Preventing Further HIV Infections in Youths

Being text of an address delivered by Dr Ikechukwu N.S. Dozie, Dept. of Microbiology, Imo State University of Owerri, at the National Association of Seadogs' organised, HIV/AIDS TRAINING WORKSHOP FOR YOUNG PERSONS held at Uyo, Akwa Ibom State on 4th February, 2005.

PREAMBLE

Chairman, NAS Capoon, Distinguished participants, Gentlemen of the Press, Ladies and Gentlemen, it is a pleasure to appear before you today to speak to you about one of the most crucial challenges of public health in the 21 st century, the HIV/AIDS scourge. There is no doubt in our minds that this scourge is the single most severe emergency, hampering social and economic development and compromising political stability in the continent. I wish to thank the National Association of Seadogs for this unique opportunity. I am also excited about the choice of the target audience- the youths. The import of this choice cannot be overemphasized considering the devastation by the epidemic on this group that represents the future of Africa. As I speak to you now, thousands of new infections are taking place and these will end up in AIDS and its terminal mandate, death. This situation generates a lot of concern to me as an African. To enable the participants/audience appreciate the urgent need to prevent further infections in our people particularly, the youths, there is need to create a holictic picture of some aspects of the HIV/AIDS epidemic. Against this background, therefore, the topic will be discussed using the following sub-titles:

   1. Definition of AIDS and Origin of the virus.
   2. Modes of Transmission.
   3. Factors responsible for the spread in Africa.
   4. Consequences on the youths.
   5. Strategies for preventing further infections.
   6. Challenges for the 21 st Century.
   7. Conclusion.

1. Definition of AIDS and Origin of the Virus.

Acquired Immune Deficiency Syndrome (AIDS) can be defined as the final clinical outcome of a prolonged infection with the Human Immunodeficiency Virus (HIV). AIDS is not a single disease but rather a spectrum of diseases (i.e. syndrome) caused by the same virus, HIV but giving rise to various clinical manifestations. The virus (HIV) on getting into the body selectively infects the cells (white blood cells) that are responsible for maintaining the immunity of the body called the T4 lymphocytes or CD4 cells. If the virus succeeds in destroying majority of the T4 lymphocytes, the body becomes prone or susceptible to a number of infections that would not ordinarily infect the healthy body. Such infections are called “opportunistic infections”. At this stage, the person is said to be suffering from AIDS. The virus (HIV) does not kill, but rather robs the body of cells that protect it from infections. What kills the person are the opportunistic organisms that will “cash in” on the immunodeficiency.

The first cases of AIDS were seen in the United States in 1981 by Dr. Michael Gottlieb of the University of California. He diagnosed an unusual disease called pneumocystis carinii pneumonia in five young men who were active homosexuals. Thereafter, similar reports started coming out from different parts of the world. The emergence of AIDS was accompanied by the usual human response to disasters, which is to blame it all on the activity of foreigners, minority groups etc. The issue was terribly politicized and became characterized by vicious racial under tones. The West claimed that the virus originated from African. Two hypotheses resulted in that namely: “Monkey Hypothesis” and “Virus Divergence Mutation Hypothesis”. The Monkey Hypothesis arose out of the discovery of a virus in African Green Monkeys (Simian immunodeficiency virus, SIV) that was similar to a variant of the human virus, HIV-2. This raised the possibility that HIV-2 might have come into human population from these simian species. This hypothesis could not be substantiated as Molecular Biology studies have revealed marked differences in the genetic sequences of the two viruses, thus indicating no ancestral relationship.

The Virus Divergence-Mutation Hypothesis followed speculations that HIV-1 (i.e. the classical HIV strain) had infected people for more than 20 years and less than a hundred years. It therefore became pertinent to know where the virus had been hiding all these while and why the world was only now experiencing an epidemic. An explanation was that HIV-1 had existed in small isolated groups in central and east Africa during which the local inhabitants acquired immunity to it and later spread to urban cities because of the migration from rural areas to urban cities. Sexual activities and blood transfusions were believed to be common events in the cities than the rural areas and thus gave rise to the later high incidence of AIDS infections in the cities. This hypothesis could be faulted for several reasons.

