hiv aids essay conclusion

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Institute of Medicine (US) Committee to Study HIV Transmission Through Blood and Blood Products; Leveton LB, Sox HC Jr., Stoto MA, editors. HIV And The Blood Supply: An Analysis Of Crisis Decisionmaking. Washington (DC): National Academies Press (US); 1995.

HIV And The Blood Supply: An Analysis Of Crisis Decisionmaking.

• Hardcopy Version at National Academies Press

8 Conclusions and Recommendations

The HIV epidemic has taught scientists, clinicians, public health officials, and the public that new infectious agents can still emerge. The nation must be prepared to deal with a fatal illness whose cause is initially unknown but whose epidemiology suggests it is an infectious disease. The AIDS epidemic has also taught us another powerful and tragic lesson: that the nation's blood supply—because it is derived from humans—is highly vulnerable to contamination with an infectious agent. A nation's blood supply is a unique, essential, life-giving resource. Whole blood and many blood products are lifesaving for many people. As a whole, our nation's system works effectively to supply the nation with necessary blood and blood products and its quality control mechanisms check most human safety threats. The events of the early 1980s, however, revealed an important weakness in the system—in its ability to deal with a new threat that was characterized by substantial uncertainty. The potential for recurring threats to the blood supply led this Committee to reappraise the processes, policies, and resources through which our society attempts to preserve its supply of safe blood and blood products.

• General Conclusions

The events and decisions that the Committee has analyzed underscore the difficulty of decisionmaking when the stakes are high, when decisionmakers may have personal or institutional biases, and when knowledge is imprecise and incomplete. The Committee attempted to understand the complexities of the decisionmaking process during the period analyzed in this report and develop lessons to protect the blood supply in the future. In retrospect, the system was not dealing well with contemporaneous blood safety issues such as hepatitis, and was not prepared to deal with the far greater challenge of AIDS .

By January 1983, the Centers for Disease Control (CDC) had accumulated enough epidemiological evidence to conclude that the agent causing AIDS was almost certainly transmitted through blood and blood products and could be sexually transmitted to sexual partners. The conclusion that the AIDS agent was blood-borne rested on two findings. First, AIDS was occurring in transfusion recipients and individuals with hemophilia who had received AHF concentrate; these AIDS patients did not belong to any other known high-risk group for contracting AIDS. Second, the epidemiologic pattern of AIDS was similar to hepatitis B, another blood-borne disease. However, the magnitude and consequences of the risk for transfusion and blood product recipients was not known at this time. Furthermore, the epidemiological pattern of the new disease was difficult to interpret because, unlike most infectious diseases, there seemed to be several years between exposure leading to infection and the development of symptoms. As a result, physicians and public health officials underestimated the large number of infectious people who had no symptoms of AIDS but could transmit the disease to others and therefore substantially understated the risk of infection.

Compared to the pace of many regulatory and public health decision processes, the federal government responded relatively swiftly to the early warnings that AIDS might be transmitted through blood and blood products. Public and private sector officials considered a range of clinical and public health interventions for reducing the risk of AIDS transmission through blood and blood products. This period, however, was characterized by a great deal of scientific uncertainty about the risks of HIV infection through blood and blood products and about the costs and benefits of the available options. The result, the Committee found, was a pattern of responses which, while not in conflict with the available scientific information, was very cautious and exposed the decisionmakers and their organizations to a minimum of criticism. This limited response can be seen in the refusal of blood banks in 1983 and 1984 to screen for and defer homosexuals or use surrogate tests ( Chapter 5 ), in the Food and Drug Administration's (FDA) cautious and inadequate regulatory approach to the recall of potentially contaminated AHF concentrate ( Chapter 6 ), and in the failure of physicians and the National Hemophilia Foundation to disclose completely the risks of using AHF concentrate and the alternatives to its use ( Chapter 7 ).

Blood safety is a shared responsibility of many diverse organizations. They include U.S. Public Health Service agencies such as the CDC, the FDA, and the National Institutes of Health (NIH), and private-sector organizations such as community blood banks and the American Red Cross, blood and plasma collection agencies, blood product manufacturers, groups such as the National Hemophilia Foundation (NHF), and others. The problems the Committee found were inadequate leadership and inadequate institutional decisionmaking processes in 1983 and 1984. No person or agency was able to coordinate all of the organizations sharing the public health responsibility for achieving a safe blood supply.

Decisionmaking Under Uncertainty

The management of a public health risk requires an evolving process of decisionmaking under uncertainty. It includes interpretive judgment in the presence of scientific uncertainty and disagreement about values. Public health officials must characterize and estimate the magnitude of the risk, which involves considering both the likelihood that infection might occur in various circumstances, and the costs and benefits associated with each of the possible uncertain outcomes. They must also develop and test public health and clinical care strategies, and communicate with the public about the risk and strategies for reducing it. When confronted with a poorly understood and anomalous public health threat, inertia often influences decisions. It is often easier to maintain the status quo than to make a change. In fact, regulatory policymakers, health scientists, and medical experts often require substantial scientific evidence before informing the public and adopting remedial action. Lack of scientific consensus becomes a kind of amplifier for the usual discord and conflict that can be expected whenever an important science-based public policy decision—one profoundly affecting lives and economic interests—must be made. First, uncertainty creates opportunities for advocates of self-interested and ideological viewpoints to advance plausible arguments that favor their desired outcome. Second, uncertainty intensifies bureaucrat cautiousness.

In the course of its investigations, the Committee learned several lessons about decisionmaking under uncertainty. These are set out here both as general lessons and to provide a framework for the recommendations that follow.

Risk Perception

Risk perception is shaped by social tensions, and cultural, political, and economic biases (Douglas 1985). It is important to understand the different contexts in which risk is perceived and the complex system of beliefs, values, and ideals that shape risk perception (Nelkin 1989). There are several other factors that influence risk perception, including locus of control, the type of risk posed by the threat, and the time interval involved in evaluating the risk. For example, people tend to underestimate risks that they perceive to be under their control, risks associated with a familiar situation, and low probability events (Douglas 1985). People have difficulty accepting estimates of a risk that is involuntary, uncertain, unfamiliar, and potentially catastrophic (Fischoff 1987). The epidemic caused by HIV in the blood supply illustrates these patterns of perception and behavior with respect to risk.

Risk Assessment Versus Risk Management

A central precept of risk management is to separate the assessment of risk from the management of its consequences (NRC 1983). Otherwise, risk managers tend to bias their estimates of the magnitude of the risk in favor of their preconceived notions about appropriate or desirable policy choices. The events that the Committee studied provide examples of what can happen when this precept is not followed. When there is uncertainty, it may be necessary to assess risk by making subjective estimates rather than by obtaining objective measures. Such was the case in 1983 when, as part of implicit risk-benefit calculations about donor screening and deferral, blood banks and blood product manufacturers had to make judgments about the risk that their products could transmit AIDS (see Chapter 5 ). Anticipating the consequences of taking action, which is in the domain of risk management, may bias risk estimates toward values that support risk-averse action. When blood bank officials estimated the risk of transmitting AIDS as ''one per million" transfusions, they chose a rate that was low enough to justify their reluctance to take further action. Despite mounting evidence that the risk was much higher, they maintained their original estimate throughout 1983. If the CDC had made numeric estimates of the risk, and the blood banks, blood product manufacturers, or the FDA had used these estimates in a formal analysis of the decision problem, they might have reached different conclusions about, for example, surrogate testing for AIDS.

Consider the Full Range of Possibilities

When there is uncertainty about the facts that will determine the consequences of a decision, a systematic approach is usually best (NRC 1994). One important principle is to consider the full range of assumptions and alternative actions, not only worst-case scenarios. In the events studied by the Committee, systematic denial of worst-case scenarios was a recurring theme, as can be seen in the way that the NHF and the FDA discussed the CDC's warnings in 1982 and early 1983. The plasma fractionators introduced a worst case scenario of their own at the July 1983 Blood Products Advisory Committee (BPAC) meeting, when they estimated that three or four suspect donors and an automatic recall policy could lead to recall of all of the nation's supply of AHF concentrate ( Chapter 6 ). A closely related principle is to scrutinize the evidence to ascertain what is based on fact, what is a "best-guess" estimate, and what is simply untested conventional wisdom.

One approach to such an analysis would be to use a formal group process to systematically sample expert opinion on relevant factors such as the probability of infection and the economic and noneconomic costs and benefits of each of the possible outcomes. Often these officials should use decision analysis, which takes into account the likelihood of events and the magnitude of their outcomes, as a tool to compare the expected value of the outcome of the policy alternatives under consideration. Two somewhat analogous models to consider include those used in Institute of Medicine studies to establish priorities for the development of new vaccines (IOM 1985) and to evaluate the artificial heart program of the National Heart, Lung, and Blood Institute (IOM 1991). The book Acceptable Risk (Fischoff, et al. 1981) also offers sensible approaches to dealing with this kind of situation.

Risk Reduction Versus Zero Risk

Decisionmakers tend to seek zero-risk solutions even when they are unattainable or unrealistically costly (NRC 1994). In doing so, they may run the risk of failing to implement solutions that are less effective but are certain to reduce illness. The failure to adopt risk-reduction strategies can be seen in the resistance of blood banks to screening for homosexual activity or using surrogate tests for AIDS ( Chapter 5 ) and in FDA's limited approach to product recall decisions ( Chapter 6 ). Chapter 7 also points out that many risk-reduction strategies for individuals with hemophilia were available but not fully disclosed or recommended. The perfect should not be the enemy of the good.

Risk Communication

Risk communication is a sensitive area because of its influence on the perceptions and behaviors of health professionals and consumers, regulatory policies, and public decisionmaking (Nelkin 1989). Many public health officials and physicians wish to appear in command and infallible. When uncertain, they remain silent rather than disclose their ambivalence (NRC 1989). In the Committee's view, however, the greater the uncertainty, the greater the need for communication. The Committee's analysis of physician–patient communications at the beginning of the AIDS era illustrates the tragedies that can accompany silence about risks ( Chapter 7 ). Risk-communication skills are equally important when presenting information to the general public. The blood banks' reluctance to acknowledge the risk of transfusion-associated AIDS ( Chapter 5 ) seems to have been due in part to the difficulties that they foresaw in presenting this information to potential donors and recipients.

Other important principles of risk communication are that the source of the information must be credible, the process should be open and two-way, and the message should be balanced and accurate (NRC 1989). When there was no other sources of information for physicians treating people with hemophilia and for their patients, the NHF and its Medical and Scientific Advisory Council (MASAC) took on an important risk-communication role—providing what would now be called "clinical practice guidelines." The NHF's credibility in this area was eventually seriously compromised by its financial connections to the plasma fractionation industry.

Bureaucratic Management of Potential Crises

Federal agencies had the primary responsibility for dealing with the national emergency posed by the AIDS epidemic. The Committee scrutinized bureaucratic function closely, and came to the following conclusions about the management of potential crises.

Coordination and Leadership

A crisis calls for extraordinary leadership. Legal and competitive concerns may inhibit effective action by agencies of the federal government. Similarly, when policymaking occurs against a backdrop of a great deal of scientific uncertainty, bureaucratic standard operating procedures designed for routine circumstances seem to take over unless there is a clear-cut decisionmaking hierarchy. An effective leader will insist upon coordinated planning and execution. Focusing efforts and responsibilities, setting timetables and agendas, and assuming accountability for expeditious action cannot be left to ordinary standard operating procedures. These actions are the responsibilities of the highest levels of the public health establishment.

The Public Health Service failed to bring these leadership functions to bear when CDC scientists raised concerns about the blood supply at the January 4, 1983 meeting but received no public support from the director of the CDC or the office of the Assistant Secretary for Health. Similarly, the record does not indicate that the highest levels of the FDA or the PHS were involved in responding to advice from the BPAC regarding donor deferral or product recall. Part of this leadership problem may stem from major changes in the PHS leadership that took place during this period: the leadership of the FDA, the CDC, and the NIH, and the person serving as the Assistant Secretary for Health all changed between 1982 and 1984.

Advisory Mechanisms

In the early 1980s, the FDA and other agencies did not have a systematic approach to conducting advisory committee proceedings. Such an approach requires that agencies tell their advisory committees what is expected of them, keep attention focused on high-priority topics, and independently evaluate the advice offered. No regulatory process should have its information base effectively controlled by an advisory panel. Public agencies must be able to generate and analyze the information that they need to assure that decisions serve the needs of the public. The FDA failed to observe this principle when it allowed statements and recommendations of the BPAC to go unchallenged, apparently because it could not independently analyze the information ( Chapter 6 ).

