related Quality of Life

Health-related quality of life is a multidimensional construct generally defined as a subjective evaluation of one's life across a number of dimensions including physical functioning, social functioning, pain, and energy (Nordenfelt, 52). Research on adaptation to terminal or chronic illnesses highlight the importance of a number of personal and environmental characteristics that influence health-related quality of life. These characteristics include self-esteem, quality of social and family relationships, role functioning, financial resources, and communication patterns (Servellen & Aguirre, 134).

An increasing number of empirical studies have focused on assessing health-related quality of life among PLWHA (Howland, Storm, Crawford, Ma, Gortmaker, & Oleske, 3). Early investigations of health-related quality of life among PLWHA focused on assessment methodology issues (e.g., Kaplan, Anderson, Wu, Matthews, Kozin, & Orenstein, 43). However, more recent studies have sought to identify predictors of health-related quality of life and to develop interventions by which it can be improved for PLWHA (Hughes, Jelsma, MacLean, Darder, & Tinise, 371).

Orlando, Guaraldi, Murri, Wu, Nardini, Beghetto et al. found a significant negative correlation between lipodystrophy (a disturbance in the way one's body produces, uses, or stores fat) and lower health-related quality of life among 175 AIDS patients living in Italy. Although these investigators did not measure HIV / AIDS-related stigma directly, they reported that lower role functioning as measured by their health-related quality of life scale was attributable to perceived stigma. These unpublished international studies illustrate the need for additional research to investigate the relationship between HIV / AIDS-related stigma and health-related quality of life among PLWHA in the U.S.

Cultural Impacts related to HIV / AIDS

From the research it has been improved that social and cultural factors have great influence on HIV / AIDS patients and it has been suggested to improve the social relationships at family, hospital and office level so as to improve the quality of life of the AIDS affected individuals. Extending the relationship beyond the patient and provider (e.g., doctors, nurses) to improve a patient's health-promoting behaviors (i.e., recommended healthy eating), health care behaviors (i.e., treatment adherence), and health-related outcomes and statuses (i.e., blood pressure), Tucker, Herman, Ferdinand, Bailey, Lopez, Beato, proposed a literature based, testable, and formative model for patient-centered culturally sensitive health care (PCCSHC) that also includes office staff members (e.g., front desk staff) behaviors and physical environmental characteristics (e.g., waiting room area) and policies (e.g., stated and publicly displayed statement regarding the order in which patients are seen) of the health care clinic. In their work, these authors specifically argued for the promotion of PC-CSHC environments with the ultimate goal of reducing the health disparities that currently exist between minority and majority individuals all over the world.

According to Tucker., their model consists of a PC-CSHC intervention program that includes the following three subcomponents: (a) training health care providers and office staff members to engage in behaviors and display attitudes that enable patients to feel comfortable with, trusting of, and respected by their health care providers and staff members and that enable them to feel that they and their cultures are respected (i.e., inquiring about and respecting cultural beliefs of patients); (b) changing the health care clinic physical environment and clinic policies in ways that culturally diverse patients report as making them feel a sense of comfort and belonging in the clinic and involving health care administrators and providers in making these changes (i.e., displaying culturally diverse artwork and informational materials and posting a statement regarding the order in which patients are seen); and (c) training and empowering patients to engage in health-promoting lifestyles and to motivate and inspire desired behaviors and attitudes from providers and office staff members (i.e., giving negative and positive feedback to their health care provider or front desk staff member in a constructive manner) and desired changes in the health care environment (i.e., requesting that an indoor child's play area be created in the clinic waiting area).