• The African population has been very mobile, both socially and geographically in the past three decades, during which time there was a large influx of rural residents into the urban cities. If the AIDS virus had existed in the rural population as speculated, the disease almost certainly would have observed in the urban population before the 1980s. The peculiar nature of AIDS which touches on human sexuality, makes it such that once introduced into a place, it would spread to all social classes within a relatively short time. Furthermore, if HIV had existed in African rural populations, it would have spread to the colonizers’ countries that had contact with the African rural population between the 1950s and 1970s.

• Second, seroepidemiological surveys conducted by some western scientist, which involved blood samples of old sexually inactive people living in geriatric homes in the Ugandan capital (Kampala), showed that none of the elderly people were positive for HIV antibodies. Similar surveys of 150 adults from the semi nomadic San Bush people living in the Central Kalahari Desert in Botswana proved negative for HIV antibodies. The San Bush is considered to be one of the oldest ethnic groups in Africa, and San-type skeletons date back 15000 years or more.

• Western clinicians who had medical practice in tropical Africa during the 1960s and 1970s have stated strongly that if AIDS had existed as anything but rare or sporadic cases, it would have been recognized as a clinical entity. The clinical appearances of AIDS patients now being diagnosed in parts of Africa are too striking for them to have been overlooked or misinterpreted.

• A review of records of the Belgian and French hospitals to which wealthy African patients with complicated health problems were referred and treated showed that cases consistent with the diagnosis of AIDS became common only after the 1980s. Since then, case recognition has followed an epidemic curve which on a cumulative frequency basis is identical to AIDS cases both in the US and Europe.

Sketchy evidence shows that besides the much speculated African origin of the AIDS virus, the agent could possibly be man-made, developed in the laboratory through genetic engineering techniques for use as a biological weapon or as a population control agent executed through vaccination programmes. The strongest and most convincing of these speculations was by one Donald Macarthur at US congressional hearing on Chemical and Biological warfare in 1969. He stressed that biological warfare experts could develop an unprecedented genetically engineered super germ that would be a highly effective killing agent because the immune system would be powerless against this microbe. Macarthur claimed: “Within the next 5 to 10 years, it would probably be possible to make a new infective microorganism which could differ in certain important aspects from any known disease-causing organisms. Mostimportant of these is that it might be refractory to the immunological and therapeutic processes upon which we depend to maintain our relative freedom from infectious disease”. A few years’ later, mass HIV- infections were observed in human populations. It therefore became pertinent to ask whether, HIV was a freak of nature or one of Macarthur’s man-made super germs designed to destroy the human immune system.

The origin of AIDS is a continuing mystery. Uncovering the truth however about AIDS can be liberating. Knowledge of the source of AIDS and its political implications can save the humankind. According to Alan Cantwell (a US physician): “ I no longer blame GOD, nor do I blame my lifestyle or my sexual partner. HIV was put on the planet to kill people, just like bullets and atomic bombs. As best as I can, I will try to protect my health and well being of those I love. I want to continue to alert people that knowledge of AIDS and avoidance of infection is life. AIDS can be an exceedingly painful way to die”.

2. Modes of Transmission

HIV transmission is the spread of HIV from one person to another via different routes. HIV is spread when an uninfected individual comes in contact with infected body fluids or cells. The virus has been found in blood, breast milk, semen and vaginal secretions in high concentrations and in low concentrations in saliva but nearly none in tears. HIV can be transmitted in various ways, including:

• Sexual Contact : This is the commonest mode of transmission and particularly in sub-Saharan African countries such as Nigeria. Any unprotected (no condom) penetrative sex whether vaginal, anal or oral can transmit the virus from an infected partner to the uninfected partner. Heterosexual contact (sex between a man and a woman) accounts for 70-80% of all HIV transmission in sub-Saharan Africa. Homosexuality (men having sex with men and women having sex with women) accounts for 5-10% of all HIV infections. Oral sex is associated with a lower risk but gonorrhea, genital ulcers and syphilis do increase the risk of transmission. Deep kissing where a lot of saliva is exchanged has been shown to pose some risk of HIV transmission and especially if one or both partners have bleeding gums. The risk of HIV transmission through sexual contact is influenced by a number of factors namely: the number of sexual partners, the level of virus in body fluids, sexual orientation, sex, age, STDs, and condom use.

• Mother to Child Transmission (MTCT).

The mother to child transmission of HIV (MTCT) is also referred to as vertical transmission. The worldwide rates of HIV infection from mothers to their children range from 13% to 40%. This is to say that 4 out of 10 children born to HIV positive pregnant mothers will contract HIV.

• Blood Transfusion : Use of blood and blood products that have not been screened for HIV or have been poorly screened can lead to HIV transmission. Transfusion with infected blood almost always results in the transmission of HIV to the uninfected recipient. This is the most efficient means of HIV transmission.

• Intravenous drug use/ contaminated piercing instruments :

Intravenous drug use is the administration of drugs of addiction e.g. heroin into the bloodstream by injecting into veins. Most drug users tend to “shoot” in groups and often share needles. It therefore becomes easy for a group member to introduce HIV infected blood lodged in the bore of a used needle into the vein and subsequently get infected. This is a significant mode of HIV transmission accounting for 5-10% of HIV infections.

• Rape/Occupational Exposure :

Exposure to HIV can also be as a result of rape or occupational exposure to healthcare providers such as nurses and doctors. Occupational exposure is the accidental exposure of healthcare workers to body fluids from an HIV infected patient in their care. This is most frequently due to needle pricks or cuts with surgical instruments. The risk of HIV transmission from occupational exposure is only about 0.1% (1 in 1000). Rape and sodomy victims could also get infected with HIV if the attacker is HIV positive. It is important that victims seek prompt medical attention as early treatment with anti-retroviral medicines can greatly reduce the chances of HIV infection. The attacker could also get infected if the victim is positive.

3. Factors Responsible for Spread in Africa

The dynamics and determinants of HIV spread in Africa (particularly amongst the youths) are being fostered by a combination of confounding factors including political, economic, socio-cultural, biological and behavioural. These factors are accelerating the progress of HIV as well as helping to block effective intervention.

(a) Political Factors

Firstly, the lack of genuine political commitment and vigorous action by governments are one of several reasons the epidemic has run out of control in SSA. Genuine political commitment at the highest level would help to break down the silence, denials, complacency and ignorance about the epidemic. A first hand approach would be to acknowledge the existence of the disease, discuss openly and candidly about it. Almost 2 decades after the emergence of the epidemic, government until very recently was yet to tackle it with the seriousness and urgency it demanded. It becomes easy to see why so many people do not yet sense enough danger about the disease that would translate into behavioural change. Little wonders that Nigeria has joined the League of Nations with high disease prevalence. In South Africa, for instance, genuine commitment by the government in the early 1990’s would have forestalled a rise in infection rates in the adult population from less than 1% in that period to about 20% in less than 10 years. This is the same situation with Nigeria, where HIV prevalence increased from 1.8% in 1992 to 5.4% in 1999 amongst pregnant women, with some hot spots (like Oturkpo in Benue State) having rates of 21%. This is unlike the situation in East Africa where there are “discrete declines” in HIV trends because of genuine commitment by governments.

Secondly, there is lack of legislated national policies to respect and promote human rights – those universally recognized in the international systems of declarations and covenants and in humanity’s highest spiritual values. The teaching with the greatest relevance in our common survival in the AIDS era is that human beings owe each other tolerance, respect and compassion. Respecting this rule means acting responsibly and not endangering other people’s health or rights. It means not sitting in judgment of others, not stigmatizing, rejecting or discrimination against people with HIV infection. This teaching has relevance to the relationship between sexes, as it leaves no room for subordination or sexual exploitation – a latent factor resulting in HIV infections in young girls.