Because mistakes will always be made and opportunities sometimes missed, regulatory structures must be organized and managed to assure both the reality and the continuous appearance of propriety. The prominence of representatives from blood banks and blood product manufacturers on the BPAC, with no balancing influence from consumers and no process within the FDA to evaluate its recommendations ( Chapter 6 ), is a failure of advisory committee management. Perhaps advisory committees should contain fewer topical experts and more members with expertise in principles of good decisionmaking and the evaluation of evidence. A committee so constituted might run a reduced risk of standing accused of having conflicts of interest.

Analytic Capability and Long-Range Vision

Leadership passes to the organization that has access to information and the ability to analyze it. Federal agencies should avoid exclusive reliance upon the entities which they regulate for analysis of data and modeling of decision problems. The FDA should have had some independent capacity to analyze the information presented at the July 1983 BPAC meeting that suggested that with only three or four suspect donors, an automatic recall policy would completely deplete the nation's supply of AHF concentrate ( Chapter 6 ). In addition, there did not seem to be any focus within the Public Health Service prepared to, or charged to, analyze the options, costs, and benefits of the options for protecting the blood supply that were discussed at the January 4, 1983, meeting convened by CDC.

In addition, agencies need to monitor more systematically the long-term outcomes of blood transfusion and blood product infusion and to think far ahead to anticipate both new technologies and new threats to the safety of the blood supply. Because new pathogens can enter the blood supply and be propagated very rapidly through it, a low level of suspicion about a threat should trigger high-level consideration of how to manage and monitor the problem.

Through its fact-finding interviews and through written documents, the Committee found little evidence that the PHS agency heads and the Assistant Secretary for Health were involved in making decisions about protecting the blood supply in 1983 and 1984 when HIV was becoming increasing apparent as a threat. Most decisions and interagency communication seems to have occurred several levels below the top.

Presumptive Regulatory and Public Health Triggers

The Committee believes that the Public Health Service should prepare for future threats to the blood supply by specifying in advance the types of actions that should occur once the level of concern passes a threshold. In the face of scientific uncertainty, the PHS needs a series of criteria or triggers for taking regulatory or other public health actions to protect the safety of blood and blood products. The Committee favors a series of triggers in which the response is proportional to the magnitude of the risk and the quality of the information on which the risk estimate is based. Not all triggers should lead to drastic or irrevocable actions; some merely require careful consideration of the options or developing new information. This general principle is detailed by examples in each of the Committee's four areas of inquiry. Table 8.1 summarizes these triggers and corresponding actions.

Triggers for Taking Actions in Response to Uncertain.

Product Treatment

Whenever they propose new methods of protecting the safety of the blood supply, blood regulatory agencies must perform cost-utility or cost-benefit analyses to evaluate whether the intervention will advance the public health at reasonable costs. If manufacturers do not have market incentives, resources, or access to data to test promising methods, public agencies should create incentives or provide resources or access to data. In this case, the trigger is a new proposal to increase safety, and the action is for the public sector to assume responsibility for thorough analysis and development, or to create incentives for industry to do so.

When performing a cost-effectiveness analysis of new treatments for blood products, the potential to protect against other threats should always be a part of the analysis. Here, the trigger is the initiation of a cost-effectiveness analysis, and the action is to ensure that the analysis takes into account secondary benefits.

Donor Screening

Whenever epidemiologists identify a high-risk donor group, the FDA should immediately tell blood banks to create a way to defer that group and tell collection agencies to segregate and separately treat supplies obtained from those populations. Concerns about stigmatizing subpopulations and maintaining the supply of blood products should influence the means of taking actions, not whether to take action. In this case, the trigger to action is the identification of a high-risk population, and the action is deferral and segregation of lots.

Whenever any segment of the industry institutes a donor screening program, the FDA should require all segments of the industry to follow suit with actions that they believe will be at least as effective in promoting safety. Public regulators have a responsibility to monitor these efforts and to forge consensus or to impose the most effective methods as information concerning efficacy becomes available. Here, the trigger is one company's action to take an additional safety measure, and the response is for all companies to follow suit, or to be held accountable when they do not.

Blood banks should use a partially effective intervention that has little or no risk unless they can show that a better method will rapidly supersede it. In this case the trigger is the availability of an inherently risk-free, partially effective intervention, and the response to use that test/intervention unless it is certain to become redundant prior to realizing its full benefits.

When a test or treatment makes a product safer, manufacturers should withdraw all stocks of untested or untreated product as quickly as possible. Where immediate complete withdrawal might injure the public health, withdrawals should be partial or staged. Here, the trigger is the implementation of a new test or treatment process, and the action is to recall untested or untreated products as expeditiously as possible, given other considerations of public health.

A limited, staged, or selective recall places responsibility on public regulatory agencies to establish criteria for selecting lots for recall, to provide processes to permit effective implementation of the recall by industry, and to monitor the recall to assure that removal of the products occurs in the prescribed manner. In this case the trigger is the initiation of a recall action, and the response is to provide clear guidance and monitoring.

Communication to Patients and Providers

Whenever new information triggers inquiry into a possible threat to the blood supply, both patients and their physicians should have access to the information. Public officials should presume that candid statements and rigorous actions will enhance rather than erode public confidence and that persons using blood or blood products have the right to understand fully the risks and benefits of using these products. In this case, the trigger is new information relevant to the public health, and the action is to tell affected individuals what they need to make an informed choice: the facts, the gaps in knowledge, and the implications thereof.

• Recommendations

The Committee's charge was to learn from the events of the early 1980s the lessons that would help the nation prepare for future threats to the blood supply. The Committee identified potential problems with the system in place at that time (as summarized earlier in this chapter) and proposes changes that, if implemented in the early 1980s, might have moderated some of the effects of the AIDS epidemic on recipients of blood and blood products. This analysis has led the Committee to the following recommendations for Public Health Service agencies, for the blood and plasma fractionation industry, and for health care providers and the public. These recommendations address both public health options and individual clinical options.

The Committee is mindful of several caveats. First, the Committee is acutely aware of the difficulties of retrospective analysis, as described in Chapter 1 . Second, the Committee has not considered its recommendations from perspectives other than blood safety. Finally, the Committee tried to identify opportunities for institutional change that would respond to the problems that the Committee diagnosed. The Committee based its recommendations on the institutions as they functioned in the early 1980s, not as they exist now. The organizations responsible for blood safety and public health will have to evaluate their current policies and procedures to see if they fully address the issues raised by our recommendations.

The Public Health Service

Several federal agencies necessarily play important, often different roles in managing a public health crisis such as the contamination of blood and blood products by the AIDS virus. The National Blood Policy of 1973 charged the Public Health Service (including the CDC, the FDA, and the NIH) with responsibility for protecting the nation's blood supply.

The Committee has come to believe that a failure of leadership contributed to delay in taking effective action, at least during the period from 1982 to 1984. This failure led to incomplete donor screening policies, weak regulatory actions, and insufficient communication to patients about the risks of AIDS .

In the event of a threat to the blood supply, the PHS must, as in any public health crisis, insist upon coordinated action. The Secretary of Health and Human Services is responsible for all the agencies of the Public Health Service, 1 and therefore the Committee makes

Recommendation 1: The Secretary of Health and Human Services should designate a Blood Safety Director, at the level of a deputy assistant secretary or higher, to be responsible for the federal government's efforts to maintain the safety of the nation's blood supply.

Choosing a "lead person" is important because it is in the nature of federal agencies and their leaders to be at once competitive and protective. This condition is healthy in reasonable measure and in normal times. However, a serious threat to public health requires that agencies communicate, cooperate, and learn to view the world through each other's lenses. Once there is an action plan, the Secretary of Health and Human Services must hold the agency leaders accountable for enforcing cooperation in implementing the plan.

To be effective in coordinating the various agencies of the PHS, the Blood Safety Director should be at the level of a deputy assistant secretary or higher, and should not be a representative of any single PHS agency. When a threat does arise, the Blood Safety Director should create a crisis management team.

One such action was to establish, in July 1982, the Committee on Opportunistic Infections in Hemophiliacs (see Chapter 3 ). This group seems to have been organized by the CDC, but there is no record of its operations after August of that year.

Blood Safety Council

The AIDS crisis revealed that the institutions in place to ensure blood safety, both public and private, were unable to work cooperatively toward a common goal of a safe blood supply. The institutions were not accountable to anyone but themselves, and they failed to cooperate, to coordinate their activities, and to communicate effectively with physicians and the public. The Committee has become convinced that the nation needs a far more responsive and integrated process to detect, evaluate, and respond to emerging threats to the blood supply. To this end the Committee makes

Recommendation 2: The PHS should establish a Blood Safety Council to assess current and potential future threats to the blood supply, to propose strategies for overcoming these threats, to evaluate the response of the PHS to these proposals, and to monitor the implementation of these strategies. The Council should report to the Blood Safety Director (see Recommendation 1). The Council should also serve to alert scientists about the needs and opportunities for research to maximize the safety of blood and blood products. The Blood Safety Council should take the lead to ensure the education of public health officials, clinicians, and the public about the nature of threats to our nation's blood supply and the public health strategies for dealing with these threats.

Supplying safe blood and blood products to the nation—a public good—requires the cooperation of public and private institutions. The Blood Safety Council would give voice to the public's interest in having these institutions cooperate and would provide opportunities for them to do so.

The lessons of HIV transmission through blood and blood products show the need for an advisory council with a significantly greater level of diversity, responsibility, and authority than the current Blood Products Advisory Committee of the FDA. The BPAC is limited by the regulatory mission of the FDA which it advises, and there is no other body primarily concerned with blood safety as a whole. Representatives from governmental agencies, academia, the blood bank community, industry, and the public all have relevant expertise and perspectives and should be involved in the Blood Safety Council. A broad-based range of expertise in areas of hematology, infectious diseases, epidemiology, blood product manufacturing, blood collection and delivery, risk assessment, consumer advocacy, and cost-benefit analysis is essential.

The proposed Blood Safety Council would facilitate the timely transmission of information, assessment of risk, and initiation of appropriate action both during times of stability and during a crisis. The Council should report to the Blood Safety Director (see Recommendation 1). The Council would not replace the PHS agencies responsible for blood safety but would complement them by providing a forum for them to work together and with private organizations. The PHS agencies would be represented on the Council (see below and Figure 8.1 ). The Council would not have its own surveillance capability, but would work with CDC and FDA to interpret the information that those organizations can provide. It would not carry out or fund research itself, but would work with those at NIH and in the private sector to identify priorities for blood safety research. The Council would not have regulatory power, but would inform FDA actions from a blood safety rather than a product-specific perspective.

Figure 8.1.

Blood Safety Council relationships.

The organizations and groups that should be included in the Blood Safety Council, and the reasons for including them, are as follows:

• The FDA can provide a direct link between itself, the essential regulatory agency responsible for the safety of blood and blood products, and important sources of information, scientific support, and disease surveillance findings.
• The CDC can provide expertise in epidemiology, infectious diseases, and immunology as well as communicate the results of ongoing disease surveillance studies. The CDC's newly established emerging infectious disease program would also provide valuable information.
• The NIH can provide scientific expertise and the means to communicate information about essential research needs to the appropriate institutes for support of research.
• Representatives from academia can bring independent scientific and medical expertise, especially in hematology, infectious diseases, epidemiology, risk assessment, and cost-effectiveness analysis.
• Representatives from the volunteer blood collection community can bring experience with blood safety concerns and the knowledge of blood bank operations that is necessary to evaluate proposed change.
• Representatives from the private-sector blood product manufacturers and biotechnology companies can bring both experience with blood safety concerns and knowledge of plasma fractionation operations.
• Representatives of the general public (who may in the future require blood transfusions) and individuals who currently require frequent use of blood products, such as hemophilia patients, bring important perspectives on the trade-offs that must be considered in evaluating response options.

The Blood Safety Council should consider the following activities and issues:

Surveillance. Although the FDA and the CDC keep track of events in blood and blood product recipients, their surveillance systems are passive and incomplete. The Blood Safety Council should work with the CDC to design a system of active surveillance for adverse reactions in blood recipients, as described in Recommendation 5 below. If such a system is established, the Council would benefit from its results and should participate in its governance.

Expert Panel on Best Practices . Drawing on its members' knowledge about blood and blood product safety concerns, and about clinical alternatives, the Blood Safety Council could establish a panel of experts to provide the public and providers of care with information about risks and benefits, alternatives to using blood products, and recommended best practices, as described in more detail in Recommendation 13 below.

Investigate Methods to Make Blood Products Safer. The Council should evaluate new methods to make blood and blood products safer. One promising approach is double inactivation in the preparation of blood products, which minimizes the risk of transmission of infectious pathogens in the blood of the donor pool. At present, the FDA requires only a single inactivation process (usually solvent detergent or heat treatment) for most blood products manufactured in the United States. With the goal of maximizing the safety of the blood supply at minimal added cost, the Blood Safety Council should encourage the FDA to evaluate double inactivation methods and expeditiously relicense products manufactured by the improved technologies, if appropriate. The Blood Safety Council should also consider, at least yearly, in a public forum, opportunities to maximize the safety of the blood supply.

Another promising approach is to reconsider minimum pool size requirements in plasma product manufacturing. The FDA currently requires a large number of donors to be included in plasma pools used in the manufacture of plasma products in order to ensure a wide range of antibodies in preparations of intravenous gamma globulin. Pooling of plasma obtained from numerous donors, although permitting some economy of scale, also increases the risk that a large fraction of manufactured blood products will be contaminated by a single infected donor. The Blood Safety Council should consider this issue and address the safety and efficiency trade-offs in changing the minimum pool size.

The Blood Safety Council would provide information relevant to the decisions that individuals as well as public and private decisionmakers need to make. The forum would not have direct regulatory or other authority, but would function as a forum for holding the organizations with authority responsible for blood safety. In short, the Blood Safety Council could advocate the public's need for a responsible process for decisionmaking about public health policy. The following examples illustrate how regular public discussions of blood safety issues, in the presence of representatives from the relevant organizations' perspectives, could provide an opportunity to hold the organizations with authority accountable for blood safety.

If it had existed in the 1970s, for instance, the Blood Safety Council might have called for the development of heat-treated AHF concentrate to reduce the risk of hepatitis, which would have also reduced the risk of HIV transmission. It would have been able to do so if the NIH and blood products industry representatives on the Council had been called upon to make periodic reports to the Council during the 1970s about their efforts to deal with the hepatitis problem. These representatives would have fed the discussions of the Council back into their own organizations' decisionmaking.

In 1983, the Council could have provided a forum for CDC to present its concerns about HIV in the blood supply and held the FDA, the NHF, and the blood banks and fractionators accountable for responding constructively. CDC created a forum on its own by convening the January 4, 1983, meeting in Atlanta, but as the Committee's analysis indicates, the follow-up on this meeting was insufficient. If a standing Blood Safety Council had existed, the CDC scientists who had concerns about the safety of blood and blood products would have had an opportunity to hold blood collection organizations accountable for their decisions regarding donor deferral and surrogate testing. It would also provide an opportunity to hold plasma fractionators and the FDA accountable for its decisions with regard to heat-treated AHF.

Later that year, the Council could have provided a mechanism to evaluate the claims that automatic recall of AHF would have virtually eliminated the supply of AHF. As the analysis in Chapter 6 indicates, neither the BPAC nor the FDA staff had the capacity to analyze claims that a automatic recall would have such an effect. The Blood Safety Council could have insisted that the FDA commission a formal decision analysis of the options for surrogate testing, or the Council might have performed such an analysis itself. The FDA would retain its regulatory authority, and continue to get advice from the BPAC, but the Council would have provided critical information relevant to the agency's decision.

Finally, if the Council had established an expert panel on best practices as described above and in Recommendation 13, hemophilia patients and their physicians would have had a more credible source of information about the risks of HIV infection and their clinical options than the NHF was able to provide. The operations of such a panel are described below under Recommendation 13.

Compensation Policy

When a product or service provided for the public good has inherent risks, the common law tort system fails to protect the rightful interests of patients who suffer harm resulting from the use of those products or services. Each claim requires extended, costly, and complex adjudicative procedures to establish liability. The results are erratic and unpredictable, and therefore inequitable (IOM 1985).

The doctrine of strict liability holds manufacturers accountable for injuries that are incurred from products that are inherently dangerous because diligence cannot fully eliminate their risks. The public health imperative of assuring enough vaccine for widespread use argues for limits on the strict liability doctrine for vaccine-related injuries. The chief concern is that fear of liability will discourage manufacturers from producing a vital public good. To vitate this concern, a federal compensation system has removed vaccine-related injuries from the scope of strict liability laws (Mariner 1992). The federal government established a mechanism for compensating individuals suffering harm from vaccine-related complications. Its rationale is that consent to undergo vaccination confers benefits to the entire community.

Blood -product-related injuries have also been removed from the scope of strict liability law by blood shield laws, which are in force in most states, and which protect society's interests in having an adequate blood supply. The blood shield laws serve to protect providers and manufacturers of blood and blood products from liability claims in instances where they take all due care to ensure the safety of the product. These laws, however, are unique in the manner in which they limit liability. The shield laws have made it difficult, and often impossible, to obtain compensation for HIV infection acquired from blood or blood products. To address this asymmetry between the protection that blood shield laws offer for manufacturers and adequate protection of individual rights, the Committee makes

Recommendation 3: The federal government should consider establishing a no-fault compensation system for individuals who suffer adverse consequences from the use of blood or blood products. 2

An effective no-fault system requires prospective standards and procedures to guide its operations. In a no-fault system, individual plaintiffs would not have to prove that their adverse outcome was a result of negligence related to manufacture of a blood product. Therefore, there needs to be an objective, science-based process to establish which categories of adverse outcomes are caused by blood-borne pathogens and which individual cases deserve compensation. As with vaccines, a tax or fee paid by all manufacturers or by the recipients of blood products could finance a compensation system. Rather than attempt to allocate blame for HIV infections through blood and blood products, some countries have established such no-fault compensation programs for individuals infected with HIV as a result of their use of blood and blood products. Countries fund these programs in a variety of ways, including direct government support and joint public/private resources.

Making recommendations about compensating affected individuals for damages incurred in the past is outside the Committee's mandate. However, had there been a no-fault compensation system in the early 1980s, it could have relieved much financial hardship suffered by many who became infected with HIV through blood and blood products in the United States. The no-fault principles outlined in this recommendation might serve to guide policymakers as they consider whether to implement a compensation system for those infected in the 1980s.

The Centers for Disease Control and Prevention

The CDC has an indispensable role to play in protecting our nation's health: to detect potential public health risks and sound the alert. Because of its expertise in detecting and evaluating possible infectious disease outbreaks, the Committee believes that the CDC should take responsibility for a surveillance system to detect adverse outcomes from blood and blood products. The following two recommendations embody an important principle: separating the assessment of risk from the management of the consequences of risk. The FDA, in its role as guarantor of the safety of the blood supply, has the responsibility for managing threats to the blood supply. The CDC should detect potential threats and assess the magnitude of the danger.

Early Warning Systems

A nation needs individuals and organizations that identify problems and raise concerns that may be difficult to confront. The CDC plays this role in the Public Health Service. The CDC appears to have been prescient in raising the possibility that the blood supply was contaminated early in the AIDS epidemic, but it was relatively ineffective in convincing other agencies of the potential gravity of the situation. In order to improve CDC's efficacy in this critical role, the Committee makes

Recommendation 4: Other federal agencies must understand, support, and respond to the CDC's responsibility to serve as the nation's early warning system for threats to the health of the public.

Officials in the government, scientists, and physicians in the private sector seem to have discounted the CDC warnings about the transmissibility of AIDS through blood and blood products because the swine flu episode in the 1970s had cost the agency considerable credibility. If, in 1983, the involved public and private organizations had the attitude called for in this recommendation, CDC's recommendations regarding donor screening and surrogate testing might have led to earlier, more effective screening and donor deferral policies.

Consistent with the precept of separating risk assessment and risk management as described above, CDC's role is to characterize and assess risks, and communicate this to others. The FDA and other organizations have the responsibility to manage the risks through regulation, clinical practice guidelines, and other means. The Committee believes that CDC should be able to play its designated role without fearing loss of credibility if it sometimes proves to be wrong. Implementing this recommendation may be difficult. As a start, the Secretary of Health and Human Services should insist that an agency that wishes to disregard a CDC alert should support its position with evidence that meets the same standard as that used by the CDC in raising the alert.

Surveillance

In order to carry out its early warning responsibility effectively, the CDC needs good surveillance systems. Because blood products are derived from human beings and may contain harmful biologic agents that were present in the blood of a donor, blood products are inherently risky, a principle long recognized by blood shield laws. The Committee, believing that the degree of surveillance should be proportional to the level of risk, makes

Recommendation 5: The PHS should establish a surveillance system, lodged in the CDC, that will detect, monitor, and warn of adverse effects in the recipients of blood and blood products.

If such a system had existed in 1982, data about the risks of HIV transmission through blood and blood products might have been available sooner and might have been more definitive. In dealing with newly approved pharmaceuticals, the FDA increasingly demands careful post-approval study of potential adverse effects (the so-called ''Phase IV Trial"). Two existing systems for vaccine adverse events—the CDC/FDA Vaccine Adverse Event Reporting System (VAERS) and the CDC's Large-Linked Database (LLDB)—might be useful models (Institute of Medicine 1994).

The Food and Drug Administration

The FDA has legal authority to protect the safety of the nation's blood supply. Accordingly, it is the lead federal agency in regulating blood-banking practice, the handling of source plasma, and the manufacture of blood products from plasma. The Committee found cause for concern when it evaluated the FDA's actions in protecting the public from HIV in the nation's blood supply during the 1980s. The record reveals many opportunities to improve the agency's capacity to deal with crises involving the blood supply, most notably with respect to the safety of AHF concentrate. In responding to these opportunities, the Committee's recommendations focus on decisionmaking and the role of advisory committees in formulating the FDA's response to crises.

Risk Reduction

In a crisis, decisionmakers may become so preoccupied with seeking solutions that will dramatically reduce danger that they will fail to implement solutions that are less effective but are likely to improve public safety to some degree. Partially effective risk-reducing improvements, as described herein, can save lives, pending the development of more efficacious safety measures. In order that the perfect not be the enemy of the good, the Committee makes

Recommendation 6: Where uncertainties or countervailing public health concerns preclude completely eliminating potential risks, the FDA should encourage, and where necessary require, the blood industry to implement partial solutions that have little risk of causing harm.

In the event of a future threat to the blood supply, the FDA should encourage small, low-risk solutions to large, difficult problems. The FDA's actions during the early 1980s are evidence that the agency should change its attitude toward regulation in order to adopt this proactive approach. Some examples from Chapter 6 illustrate how the FDA might have encouraged practices that would have reduced the risk faced by recipients of blood or a blood product.

Example: Destroy Unscreened Blood When Possible . When hospital blood banks first started to screen donors by questioning them for risk factors, there was a period of transition during which its stocks contained two classes of blood or plasma: blood from screened donors, which was relatively safe; and blood from unscreened donors, which had a higher probability of containing HIV. Within a few weeks of starting to screen donors, blood from unscreened donors would have been either used or discarded. In the instructions contained in its letter of March 24, 1983, the FDA could have recommended that blood banks adopt a policy of using blood from screened donors whenever possible during the transition period, a policy that some blood banks may have adopted on their own. Requiring all blood banks to adopt this policy would not have compromised the nation's blood supply, and it would have prevented at least a few instances in which a patient received an infected unit of blood.

Example: Destruction of Potentially Contaminated Cryoprecipitate . Blood banks store cryoprecipitate from a single unit of donated blood in the frozen state for up to one year. The FDA could have issued a directive that required the blood banks to check their inventory of frozen cryoprecipitate and destroy possibly contaminated units whenever they learned of a previous donor who had AIDS or was strongly suspected of having AIDS.

Example: Phased Recall. In July 1983, there was considerable reluctance to recall untreated Factor VIII concentrate at a time when much of the supply was almost certainly contaminated with HIV. The FDA apparently feared that the ensuing shortage of Factor VIII would have caused more harm than the HIV virus. A phased withdrawal would have been a compromise between no withdrawal and immediate total withdrawal. This middle path might have avoided a factor concentrate shortage and still reduced the number of hemophiliacs who became infected.

Example: Lookback. The FDA formally instituted a "lookback" policy in 1991, years after it was clear that AIDS had a long incubation period during which a patient could transmit HIV through sexual contact or contact with blood. Lookback required blood banks to contact recipients of blood from infected donors and notify them that they might be a HIV carrier and should be tested for HIV antibodies. Earlier action on lookback might have reduced secondary transmission of HIV.

Decision Processes

In all fields, decisionmaking under uncertainty requires an iterative process. As the knowledge base for a decision changes, the responsible agency should reexamine the facts and be prepared to change its decision. The agency should also assign specific responsibility for monitoring conditions and identifying opportunities for change. In order to implement these principles at the FDA, the Committee makes

Recommendation 7: The FDA should periodically review important decisions that it made when it was uncertain about the value of key decision variables.

An example illustrates the principle of iterative decisionmaking. During 1983, most blood bank officials opposed asking prospective male donors if they had ever had sex with a man. They were worried that regular donors might take offense and stop donating blood. They were also concerned about some gays would lie about their homosexuality and donate blood in reprisal for being singled out as the target of the questioning. Eventually, some blood collection centers began to ask questions about sexual preference. If the FDA had carefully monitored these experiments, it would have soon learned that the blood bank officials' fears were groundless. The FDA might then have revised its requirements for donor screening to include direct questions about high-risk sexual practices.