Thirdly, the lack of resources for promoting research, prevention and care, in addition to the judicious utilization of scarce funds allocated for such purposes.

Fourthly, the incessant political instability in most countries in SSA has resulted in wars and it’s consequent problems such as flight of refugees and break up of families. In such situations sexual violence against women are bound to be rife and contribute to vulnerability to HIV infections.

(b) Economic Factors

In the words of Louis Pasteur, “the microbe is nothing, the terrain is everything”. This explains how the cycle of poverty and sharp economic downturns experienced by many countries in SSA have become the bane of HIV/AIDS in Africa. That Africa is the poorest continent and that Africa is facing the biggest epidemic of AIDS translates to the relationship between poverty and AIDS. According to a farmer in Mwanza Tanzania: “My son, here AIDS is not about the virus, it is about food. This is a very dry area. Rains come 3 months every year. By April, the place is dry and our harvest is in the stores. By end of August, rice stores have run out and you have families without food. So if I have a teenage girl and she goes out and comes back with a kilo of rice, I will not ask”. This compares with the situation many women and girls have found themselves and who out of poverty, desperation, hunger, gender differences in access to resources are more likely to exchange sex for money or favours, less likely that they will succeed in negotiating safer sex and less likely that they will abandon a relationship they perceive to be risky. In most instances, majority of these women are left with a choice between immediate survival for families and the fears of infection and its delayed consequences later in life.

(c) Socio-Cultural Factors

Firstly, in many African societies, issues relating to sex are taken to be sacred and not discussed with young people. This culture of silence that surrounds sex dictates that “good women” are expected to be ignorant about sex and passive in sexual interactions. This makes it difficult for women, especially girls to be well informed about risk reductions or even when informed, makes it difficult for them to be proactive in negotiating safer sex.

Secondly, the practice of female genital mutilation (FGM) and other forms of male circumcision with unsterilized materials are also latent factors responsible for infections in children and young people in rural communities of SSA.

(d) Biological Factors

The history of sexually transmitted diseases (STDs) has been identified as relevant to spread of HIV infections in SSA. These STDs promote HIV transmission by causing inflammation and lesions of the genital tract, thus creating an easy access for HIV.

4. Consequences on Youths

The consequences of HIV/AIDS in the youth are very grave especially as this group has been defined as “the mainstay of family, the pillars of the society and the very heart of the work force”. In the Africa (Nigeria), social security means not a government cheque but having enough able-bodied people in the family to rely on for food and shelter. AIDS is cutting big holes in this ancient safety net and millions of people are falling through. Elderly people having lost their adult children to AIDS, live out their last few years impoverished and alone or having to look after their grand children and themselves.

Furthermore, about 12 million children have become orphans at the turn of the century and will be joined by many more in the next few years. The large number of homeless orphans poses a grave challenge particularly when society does not succeed in saving them the fate of becoming street children, delinquents and criminals by providing suitable care and education. Most of them will sink into penury, drop out of school, and suffer malnutrition, ostracism, and psychic distress. Without maternal care and education, the girls’ fall into prostitution and the cycle of new HIV infections continue unabatedly.

A new and frightening dimension of the HIV/AIDS saga in Africa is the number of students and graduates – (the young, educated people, the continent desperately need) that are infected with HIV. The University of Nairobi estimates that 20-30% of their 20,000-student population is HIV positive. Officials have it that most do not know that they are carrying the virus and may be infecting others. According to Josphat Kirimania, the Personal Assistant to the Vice-Chancellor, “You train and start your career and then by 30, you die. This is the tragedy of the Universities in Africa”. The deaths caused by AIDS so far have left gaping holes in the university’s faculties, which would be hard to replace as the deaths represent the loss of many years of investment. Generally, the death of millions of young adults, many of them well educated members of the socioeconomic or political elite will affect the African society at the macro level.