Regulatory Efforts

Although the FDA has a great deal of regulatory power over the blood products industry, the agency appears to regulate by expressing its will in subtle, understated directives. This informal approach to regulation is often necessary to permit a timely response and to preserve needed flexibility. The FDA used this approach, for example, in July 1983 when it issued recommendations to withdraw lots of AHF concentrate that plasma fractionators had identified as containing material from a donor that had AIDS . The language in the July 1983 communication failed to specify, however, whether the agency considered the recommendations to be binding on industry. While most regulated industries might have interpreted these letters as mandatory, that question should not have been left to the judgment of individual entities. Taking this into account, the Committee makes

Recommendation 8: Because regulators must rely heavily on the performance of the industry to accomplish blood safety goals, the FDA must articulate its requests or requirements in forms that are understandable and implementable by regulated entities. In particular, when issuing instructions to regulated entities, the FDA should specify clearly whether it is demanding specific compliance with legal requirements or is merely providing advice for careful consideration.

In 1983, the FDA chose a middle ground when faced with the decision to withdraw all AHF concentrate. The agency recommended that plasma fractionators withdraw individual lots of AHF concentrate when a donor was suspected of having AIDS . This decision was certainly defensible. However, the process for this "case-by-case" withdrawal was seriously compromised by the vagueness of the criteria specified for a recall. The agency failed to specify a process for deciding whether a donor may have had AIDS. The agency should have specified a process for reviewing donors who did not fully satisfy the diagnostic criteria for AIDS but who were suspected of having the disease. When deciding whether to withdraw a lot of AHF concentrate, the FDA asked plasma fractionators to take into account the time of the donation in relation to the diagnosis of AIDS and the effect of the recall on product availability. However, the FDA did not specify parameters for assessing either of these decision criteria. With greater forethought, the FDA could have avoided the potential for a seriously flawed implementation of a policy that otherwise appeared to balance benefits, risks, and harms.

Advisory Committees

The FDA made several decisions in 1983 that appear to have been influenced by the blood-industry-based (profit and nonprofit) members of the BPAC. The BPAC membership did not include individuals with expertise in the social, ethical, political, and economic aspects of the issues that BPAC was deliberating at the time. The FDA apparently did not seek independent analysis of the recommendations made by the members of the BPAC, some of whom were employed by the blood industry. In the early 1980s, the FDA appeared too reliant upon analyses provided by industry-based members of the BPAC and the BPAC. For example, see the discussion in Chapter 6 of the July 19, 1983, BPAC meeting which resulted in the decision for case-by-case rather than automatic recall of lots of AHF when one donor was suspected of having AIDs. Chapter 6 also contains a discussion of the December 15, 1983, BPAC meeting, which effectively curtailed actions on surrogate testing of blood for months. The Committee's analysis of the FDA's management of its advisory committee leads to the following three recommendations:

Recommendation 9: The FDA should ensure that the composition of the Blood Products Advisory Committee reflects a proper balance between members who are connected with the blood and blood products industry and members who are independent of industry.

The FDA should select some BPAC members because they can provide independent judgment, question the analyses provided by blood-industry-based BPAC members, and hold the FDA accountable for a high standard of public responsiveness. The BPAC should have at least one voting member who is a representative of consumer interests. BPAC members who vote to establish policy should have neither the appearance of a conflict of interest nor a true conflict of interest.

An agency that is practiced in orderly decisionmaking procedures will be able to respond to the much greater requirements of a crisis. The BPAC meetings cited before Recommendation 9 above provide examples to support this recommendation. Applying this principle to the use of advisory committees, the Committee makes

Recommendation 10: The FDA should tell its advisory committees what it expects from them and should independently evaluate their agendas and their performance.

The FDA staff and its advisory committees should structure their relationship so that they invigorate each other. The agency should hold an advisory committee accountable for its performance through periodic independent evaluation. By placing unresolved issues on future agendas, the committee can hold the FDA accountable for taking follow-up action between committee meetings. The IOM Committee to Study the Use of Advisory Committees by the Food and Drug Administration makes further recommendations to strengthen the FDA advisory committee system (IOM 1992).

Advisory committees provide scientific advice to the FDA; they do not make regulatory decisions for the agency (IOM 1992). As Chapter 6 indicates, the FDA in 1983 did not independently verify the estimates of the risk of blood-product-related HIV infection. The FDA did not analyze the public health implications of the BPAC's recommendation against automatic recall of AHF concentrate that contained plasma from donors suspected of having AIDS . The FDA's lack of independent information and its own analytic capacity meant that it had little choice but to incorporate the advice of the BPAC into its policy recommendations. To ensure the proper degree of independence between the FDA and the blood products industry, the Committee makes

Recommendation 11: The FDA should develop reliable sources of the information that it needs to make decisions about the blood supply. The FDA should have its own capacity to analyze this information and to predict the effects of regulatory decisions.

Communication to Physicians and Patients

One of the crucial elements of the system for collecting blood and distributing blood products to patients is the means by which to convey concern about the risks inherent in blood products. In today's practice of medicine, in contrast to that of the early 1980s, patients and physicians each accept a share of responsibility for making decisions. Patients' informed consent is required for risky procedures. From early 1983, it was clear that AHF concentrate was a risky product. The failure to tell hemophilia recipients of Factor VIII concentrate about the risks of this treatment and about alternative treatments seems especially serious in the light of present-day emphasis on the autonomy of patients in decisions involving their health.

Clinical Practice

One powerful lesson of the AIDS crisis is the importance of telling patients about the potential harms of the treatments that they are about to receive. The NHF dedicated itself to providing information to individuals with hemophilia and their physicians. Their strategy, however, was seriously flawed. As discussed in Chapter 7 , the NHF provided treatment advice, not the information on risks and alternatives that would enable physicians and patients to decide for themselves on a course of treatment. Hemophilia patients did not have the basis for informed choice about a difficult treatment decision.

Considerable scientific and medical uncertainties characterized the early years of the AIDS epidemic. For individuals medically dependent on the use of blood and blood products, these uncertainties created complex dilemmas about clinical options for their continued care. In instances of great uncertainty, it is crucial for patients to be fully apprised of the full range of options available to them and to become active participants in the evaluation of the relative risks and benefits of alternative treatments. As the case studies in Chapter 7 indicate, the failure to communicate adequately about these options prevented many hemophiliacs from making choices in which they accepted responsibility for balancing the risk of AIDS and the risks of bleeding. Ultimately the failure to communicate led to a powerful sense of betrayal that exacerbated the tragedy of the epidemic for many patients and their families. To encourage better communication, the Committee makes

Recommendation 12: When faced with a decision in which the options all carry risk, especially if the amount of risk is uncertain, physicians and patients should take extra care to discuss a wide range of options.

Medicine has many "gray areas" in which the correct course of action is not clear. Guidelines should identify these areas and spotlight the importance of full disclosure of risks, discussion of the broadest range of clinical options, and incorporation of the patient's preferences into an individualized recommendation. Given the inherent risks and uncertainties in all blood products, the public and the providers of care need expert, unbiased information about the blood supply. This information includes risks and benefits, alternatives to using blood products, and recommended best practices. As Chapter 7 indicates, the NHF (the only organization that stepped in to provide information to hemophiliacs and the physicians who were treating them) focused on practice recommendations rather than complete information on risks and options. In order to provide the public and providers of care with the information they need, the Committee makes

Recommendation 13: An expert panel should be created to inform the providers of care and the public about the risks associated with blood and blood products, about alternatives to using them, and about treatments that have the support of the scientific record.

One lesson of the AIDS crisis is that a well-established, orderly decisionmaking process is important for successfully managing a crisis. This applies as much to clinical decisionmaking as to the public health decision process addressed by the earlier recommendations. As the narrative indicates, there are both public health and clinical approaches to reducing the risk of blood-borne diseases. The Blood Safety Council called for in Recommendation 2 would deal primarily with risk assessment and in the public health domain, actions that would reduce the chance that blood products could be vectors of infectious agents. The primary responsibility of the expert panel on best practices called for in Recommendation 13 would be to provide the clinical information that physicians and their patients need to guide their individual health care choices. To be most effective, this panel should be lodged in the Blood Safety Council (see Recommendation 2) so that both bodies can interact and coordinate their activities in order to share information about emerging risks and clinical options.

Any organization that supplies this information must adhere to accepted norms for documenting evidence. The Committee believes that the public's interest would be best served by creating one publicly accountable source of this information. This function would build on the experience of the Agency for Health Care Policy and Research, which has an established guideline development process and issues guidelines on topics such as the management of chronic pain, screening for AIDS , and management of urinary incontinence (El-Sadr, et al. 1994; Jacox, et al. 1994).

Experience in developing practice guidelines for hemophilia treatment and blood transfusion is an important element of preparedness for future threats to the blood supply. There are now well-established processes such as those recommended by the IOM Committee to Advise the Public Health Service on Practice Guidelines (IOM 1990, 1992) and used by the Agency for Health Care Policy and Research. The U.S. Preventive Services Task Force (1989) uses another system process. Guideline developers should perform a thorough literature search, identify well-designed studies, describe fully the evidence on harms and benefits, and explain the connection between the evidence and the recommendations. They should seek critical evaluation from a wide spectrum of individuals and organizations and should periodically reexamine the recommendations in the light of changing knowledge.

Credibility

During the early 1980s, in its role as the guardian of the interests of the hemophilia patient community, the NHF was the principal source of information about using blood products. The outcome of the NHF efforts was that individuals with hemophilia and their families lost faith in the NHF as the rightful steward of their interests. The reasons discussed in Chapter 7 include the NHF's unwavering recommendation to use AHF concentrate, its dependence on funds contributed by the plasma fractionation industry, and the composition of the NHF expert panel (MASAC) that formulated treatment recommendations (e.g., the panel's lack of infectious disease experts and decision analysts).

Toward the end of providing the highest-quality, most credible information to patients and providers, the Committee makes

Recommendation 14: Voluntary organizations that make recommendations about using commercial products must avoid conflicts of interest, maintain independent judgment, and otherwise act so as to earn the confidence of the public and patients.

One of the difficulties with using experts to give advice is the interconnections that experts accumulate during their careers. Organizations that regulate an industry may get advice from the same experts who advise the industries. Organizations that give treatment advice may rely on experts whose employer relies upon support from industry. As a result, an expert may have a history of relationships that raise concerns about whether he or she can be truly impartial when advising a course of action in a complex situation. The Committee believes that the best way to avoid these risks is to choose some panelists who are not expert in the subject of the panel's assignment but have a reputation for expertise in evaluating evidence, sound clinical judgment, and impartiality.

Financial conflicts of interest influence organizations as well as individuals. As indicated in Chapter 7 and above, the financial relationships between the NHF and the blood products industry seriously compromised the NHF's credibility. The standards for acknowledging conflicts of interest are higher than they were 12 years ago. Public health officials and the medical professions must uphold this new standard. Failure to do so will threaten the fabric of trust that holds our society together.

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HIV/AIDS: A Postmodern Epidemic and Its Depiction (March 2016): Looking Forward and Conclusion

• A Brief Overview
• The Epidemic: A Time Line
• The Sociology of AIDS
• Global Health and Human Rights
• Cultural Responses
• Looking Forward and Conclusion

Works Cited

Looking forward.

Although new HIV infections have fallen by almost 40 percent since 2001, UNAIDS reported that an estimated 1.5 million people worldwide died from AIDS-related illnesses in 2013.  In the Western world, the sense of urgency about AIDS has decreased since combination therapy became available in the mid-1990s.  An unexpected consequence of the success of combination therapy is that people have become complacent about safe-sex methods—and the need to use them consistently—which has led to a resurgence in new infections.  As the Kaiser Family Foundation’s 2011 survey HIV/AIDS at 30: A Public Opinion Perspective makes clear, in the United States the stigma of HIV infection continues.

Many international agencies are working on vaccine development, prevention strategies, structural remedies, and poverty relief in the hope that by scaling up prevention and treatment programs they will eventually outpace and even eliminate the disease.  Nathalia Holt’s recent Cured: How the Berlin Patients Defeated HIV and Forever Changed Medical Science describes the cases of two men who were declared “functionally cured” of HIV infection, in one case following a painful and expensive bone marrow transplant of HIV-resistant stem cells.  Although the technique appears to have worked in one patient, the economic feasibility and logistics must be assessed.  Biomedical Advances in HIV Prevention: Social and Behavioral Perspectives , edited by Lisa Eaton and Seth Kalichman, focuses on biomedical technologies currently being researched (e.g., topical microbiocides/gels and vaccines) to help end the spread of HIV.  Pre-exposure prophylaxis (known as PrEP) and post-exposure prophylaxis (PEP) are other treatment options being explored.  Rethink HIV: Smarter Ways to Invest in Ending HIV in Sub-Saharan Africa , edited by Bjørn Lomborg, ranks HIV prevention and treatment policies using a cost-benefit analysis.  A priorities ranking report put together by the aids2031 Consortium, AIDS: Taking a Long-Term View , suggests that researchers take a fresh, proactive approach as well as a long-term approach.  The international organization UNITAID, launched by the United Nations in 2006, is using innovative financing to encourage pharmaceutical companies to participate in the Medicines Patent Pool, which allows drugs to be used on an open-access basis by researchers in developing countries.  And fast-track programs such as that initiated at USAIDS support scaling up HIV prevention and treatment programs with an eye toward ending the epidemic as a public health issue within the next few decades. [1]

[1] UNAIDS, Fast-Track—Ending the AIDS Epidemic by 2030 , http://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report

As this essay shows, the range of HIV/AIDS literature is broad and spreads across many disciplines.  Publication of monographs in the clinical sciences has slowed, with journals providing the most up-to-date research.  Most of the monographs fall under the heading of public health, although the sociology literature on HIV/AIDS is steadily growing as a generation of survivors reaches more milestones.  Stopping the disease will involve using all the techniques available—education, prevention, treatment, and research—and overcoming financial impediments.  The disease is still active, and academic interest in it will continue.  One hopes the literature will eventually move from such immediate topics as treatment and prevention to historical observations.

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What Is HIV?

HIV ( human immunodeficiency virus ) is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases. It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex (sex without a condom or HIV medicine to prevent or treat HIV), or through sharing injection drug equipment.

If left untreated, HIV can lead to the disease AIDS ( acquired immunodeficiency syndrome ).

The human body can’t get rid of HIV and no effective HIV cure exists. So, once you have HIV, you have it for life. Luckily, however, effective treatment with HIV medicine (called antiretroviral therapy or ART) is available. If taken as prescribed, HIV medicine can reduce the amount of HIV in the blood (also called the viral load) to a very low level. This is called viral suppression. If a person’s viral load is so low that a standard lab can’t detect it, this is called having an undetectable viral load. People with HIV who take HIV medicine as prescribed and get and keep an undetectable viral load can live long and healthy lives and will not transmit HIV to their HIV-negative partners through sex .

In addition, there are effective methods to prevent getting HIV through sex or drug use, including pre-exposure prophylaxis (PrEP) , medicine people at risk for HIV take to prevent getting HIV from sex or injection drug use, and post-exposure prophylaxis (PEP) , HIV medicine taken within 72 hours after a possible exposure to prevent the virus from taking hold. Learn about other ways to prevent getting or transmitting HIV .

What Is AIDS?

AIDS is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus.

In the U.S., most people with HIV do not develop AIDS because taking HIV medicine as prescribed stops the progression of the disease.

A person with HIV is considered to have progressed to AIDS when:

• the number of their CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3). (In someone with a healthy immune system, CD4 counts are between 500 and 1,600 cells/mm3.) OR
• they develop one or more opportunistic infections regardless of their CD4 count.

Without HIV medicine, people with AIDS typically survive about 3 years. Once someone has a dangerous opportunistic illness, life expectancy without treatment falls to about 1 year. HIV medicine can still help people at this stage of HIV infection, and it can even be lifesaving. But people who start HIV medicine soon after they get HIV experience more benefits—that’s why HIV testing is so important.

How Do I Know If I Have HIV?

The only way to know for sure if you have HIV is to get tested . Testing is relatively simple. You can ask your health care provider for an HIV test. Many medical clinics, substance abuse programs, community health centers, and hospitals offer them too. If you test positive, you can be connected to HIV care to start treatment as soon as possible. If you test negative, you have the information you need to take steps to prevent getting HIV in the future.

To find an HIV testing location near you, use the HIV Services Locator .

HIV self-testing is also an option. Self-testing allows people to take an HIV test and find out their result in their own home or other private location. With an HIV self-test, you can get your test results within 20 minutes. You can buy an HIV self-test kit at a pharmacy or online. Some health departments or community-based organizations also provide HIV self-test kits for a reduced cost or for free. You can call your local health department or use the HIV Testing and Care Services Locator to find organizations that offer HIV self-test kits near you. (Contact the organization for eligibility requirements.)

Note: State laws regarding self-testing vary and may limit availability. Check with a health care provider or health department Exit Disclaimer for additional testing options.

Learn more about HIV self-testing and which test might be right for you .

Related HIV.gov Blogs

• HIV Testing Day National HIV Testing Day
• World AIDS Day
• HIVinfo.NIH.gov – HIV and AIDS: The Basics
• CDC – HIV Basics
• NIH – HIV/AIDS
• OWH – HIV and AIDS Basics
• VA – HIV/AIDS Basics

Prevention and Treatment of HIV/AIDS Expository Essay

Introduction.

HIV/AIDS has become a concern to everybody in the world. Many countries and individuals have found it very hard to deal with it because of the lack of funds. Therefore, organizations have come up to help them handle this problem. Notable organizations that have offered their support include WHO, PEPFAR, the Clinton’s AIDS Initiative, the Gates Foundation and the Global Fund.

WHO HIV/AIDS Treatment and Prevention Program Policy

The World Health Organization Department of HIV/AIDS provides normative and policy support to its members basing on enough evidence ( WHO | Guidelines, 2014). The purpose of this support is to improve the treatment, care provision and prevention services ( WHO | Guidelines, 2014).

The global vision of WHO is to eradicate HIV infections, deaths and discrimination against infected people. It aims at attaining universal and comprehensive HIV prevention, treatment and care. It also aims at combating HIV/AIDS, malaria and other diseases ( WHO | Guidelines, 2014). WHO developed strategic directions that health units should adopt in achieving its goals. They are:

• Optimizing the prevention, diagnosis and provision of care for HIV victims ( WHO | Guidelines, 2014)
• Leveraging wider outcomes in health through appropriate response to HIV ( WHO | Guidelines, 2014)
• Reducing susceptibility and getting rid of barriers to accessing services ( WHO | Guidelines, 2014)

The World Health Organization also proposes treatment and preventive methods that are specific to the needs of individual countries. Among the methods it proposes for the countries include the use of male and female condoms, male circumcision, antiretroviral therapy, prophylaxis and behavior change counseling ( WHO | Guidelines, 2014).

WHO also volunteered to expand HIV prevention methods in every country ( WHO | Guidelines, 2014). Currently, it has plans to develop a HIV prevention strategy based on national evidence and push for the creation of better prevention methods and interventions.

The Role of other Organizations

Global fund.

The Global Fund partners with governments, civil societies, the private sector and victims of AIDS, Tuberculosis, and malaria in 140 countries worldwide ( HIV/AIDS-The Global Fund, 2014). It spends over $4 billion every year on these partnerships. This support has greatly accelerated the rate at which the prevalence of AIDS reduces.

The fund was developed with the purpose of giving HIV victims financial support to reduce the rate of infections ( HIV/AIDS-The Global Fund, 2014). In addition, the Global Fund ensures that all infected people in the world can access antiretroviral therapy. By last year, the fund had helped 6 million victims of HIV get access to ARV ( HIV/AIDS-The Global Fund, 2014).

Its efforts have largely depended on the realization that ARV reduces the chances of HIV transmission by close to 90%. The Global Fund concentrates its services and support in areas where the effects of HIV/AIDS are more prevalent. It looks for geographic and demographic information, making it easier to focus on certain countries and populations around the world. It mostly focuses on stigmatized groups such as women, girls, drug users, migrant workers and inmates.

Gates Foundation

The main objective of the Gates Foundation is “to reduce the incidence of HIV infection and extend the lives of people living with HIV” ( HIV, 2014, par. 4). The organization offers support to all the efforts of reducing worldwide transmission of HIV. It also helps the victims of the virus live long and healthy lives.

The organization mainly focuses on populations living in Sub-Saharan regions of Africa. HIV has greatly affected the population in these regions ( HIV, 2014). These regions are very poor and cannot afford HIV medication without support. The foundation gives grants to organizations that fight HIV. It also offers financial support to the Global Fund.

So far, it has given approximately $2.5 billion to organizations in all countries and $1.4 billion to the Global Fund ( HIV, 2014). The foundation also advocates sustainability and increase in funding programs that aim at reducing HIV/AIDS prevalence.

The fund also supports the search for a HIV vaccine. It invests in research that aims at coming up with the vaccine. It partners with private institutions, individual researchers and governments in researching on several types of possible vaccines. It also provides antiretroviral therapy and other products such as vaginal rings and injections to the victims.

In addition to other activities, the foundation provides tools for carrying out voluntary male circumcision in 14 Sub-Saharan countries ( HIV, 2014). It also supports efforts by governments and other private institutions to diagnose and measure the prevalence of HIV.

Clinton’s AIDS Initiative

The Clinton Health Access Initiative was established with the purpose of helping all victims of HIV get access to medication and reduce its cost ( HIV/AIDS , 2014). Since its inception, the number of people accessing HIV medication has risen from 200, 000 in 2002 to over 8 million today ( HIV/AIDS , 2014).

In addition, the cost of the treatment has fallen from $ 10, 000 to approximately $100. The initiative has partnered with many countries around the world in formulating programs aimed at fighting HIV/AIDS ( HIV/AIDS , 2014). The best example of such partnerships includes the partnership with Ukraine.

This partnership aimed at increasing the access to HIV/AIDS treatment. President Clinton and Preval’s agreement to expand HIV/AIDS services and strengthen health systems in Haiti and the partnership with UNITAID that focused on reducing the prices of important AIDS medicine were also part of this initiative ( HIV/AIDS , 2014).

The main goal of PEPFAR is to save many lives through upgrading existing strategies and supporting efforts by different countries to improve their people’s health ( The U.S. President’s Emergency Plan for AIDS Relief, 2014). In 2008, the president of America signed an act that authorized the use of $ 48 billion in the fight against HIV, malaria and TB.

PEPFAR also aims at promoting sustainable AIDS eradication programs ( The U.S. President’s Emergency Plan for AIDS Relief, 2014). This initiative also supports countries in responding to HIV because of the belief that fighting AIDS is more effective when countries take charge of their affairs ( The U.S. President’s Emergency Plan for AIDS Relief, 2014). PEPFAR also focuses on other challenges that come with HIV/AIDS such as stigma and opportunistic diseases.

Recommendation

The organizations should provide more material support compared to money since most countries misuse the funds they receive.

Many countries in the Sub-Saharan Africa are too poor to provide good preventive and treatment methods of HIV/AIDS to their citizens. Close to 18% of their population is infected with the virus.

This situation has prompted many private and international organizations to come to their rescue. WHO, PEPFAR, the Clinton’s Organization and the Gates Foundation have provided support in these regions for a long time.

Private and International organizations have been very supportive in the fight against HIV/AIDS. Many countries and individuals could not afford the HIV/AIDS prevention and treatment without the support of PEPFAR, WHO, Clinton’s AIDS Initiative, Gates Foundation and other organizations. These organizations have invested lots of money and material support in regions with the most prevalent cases of HIV/AIDS.

HIV/AIDS (2014). Web.

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1. IvyPanda . "Prevention and Treatment of HIV/AIDS." June 22, 2019. https://ivypanda.com/essays/prevention-and-treatment-of-hiv-aids/.

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• HIV and AIDS Prevention Among the Youth in Asia

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This volume demonstrates that the social sciences can contribute significantly to a better understanding of the complexities of the HIV/AIDS epidemic and to developing effective and appropriate prevention, care, and support programs in Sub-Saharan Africa during this time of stepped-up responses. Disciplinary blindness and biased research pursuing biomedical objectives, procrastination by some governments and the international community in responding to the epidemic in a timely fashion, and the vested interests of aid organizations contributed to discrepancies between national research agendas and the realities of HIV risk, impacts, and vulnerabilities and the needs of the African people. The lesson that is still being learned in some quarters is that most HIV prevention programs in Africa have failed mainly because biomedical researchers and administrations failed to adequately address the social, cultural, economic, and political context of HIV/AIDS and human sexuality. Where collaboration between the social and biomedical sciences was achieved, research results were not always considered in policies and interventions. For example, the global governance of HIV/AIDS still fails to take into account local perceptions, experiences, and responses to the disease, as noted by Getnet Tadele in the Introduction. These shortcomings are also apparent in the design and implementation of some programs at the local level in Sub-Saharan Africa, reflecting deeprooted traditions, perceptions, and practices that cannot be changed without adequate understanding of socioeconomic and cultural constraints affecting the participation of HIV-infected and affected people and communities.

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Mariam, D.H., Kloos, H. (2013). Conclusion. In: Vulnerabilities, Impacts, and Responses to HIV/AIDS in Sub-Saharan Africa. Palgrave Macmillan, London. https://doi.org/10.1057/9781137009951_13

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Essay on AIDS for Students and Children

500+ words essay on aids.