5. Prevention of further HIV Infections

Prevention of HIV infections poses a fundamental challenge, since it is the most important weapon in our struggle against AIDS. Given the magnitude and devastating consequences of the epidemic, a protective vaccine would have been the best option to check the spread of the virus. Since there are no drugs for cure or protective vaccines, all strategies therefore, must be anchored on projects involving behavioural changes, and in particular sexual behaviour, which is the key factor in the spread of AIDS in Africa. Strategies adopted for the prevention of HIV infections include: health education through mass media campaigns, health education at family level, health education in school, advocacy for use of condoms.

Abstinence is the only sure way one (you and I) is safe from the virus (HIV). Even though people advocate condom use as a means of prevention, this practice gives people a false sense of security. This is because no one would want to have sex with an infected person using a condom in the supposition that would protect him or her. It implies, therefore that the use of condom for HIV prevention is a technical solution to the problem. The real solution would be changes in sexual behaviour – abstinence by young people and mutual fidelity by married young adults.

6. Challenges for the 21 st Century

Despite the grave picture of HIV/AIDS epidemics in Africa youths, there are clear signs of hope. Much is known about HIV to help put in place adequate preventive strategies. So far some countries have recorded significant success in checking the spread of this virus. The genuine commitment of the Ugandan government and the concerted efforts put in place at all levels of civil society have turned around increasing HIV prevalence rates. Furthermore, the rapid response programs adopted by the Senegalese government early in the epidemic have kept HIV prevalence rates low. These successes can be repeated elsewhere including Nigeria.

There should be economic empowerment of young people through programs for poverty alleviation like the micro-enterprise development initiatives (i.e. small business enterprises), which involves vocational skill acquisition, business education, micro financing and micro-credit administration.

Other programs should be targeted towards intensive and sustained health education for youths in school (including sex education and moral instruction) and these out of the formal educational sector. Sex education should include the concept of partnership and the development of responsible sexual behaviour (i.e. positive sexuality). It should include the empowerment of young girls on ways to protect them. Appropriate personnel to use in health education for youths should be young people living positively with HIV.

In Africa, HIV/AIDS is a family disease because of its far-reaching health, social, psychological and economic implications for all the members of the immediate and extended family. The very nature of HIV/AIDS demands that the family becomes a responsibility unit for the protection of its members. In the words of Dr. Merson, a former Director of the Global Programme on AIDS (now UNAIDS), “families whose bonds are based on love, trust, nurture and openness are best placed to protect their members from infection and to give compassionate care and support to those affected by the disease. Families are also the place where the young learn to practice safe behaviour and reject discrimination”. The struggle against AIDS must start in the home; it can no longer be business as usual. The persisting vicious cycle of silence, pretence must be broken. Mothers and elder siblings must be used as tools to drive home and translate preventive messages into behavioural changes. This is because they appreciate the peculiar needs of young people for effective communication. The success of this strategy is anchored on person-to-person approach.

There should be provision of youth friendly health services through the establishment of youth friendly clinics with policies and attributes that attract youths to such facilities (i.e. meeting the needs of young people in an atmosphere of confidentiality and ability to retain them for follow up and repeat visits).

7. Conclusion

HIV/AIDS is a tragic and inescapable fact of life in every country on this planet. We must summon up the will, the commitment and resources to prevent HIV transmission in the 21 st century. If we don’t act now, millions of unprevented infections will result in millions of deaths. The cost of alleviating the epidemic’s devastating socioeconomic impact will no longer be the hundreds of millions of dollars needed today, but billions or even trillions. To put it simply, the cost to us of not intervening now will be simply unaffordable. We know what works and we know the rewards of acting quickly on this information. Let us not miss this precious opportunity that the 21 st Century presents.

Dr Ikechukwu N.S. Dozie
Dept. of Microbiology
Imo State University of Owerri