Acquired Immune Deficiency Syndrome or better known as AIDS is a life-threatening disease. It is one of the most dreaded diseases of the 20 th century. AIDS is caused by HIV or Human Immunodeficiency Virus, which attacks the immune system of the human body. It has, so far, ended more than twenty-nine million lives all over the world. Since its discovery, AIDS has spread around the world like a wildfire. It is due to the continuous efforts of the Government and non-government organizations; AIDS awareness has been spread to the masses.

AIDS – Causes and Spread

The cause of AIDS is primarily HIV or the Human Immunodeficiency Virus. This virus replicates itself into the human body by inserting a copy of its DNA into the human host cells. Due to such property and capability of the virus, it is also known as a retrovirus. The host cells in which the HIV resides are the WBCs (White Blood Cells) that are the part of the Human Immune system.

HIV destroys the WBCs and weakens the human immune system. The weakening of the immune system affects an individual’s ability to fight diseases in time. For example, a cut or a wound takes much more time to heal or the blood to clot. In some cases, the wound never heals.

HIV majorly transmits in one of the three ways – Blood, Pre-natal and Sexual transmission. Transfusion of HIV through blood has been very common during the initial time of its spread. But nowadays all the developed and developing countries have stringent measures to check the blood for infection before transfusing. Usage of shared needles also transmits HIV from an infected person to a healthy individual.

As part of sexual transmission, HIV transfers through body fluids while performing sexual activity. HIV can easily be spread from an infected person to a healthy person if they perform unprotective sexual intercourse through oral, genital or rectal parts.

Pre-natal transmission implies that an HIV infected mother can easily pass the virus to her child during pregnancy, breastfeeding or even during delivery of the baby.

AIDS – Symptoms

Since HIV attacks and infects the WBCs of the human body, it lowers the overall immune system of the human body and resulting in the infected individual, vulnerable to any other disease or minor infection. The incubation period for AIDS is much longer as compared to other diseases. It takes around 0-12 years for the symptoms to appear promptly.

Few of the common symptoms of AIDS include fever , fatigue, loss of weight, dysentery, swollen nodes, yeast infection, and herpes zoster. Due to weakened immunity, the infectious person falls prey to some of the uncommon infections namely persistent fever, night sweating, skin rashes, lesions in mouth and more.

Get the huge list of more than 500 Essay Topics and Ideas

AIDS – Treatment, and Prevention

Till date, no treatment or cure is available for curing AIDS, and as a result, it is a life-threatening disease. As a practice by medical practitioners, the best way to curb its spread is antiretroviral therapy or ART. It is a drug therapy which prevents HIV from replicating and hence slows down its progress. It is always advisable to start the treatment at the earliest to minimize the damage to the immune system. But again, it is just a measure and doesn’t guarantee the cure of AIDS.

AIDS prevention lies in the process of curbing its spread. One should regularly and routinely get tested for HIV. It is important for an individual to know his/her own and partner’s HIV status, before performing any sexual intercourse activity. One should always practice safe sex. Use of condoms by males during sexual intercourse is a must and also one should restrict oneself on the number of partners he/she is having sex with.

One should not addict himself/herself to banned substances and drugs. One should keep away from the non-sterilized needles or razors.  Multiple awareness drives by the UN, local government bodies and various nonprofit organizations have reduced the risk of spread by making the people aware of the AIDS – spread and prevention.

Life for an individual becomes hell after being tested positive for AIDS. It is not only the disease but also the social stigma and discrimination, felling of being not loved and being hated acts as a slow poison. We need to instill the belief among them, through our love and care, that the HIV positive patients can still lead a long and healthy life.

Though AIDS is a disease, which cannot be cured or eradicated from society, the only solution to AIDS lies in its prevention and awareness. We must have our regular and periodical health checkup so that we don’t fall prey to such deadly diseases. We must also encourage and educate others to do the same. With the widespread awareness about the disease, much fewer adults and children are dying of AIDS. The only way to fight the AIDS disease is through creating awareness.

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Aids Hiv - List of Essay Samples And Topic Ideas

The HIV/AIDS epidemic continues to be a pressing global health concern, affecting millions of individuals and communities worldwide. Essays could delve into the history of the HIV/AIDS epidemic, exploring its origins, spread, and the global response. The discourse might extend to the medical advancements in HIV/AIDS research, discussing the development of antiretroviral therapies, preventive measures like Pre-exposure prophylaxis (PrEP), and the ongoing efforts towards finding a cure. Discussions could also focus on the societal and economic impacts of HIV/AIDS, exploring the stigma, discrimination, and the financial burden associated with the disease. Moreover, essays could examine the policy responses, healthcare infrastructure, and public awareness campaigns aimed at combating HIV/AIDS and supporting affected individuals and communities. The broader global health context, the lessons learned from the HIV/AIDS response, and the implications for future global health challenges could also be discussed. We have collected a large number of free essay examples about AIDS/HIV you can find at PapersOwl Website. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

Infectious Diseases HIV AIDS TB and Malaria in Adolescents

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Acquired Immune Deficiency Syndrome

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AIDS – Major Issue in our Society Today

AIDS has been a major issue in our society today. It has created many problems for people, and has taken many lives. There was about 36.9 million people that were infected by AIDS/HIV in 2017 alone. Of this 36.9 million, 1.8 million of the infected were children. Most people do not typically think about how children can come into contact with the disease even though they do not know what it is. AIDS stands for Acquired immune deficiency syndrome. It […]

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The Human Immunodeficiency Virus

The Human Immunodeficiency Virus (HIV) attacks the CD4 cells of the body's immune system and weakens the defense mechanism from protecting against infections and diseases. As the number of CD4 cells decreases the body becomes more vulnerable to all opportunistic diseases and cancers. AIDS is the most advanced stage of HIV infection with severe immune deficiency i.e. least CD4 count (less than 200 cells/ cubic meter), it takes nearly 2 15 years for the virus to develop into this stage. […]

The Role of HIV in Serious Diseases

HIV/AIDS is a serious disease that can affect anyone if they are not careful enough to protect themselves. HIV is a virus that attacks the immune system, and without proper attention, it can completely destroy someone's immune system. This happens when the virus destroys a white blood cell called a CD4 cell, which is essential for fighting off infections. There are two types of these cells: the T4 cell, which helps fight the infection, and the T8 cell, which kills […]

The Prevalence of AIDS in Dominican Republic Haiti and U.S

""HIV, the infection that causes AIDS, is one of the world's most genuine general wellbeing challenges."" (Hiv.org) there were roughly 36.7 million individuals overall living with HIV/AIDS toward the finish of 2016. HIV is a human immunodeficiency infection which can cause (AIDS) which influences the cells of the safe framework, and crushes or disables their capacity, which makes it difficult to fend off contamination or sickness. There are a few distinctive courses about why HIV/AIDS is across the board far […]

Progress against AIDS

Many people today speak of a certain infamous group of symptoms known as AIDS. Though not many of these people know what it is from a pathophysiological perspective, they are all aware of its growing, lethal, and frighteningly ubiquitous reputation. AIDS is indeed known to the world as a dangerous syndrome with no known cure. With this being the case, one can imagine that medical researchers from all over the world have been working collaboratively for years to find ways […]

History of AIDS: Treatment Efficacy in 1990s North America

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First AIDS Outbreak in America

The first AIDS outbreak occurred in America in the 1980s and little attention was given to those who suffered from the disease. America had a severe lack of knowledge about its origins and how to treat it. The majority of ""the healthcare industry and the federal government ignored the epidemic as it emerged among gay men (Myers). With only one expensive drug available, coupled with unproductive clinical trials, a lack of funding, and society, including Reagan, ignoring the issue, the […]

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HIV/AIDS and the Surgery

In the past surgeries were used to kill people. Of course it wasn't done on purpose but the methods by today's standards were barbaric. Knowledge only came from speculation of the body and religious beliefs, none of which probably went through any type of scientific process or trial. Also, the methods were based on the written work of ancient physicians like Galen and everyone just stuck with it, because why doubt a famous and successful person? Only when new discoveries […]

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My patient is a 9 years old Hispanic female. She has a Sonicare Kid toothbrush. She does not use any mouth rinse or interdental devices. She brushes her teeth once a day for 30 seconds. She presents a Class I permanent dentition excluding all maxillary and mandibular 1st and 2nd molars not erupted yet. She presents a healthy and firm v shape interdental gingiva filling the interproximal area, which classifies her with Type I gingival embrasure. No presence of of […]

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AIDS and Accusation: Haiti and the Geography of Blame by Paul Farmer, and Unimagined Community: Sex, Networks, and AIDS in Uganda and South Africa bring the Western reader into a confrontation of largely ingrained belief systems regarding self, wellness, disease, one's place in economy and privilege, and the vast differences in outcome that social isolation, economic position, and culture can effect on disease management. Farmer's book was initially published in 1992 and published again in 2006. Thornton's book was published […]

Brazilian Infringement on AIDS Drug Copyright Theft or Philanthropy

In May 2007, Brazil issued its first compulsory license for an antiretroviral drug, efaviren, which is currently used by hundreds of thousands of Brazilians to treat and prevent HIV/AIDS. A compulsory license is a legal mechanism that allows a country to manufacture or buy generic versions of patented drugs while paying the patent holder only a small royalty. The patent holder, Merck, was strongly apposed to this breach in patent, and claim this is an unethical act that should be […]

Traditional Chinese Medicine for Treatment of HIV-AIDS

Background: Aids is a retrovirus which infects and kills T-cells, macrophages and dendritic cells. As these defense mechanisms are destroyed our immune systems are not as efficient, causing us to be more susceptible to infection and rendering us unable to fight off disease by destroying our adaptive immune system. AIDS is taking over the Middle East and is currently considered to be endemic in parts of Asia, China, and Southern Africa. Herbal remedies are frequently used by HIV-AIDS patients, as […]

Effect of Aids and the Impact on People

Do you know the effect of aids and the impact it has had on people? What makes it different from other STDs ?.Not many know the full extent to this disease or that the virus has actually been around since the 1920's. But the first recorded person was in 1980's. It is widely believed that aids came from in Kinshasa the Democratic Republic of Congo. Crossed from chimpanzees to humans. HIV was something new for people it was unknown and […]

AIDS in Bellevue Hospital

Located in the Kips Bay neighborhood on First Avenue, sits the oldest public hospital in the United States: Bellevue Hospital. Now affiliated with NYU School of Medicine offers a range of health services but its humble roots trace back to the city's first almshouse in what is now City Hall Park. The hospital is credited with many medical breakthroughs especially during the AIDS epidemic that raged throughout the nation. The doctors of Bellevue were one of the first forward thinking […]

HIV/AIDS – Virus that Attacks the Immune System

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Millions have been affected by this disease and numerous people remain unaware that they are HIV positive. This is frightening especially considering how advanced our country is in the medical field. Prevention and education are a major way to slow HIV spreading and increasing awareness will help with the pandemic. As seen with drugs like Narcan which helps counteract an opioid overdose, laws can be put in place to help people. Getting the preventative measures like pre-exposure prophylaxis or ""PrEP […]

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Today's society is plagued with diseases and issues that concern us all. One of the biggest problems officials around the world are having, and have been dealing with for a long time now, is the AIDS epidemic in Africa. This disease has claimed millions of lives and has devastated a large portion of the country. Although this issue is widely known, more needs to be done to stand in the way of it spreading. The medications are too expensive and […]

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Abstract It is believed to have originated in the Democratic Republic of Congo around the 1920s, until sixty years later they had no clue how many people had the disease or how many died from the disease. HIV was unknown and was not known how it transferred since it showed no signs or symptoms. By the 1980s HIV had spread to five continents and 100,000-300,000 people were already infected by it. Aids/HIV is a virus that spreads through your body […]

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Giving What We Can no longer conducts our own research into charities and cause areas. Instead, we're relying on the work of organisations including J-PAL , GiveWell , and the Open Philanthropy Project , which are in a better position to provide more comprehensive research coverage.

These research reports represent our thinking as of late 2016, and much of the information will be relevant for making decisions about how to donate as effectively as possible. However we are not updating them and the information may therefore be out of date.

The human immunodeficiency virus (HIV) infects cells of the human immune system, destroying or impairing their function. In the early stages of infection, no symptoms are apparent. However, as the infection progresses the immune system becomes weaker, and the patient becomes more susceptible to opportunistic infections such as Kaposi’s sarcoma or tuberculosis (TB). As many as 13% of new TB cases are also infected with HIV (WHO factsheet 2011).

The most advanced stage of HIV infection is called acquired immunodeficiency syndrome(AIDS). It can take 10–15 years for an HIV-infected person to develop AIDS; antiretroviral drugs can slow this process down even further.

HIV is transmitted through unprotected sexual intercourse, transfusion of infected blood, sharing of contaminated needles, and mother-to-infant transmission during pregnancy, childbirth and breastfeeding.[1]

According to WHO and UNAIDS estimates, 34.2 million people were living with HIV at the end of 2011. That same year, some 2.5 million people became newly infected, and 1.5 million died of AIDS-related causes. Of these deaths, 230,000 were children.

More than two-thirds of HIV infections are in sub-Saharan Africa.[2]

COST-EFFECTIVENESS

Though there is no known cure for HIV, antiretroviral treatment can substantially prolong patients’ lives. Standard antiretroviral therapy (ART) consists of the use of at least three antiretroviral drugs to suppress the HIV virus and stop the progression of the disease.

There are various methods of reducing the rate of HIV transmission, such as education on preventative methods and distributing and promoting condom use. This can be applied both to the general public and to specific groups such as sex workers.

We have been unable to find estimates of cost-effectiveness from the websites of charities that focus on HIV/AIDS. The DCP2 and WHO-CHOICE cost-effectiveness estimates are as follows:

In other words, according to these reports, it would cost $1000 to extend one HIV-sufferer's life for two years through antiretroviral therapy. [3] But the same $1000 could add a total of around 950 years of life to a population if spent on mass media HIV/AIDS education.[4]

The cost-effectiveness estimate for mass media education from WHO-CHOICE is the most favourable we have come across. However, we are unsure how much confidence to place in this figure: while it is plausible that mass media education could be an extremely cost-effective intervention, there is at least some countervailing evidence.[5]

Peer support education for high risk groups is also extremely impressive, but it too should be treated as only a rough estimate.

Other information

Side-effects.

Positive side-effects of the treatment and prevention of HIV/AIDS include:

• A decrease in the incidence and transmission of other diseases, such as TB.
• Prevention strategies for HIV/AIDS can also help to prevent other sexually transmitted diseases.
• Reducing the prevalence of HIV/AIDS has far-reaching socioeconomic benefits.

Education appears to be the most effective way to reduce the number of people who will suffer and die from HIV/AIDS. While we can't place a great deal of confidence in the WHO-CHOICE figures, if these are correct to within even an order of magnitude then peer education programmes for sex workers and, especially, mass media education, are hugely cost-effective.

Unfortunately, we have been unable so far to find charities that focus on or dedicate a significant amount of their resources to mass media education or education of high-risk groups. We therefore currently have no recommended charities for HIV/AIDS.

• WHO summary of HIV/AIDS .
• WHO online Q&A on HIV/AIDS .
• Using a figure of $500 per DALY, with a disability weight for HIV of 0.135.
• Using a figure of $1.25 per DALY, with a disability weight for HIV of 0.135.
• Jane Bertand et al. , 2006. 'Systematic review of the effectiveness of mass communication programs to change HIV/AIDS related behaviours in developing countries' , Health Education Research 21:567–97.

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• Published: 15 May 2024

Trend and principal components of HIV/AIDS among adults in SSA

• Bayuh Asmamaw Hailu 1  

Scientific Reports volume  14 , Article number:  11098 ( 2024 ) Cite this article

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This study aimed to identify the most important principal components (PCs) that contribute to the prevalence and change of HIV/AIDS in 44 SSA and data from different national and international datasets. The study estimated HIV prevalence, trend, and principal component analysis (PCA). Using the elbow method, the number of important PCs and contributions was identified. The quality of representation was checked, and more contributing variables for most important PCs were identified. Finally, the status by prevalence, the progress by trend, the more influenced component by PCA, and the more influenced variable with quality of representation by PCs were reported. The study found that HIV prevalence varied significantly, with 30 of the countries showed good progress/decline. Four PCs accounted for 51% of the total variance. Literacy, cohabitation, media exposure, and HIV status awareness are highly contributing factors. Based on these findings, a gap-based response will help reduce the burden of HIV.

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Introduction.

Since the beginning of the first decade of the twentieth century, there have been several landmark events in global efforts to advance HIV/AIDS response. These include the Ryan White Comprehensive AIDS Resources Emergency in 1990 1 , the red ribbon symbol of AIDS in 1991 2 , the establishment of The Joint United Nations Programme on HIV/AIDS in 1996 3 , antiretroviral therapy was introduced in 1996 4 , goal was set to halt the spread of HIV/AIDS by 2015 5 , the President’s Emergency Plan for AIDS Relief was launched in 2003 6 .

In 2015, the world delivered on the AIDS targets of Millennium Development Goal 6—halting and ensuring healthy lives 7 and promoting well-being for all at all ages 8 . In 2016, The United Nations General Assembly adopted the Political Declaration on Ending AIDS, which set new targets for 2020 and 2030 9 . In 2018, UNAIDS launched the “Miles to go—closing gaps, breaking barriers, righting injustices” report, which highlighted the progress made in the global response to HIV/AIDS and identified areas where more work is needed 10 . In 2019, the World Health Organization (WHO) recommended that people at high risk of HIV infection should be offered pre-exposure prophylaxis 11 . In 2020 and 2021, there were many long efforts to end the HIV epidemic globally and domestically 12 . However, in 2022 UNAIDS said that we are “IN DANGER” 13 .

Globally, HIV infection has declined annually from 2010 to 2022. However, around two-fifths of the region experienced an increase in HIV infection 14 . Sub-Saharan Africa (SSA) is home to two-thirds of all people living with HIV globally and is the hardest-hit region in the world 14 . While HIV varies across countries 15 , 16 , 17 and within countries 18 , 19 , this heterogeneity has been explored to some extent. Each community contributes to a specific component, and the factors that influence each community more than their neighbors, the progress over time potential components and influenced variables on the most relevant components do not have been explored at all. This work clearly shows the prevalence, change over time, each community/variable contribution for the specific component, and the highly influenced variable in each component by community. Due to culture, economy, and other reasons, the way of response differs from one area to another area. Programmers, policymakers, and other concerned bodies can make more reduction efforts based on their problem. This analysis clearly showed what the progress is, where is the problem more happening and what the potential reason is clearly set.

The objective was to identify and obtain individual/community-level data from all repeated nationally representative Demography and Health Survey (DHS), Malaria Atlas Project, NASA Socioeconomic Data and Applications Center (SEDAC), Global Health Data Exchange (GHDx), and sentinel surveillance of antenatal care clinics (ANC data) that included information on HIV/AIDS status and/or other intervention areas. A maximum of 44 countries were included based on conditions, reducing some countries in some analyses. For example Zimbabwe included in the trend, PCA, community, and national prevalence. South Sudan, Mauritius, Equatorial Guinea, and Botswana included only in national prevalence analysis but not included in other analysis.

(Supplementary Figs. 1 , 2 ).

For HIV analysis, data from DHS and GHDx were used 20 , 21 , which are highly comparable and nationally representative. DHS is one of the main publicly available sources of information for low-income and middle-income countries. Given their focus on adult HIV tests, these surveys target both women and men aged 15–49 years. SSA was selected because most of the countries have conducted at least one HIV test result or geospatial coordinate, and 15 of them collected data from 2015 to 2021 by DHS, almost all of them estimated by GHDx in 2018, and in 2021 by ANC sentinel 22 (Supplementary Figs. 1 – 3 ; Supplementary Table 1 ). The ethical responsibility for all data sources included in this study lies with the institutions that conducted the surveys in each country; therefore, ethics approval for this study was not required.

Data management and analysis

This analysis presents community-based prevalence from 2015 to 2021, country-level prevalence in 2021, and the change over time from 2000 to 2018 (some countries extended to 2021) in Sub-Saharan Africa. The period of 2000–2021 and the age group of 15–49 years were selected to maximize data availability, and most countries’ data sources focus on the 15–49 years age range as the most commonly reported age range. Trend in the form of regression ordinal logistic models were implemented. In this analysis, the data is converted into the prevalence of enumeration areas or communities but for this purpose converted to an ordinal model. Cluster-level HIV prevalence was recategorized into quartiles, where the first quarter is the lowest prevalence and the fourth quarter is the highest prevalence.

For Principal Component Analysis (PCA), only countries that had standard DHS data with GIS coordinate/shape file data information at least once since 2012 were included. Based on DHS coordinate data, extract the cluster value from other sources of data.

This analysis used community-based geographic coordinates (point) data rather than polygon (administrative areas) for HIV prevalence analysis. In point data, the value of HIV prevalence is shared country to country across the border. For this reason, the different years of data collection of each country could be influenced by other neighbors. To control the time variation of data collection, I adopted the country in which HIV test data was collected since 2015 from DHS and the rest from the 2018 GHDx. The country-level prevalence is data from sentinel surveillance of antenatal care clinics (ANC data). ANC data were primarily derived from national HIV estimate files developed by national teams and compiled and shared via UNAIDS. Therefore, I used final UNAIDS compiled data of 2021 22 . For change over time, used both DHS and GHDx data. For community-based change over time, I used GHDx raster data of 2000, 2005, 2010, and 2018. For country-based trend (change over time) regression analysis, all DHS datasets since 2000 which have HIV test results included were used. If the country did not have data or enough data within the 5 years of interval extracted from GDB raster data based on the most recent GPS coordinates of DHS (Supplementary Fig.  4 ).

This analysis included 27 pre-existing covariates from different sources, such as DHS 20 , Atlas Malaria project 23 , 24 , 25 , NASA socioeconomic data 26 , 27 , 28 , 29 , 30 , 31 , and GHDx 32 . Extracting the important information from multivariate data from different datasets to express this information as a set of few new important variables and the most important variables helps combat HIV and other similar problems to achieve 2030 goals. For this analysis, PCA was used. For PCA analysis, variables from DHS individual-level variables changed to community prevalence, and variables from other sources were extracted based on those community-based coordinate datasets. In general, 19,546 point data from 34 countries with 27 variables from four different datasets were extracted (Supplementary Fig.  2 ; Supplementary Table 1 ).

Due to the sensitivity of PCA for outliers, the outlier is identified using a boxplot. It is treated by replacing the outlier with a value that is close to the outlier but not as extreme (winsorization). If the outlier is extreme and cannot be treated by the winsorization method, first reduce the effect by using log transformation and finally use winsorization (Supplementary Fig.  3 ).

All variables are continuous but the effects were found in different dimensions. Some variables are disadvantaged by lower values, while others are inverse. To control this problem and put it into the same dimension (more negatively influenced by higher value), it is transformed by multiplying -1. The variables were from different sources and had different units of measurement. Due to this reason modifies by harmonizing its variability in all directions of the original vectors or standardizing the variables.

To obtain the results of PCA, the eigenvalues/variance and its percent obtained in each principal component are extracted and visualized. The eigenvalues are plotted according to their size (scree), and the elbow point is identified, which is the point where the slope of the graph goes from steep to flat. The components before the elbow are kept, which is determined by looking at an elbow shape of Scree Plot, which is the plot of eigenvalues ordered from largest to smallest 33 , 34 , 35 .

The quality of representation (cos 2 ) of both variables and observations/clusters to each PCs were identified. The contributions of variables and clusters in accounting for the variability in a given PCs are expressed. The most significantly associated variables (according to their contributions) with a given principal component are identified by dimension description. All flow from data extraction to data analysis see the flow chart in the supplementary material (Supplementary Fig.  4 ).

This analysis do not use of experimental animals, or human participants and I use only global/national open source data. So, institutional and/or licensing committee approval for this study was not required.

Analyses were conducted using STAT for data management R for statistical computing (Outlier, PCA, graph, regression), and SAGA and QGIS (Interpolation).

Ethical approval

The utilized DHS data sets are publicly available, and the DHS Programme de-identifies all data before making them available to the public. All other geospatial data sources and DHS do not contain variables at the level of human subjects. Therefore, this work did not require ethical approval.

HIV prevalence varied significantly at the community level and among countries throughout Sub-Saharan African countries. This variation indicated that every country had both edges of HIV prevalence within their communities or grid cells. Within countries, some had a relatively high overall HIV prevalence (e.g., Lesotho, Botswana, and South Africa). Out of 44 countries, except 10 countries have shown good progress or decline in HIV prevalence since 2000 (Fig.  1 ; Supplementary Figs.  5 – 7 ).

HIV trend in SSA. HIV change over time of each countries by year multilevel logistic regression compared by crude odds ratio (COR). To conduct this analysis use R version 4.3.2, available at: https://cran.r-project.org/bin/windows/base/ .

In Sub-Saharan Africa, HIV has declined the risk of transition to high severity from the beginning of the first decade of the twenty-first century to the end of the second decade of the twenty-first century. In most countries, decline occurred over time (e.g., Benin, Burkina Faso, Burundi), and in 10 countries it coincided with an increased risk of HIV moving from lower severity to higher severity in the recent time period (e.g., Angola, Lesotho). Some countries like Mali had lower prevalence; the trend indicates increased HIV severity since 2000. Some countries more infected by HIV like South Africa and Lesotho showed increased over time. Change over time based on each grid cell HIV prevalence in Sub-Saharan Africa showed that the change between the first decade of the twenty-first century at the beginning and the end had better achievement compared to the change between the second decade of at the beginning and the end. The southern part of Sub-Saharan Africa was a reverse achievement. Most countries continue as it has neither declined nor increased especially in the second decade of twenty-first century. The southern Sub-Saharan Africa in recent decades is good compared to the first decade but still showed a higher increment in recent decades (Fig.  1 ; Supplementary Figs. 5 – 7 ).

The outcome measurement survey’s construct validity was calculated using PCA. According to PCA, the total of four principal components (PCs) could account for 51% of the total variance (based on the elbow method). The first component expresses 26.41% of data variability, which is 2.66, 3.44, and 3.8 times more variables than the next three components, respectively. The first two components represent 36.32% of the data (Fig.  2 ; Supplementary Table 2 ).

Eigenvalues/variances of principal components. Proportion of information retained by the top ten principal component.

The list of variables that quality of representation was checked the most to the first or most influenced component were literacy, cohabitation, media exposure, HIV status, negotiating sex, MER, GDP, stigma, and PPT. These variables contributed 8.9%, 7.62%, 6.99%, 6.77%, 6.53%, 6.47%, 5.74%, 5.21%, and 5.16%, respectively. Literacy alone contributed 8.9%. In the second most influenced component, the number of partners excluding spouse, number of sex partners, PPT, city, MER, GDP, and disaster were the more contributing variables that accounted for 12.65%, 11.31%, 10.61%, 8.96%, 8.36%, 6.57%, and 6.36%. For the third more likely influenced component male circumcision, housing, migration, stigma, HIV test, and mother to child transmission knowledge were contributing variables that accounted for 19.58%, 10.05%, 9.57%, 8.77%, 8.7%, and 6.45% respectively. Working status (15.09%), food insecurity (14.54%), number of sex partners (10.74%), STI (10.33%), and age at first sex (8.34%) contributed to the fourth component. Those variables contributed about two thirds of the corresponding component (Fig.  3 ; Supplementary Figs. 8 , 9 ; Supplementary Table 3 ).

Variable contribution and Quality of representation for the selected first 4 PCs (Dim) in left and right panel respectively.

The quality of representation of a variable in each principal component is well represented by the principal component. In every principal component separately, the high percentage of variable contributions has high quality of representation by principal components. Almost all the variables listed above contributed to the first component, and male circumcision in the third component was highly represented by its principal component (Fig.  3 ; Supplementary Fig.  10 ; Supplementary Table 4 ).

The list of communities/clusters that contributed the most to the first or most influenced component were the Northern part of West Africa and most areas of DR Congo, Ethiopia, and South Africa. Communities from all areas of Gabon and Southern African countries except the North East direction of South Africa, some areas of Cameroon, Senegal, Nigeria, and Liberia were highly contributing to the second most principal components. The third most influenced components were highly contributed to by Mauritania, Rwanda, Burundi, countries in the southern part of East Africa and northern parts of South Africa, and some countries like Ivory Coast. In the fourth most influenced components, highly contributing communities were the Northern edge of West Africa, most areas of Sierra Leone, Liberia, Mozambique, Madagascar, Kenya and Ethiopia and some areas of other countries like Angola and DR Congo (Fig.  4 ).

Communities’ contribution of for the selected first 4 PCs (Dimensions). To conduct this analysis use QGIS version 3.28.15 with SAGA GIS version 7.8.2, available at: https://download.qgis.org/downloads/ .

The quality of representation of a cluster/community in each principal component is well represented by a principal component. In every principal component separately, the high percentage of community contributions has high quality of representation by principal components (Supplementary Fig.  11 ).

The four most significant variables contributing to the most important principal components were literacy, cohabitation, media exposure, and HIV status awareness. Most Western SSA and some Eastern SSA countries had a higher prevalence of communities unable to read and write. Except for southern SSA countries, the rest are living with the problem of being unable to read and write. The second most important variable was marital status. Most Western SSA countries of their community pass on unstable lives with partners. That means a higher percentage of the community is either divorced, widowed, or separated. The third important variable that contributed to the first principal components was media exposure. Most communities in central and some areas of Western and Eastern SSA did not have access to radio, television, and newsletters. The fourth was awareness of HIV status. Almost all countries in Western and Central SSA, Madagascar, and some areas of Ethiopia did not know their HIV status (Fig.  5 ).

The prevalence of the most important variables highly contribute for the first most important component.

The four most significant variables contributing to the second most important principal components were the number of partners excluding spouse, number of lifetime sexual partners, PPT, and accessibility cities. Almost all communities of Southern SSA, Gabon, Cameroon, and Liberia from Western SSA had at least one partner excluding a spouse. Most communities in all areas of Northern, Central, and Eastern SSA except Tanzania, Uganda, Ethiopia and Kenya in the direction of Ethiopia, Western edge of West Africa Gabon to Sera Lion had more and more number of sex partners. Except South Africa, Rwanda, Burundi, Uganda, Nigeria, and some areas of Benin, Togo, Ghana, Ivory Coast, Ethiopia, Kenya, and Angola were under the economic productivity and standards of living or lower productivity and growth. All areas of Mauritania, Chad, Madagascar, Namibia and Gabon, and some areas of Northern part of West Africa, D.R. Congo and others were talking a long time to travel time to cities to assess inequalities in accessibility (Fig.  6 ).

The prevalence of the most important variables for the second most important component.

Since the first decade of the twenty-first century, the global community has been working to combat HIV and AIDS. The United Nations Security Council and the U.S. President’s Emergency Plan for AIDS Relief took different actions to respond to HIV and AIDS globally 36 , 37 , 38 . Thanks to an uninterrupted effort on access to antiretroviral therapy, HIV-positive people now live longer and healthier lives and prevent onward transmission, leading to a decline in HIV prevalence and death.

The global community has set interim targets for 2020 and 2025 to help achieve the goal of ending the AIDS epidemic by 2030. The 2020 targets for a declined number of newly infected and AIDS-related deaths were missed 39 , and this target is extended to 2025 with some improvement in reducing the burden 40 , 41 . Considering UNAIDS 2022 14 , achieving the 2025 target will be challenging. We are in the mid-year of the second interim target and now need to take more important action to achieve the target or reduce the gap. This work contributes to showing the path that ends AIDS. Not only does it contribute to HIV/AIDS efforts, but it also contributes to achieving other SDG goals by identifying present analysis and potential for future directions.

The proportion of HIV has declined over time in Sub-Saharan Africa (SSA) and fallen in most countries but increased in others. These analyses show substantial differences between and within countries in levels and trends in HIV prevalence and the spatial distribution of communities living with HIV. Some countries as well as their communities with high prevalence have increased since the beginning of the first decade of the twenty-first century 42 .

Most communities that contributed to PC1 were found in West Africa, D.R. Congo, Ethiopia, and the Northern part of South Africa. Most areas of West Africa had a higher prevalence of communities unable to read and write and did not know their HIV status. In East parts, there was an additional higher rate of being unable to stay in marriage and low access to media. Most areas of Central and Eastern SSA, especially D.R. Congo, Madagascar, and Ethiopia, had lower media exposure and awareness of HIV status. Efforts on those more significant variables in Western, Central, and Eastern SSA can reduce the gap of SDG goals and achievements not only in HIV/AIDS but also with other most SDG goals.

Most communities that contributed to PC2 were highly infected by HIV. In these areas, the community has more lifetime sexual partners even if they had partners exposed to more additional partners for sexual purposes. In SSA, reductions in the numbers of new HIV infections have been modest. Compared to other regions, SSA is home to new HIV infections 14 . For effective new HIV reduction working related to sexual intercourse is predominant. For HIV reduction hotspot of SSA there are the underline areas of intervention for tangible response were sexual-related problems.

This sexual-related problem not only in Southern SSA but also in Western SSA cannot be shown in response to PC1 Central Africa and Northern part of Eastern SSA including Madagascar. The other possible influencing factors in SSA were economic problems. Throughout all SSA countries except South Africa, some part of West Africa in the location of Ghana and its neighbor, and some part of East Africa showed a lack of economic growth and standards of living in different countries with a common currency/basket of goods and travel time to cities to assess inequalities in accessibility.

The diversity seen in permutations of levels of literacy, cohabitation, media access, HIV test, more sexual intercourse partners, and economic situation has led to considerable variations in ways in which different countries are addressing and meeting the targets. This analysis used for policy response can be used for effective HIV response. Additionally, this effort can be used for other SDG goal responses in parallel.

Limitations

This analysis has several limitations. First, some SSA countries do not have data with DHS and are not included in this analysis. The data source is from different open-source datasets, and data collection time is varied. Some covariates of the surveys, potential non-response bias, and recall bias are particular concerns 43 . The covariate may also be suboptimal in some situations, such as age at first sex 44 . The surveys rely on self-reported data, which may be subject to recall bias or social desirability bias for covariates. Finally, the surveys may not be representative of certain subgroups of the population, such as those living in remote areas or those who are not included in the sampling frame 45 . Due to this reason, unmeasured communities are predicted by the result of the nearest neighbor community.

Data availability

The data that support the findings of this study are available from the DHS ( http://www.measuredhs.com ), NASA Socioeconomic Data and Applications Center (sedac) ( https://sedac.ciesin.columbia.edu/ ), GBD/GHDx ( https://ghdx.healthdata.org/ihme_data ), Malaria Atlas Project ( https://data.malariaatlas.org/trends?year=2020&metricGroup=Malaria&geographicLevel=admin0&metricSubcategory=Pf&metricType=rate&metricName=incidence ), and UNAIDS ( https://www.unaids.org/en/resources/documents/2021/2021_unaids_data ). All data sources are publicly accessible except for the Department of Homeland Security (DHS), which necessitates a formal request. Therefore, data are available from the corresponding author (Bayuh Asmamaw Hailu) upon reasonable request.

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The author expresses their gratitude to all data sources for allowing them to use their archives to obtain the data set of 44 Sub-Saharan African countries.

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Bayuh Asmamaw Hailu

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Hailu, B.A. Trend and principal components of HIV/AIDS among adults in SSA. Sci Rep 14 , 11098 (2024). https://doi.org/10.1038/s41598-024-55872-2

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Criminalisation of homosexuality undermines HIV testing in sub-Saharan Africa

Gay and bisexual men living in sub-Saharan countries where homosexuality is legal were twice as likely to have ever tested for HIV compared to those where homosexuality is illegal. Targeted HIV policies for this key population were associated with a more than two-fold increase in HIV testing, compared to countries with no such policies.

Twenty-six sub-Saharan African countries currently have laws that criminalise homosexuality, ranging from fines to the death penalty. HIV prevalence among gay and bisexual men in this region is five times higher than for the general population. However, in many instances, this key population is not prioritised in national HIV strategic plans and targeted HIV policies are lacking.

The adoption of the World Health Organisation’s (WHO) guidelines on HIV prevention and management among key populations, such gay and bisexual men, has been slow in the region. Furthermore, very few African countries are on track to achieve the first UNAIDS 95 goal by 2030: that 95% of all people living with HIV know their HIV status.

Countries that criminalise same-sex relationships were previously found to have poorer HIV outcomes , both in terms of knowledge of HIV status and viral suppression among those living with HIV.

key populations

Groups of people who are disproportionately affected by HIV or who are particularly vulnerable to HIV infection. Depending on the context, may include men who have sex with men, transgender people, sex workers, people who inject drugs, adolescent girls, prisoners and migrants.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the resources of ten United Nations organisations in response to HIV and AIDS.

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

odds ratio (OR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

Using data from an anonymous online survey and policy information about each country, researchers considered how HIV testing among gay and bisexual men was impacted by both criminalisation of same-sex relationships and the presence or absence of targeted HIV policies for this key population in 44 sub-Saharan African countries.

Responses from men living in sub-Saharan African countries who participated in the 2019 Global LGBTI Internet Survey were included. This recruited adult self-identified LGBTQ participants through community networks and online advertisements on dating apps, WhatsApp, Facebook and other platforms. The survey was offered globally in 32 languages by UNAIDS and other partners.

At the country level, additional factors were considered. These included HIV epidemic type (concentrated among specific key populations or generalised, where HIV prevalence in the general population is higher than 1%) and funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR).

A total of 3,191 adult HIV-negative gay and bisexual men participated in the anonymous online survey, providing demographic information and two self-reported HIV testing measures: whether they had ever tested for HIV, and whether they had done so within the past 6 months. The age category for just under half of the sample was 25 to 34, with most men identifying as gay (71%) or bisexual (24%). Most had either completed high school (40%) or had a university education (53%), and lived in large cities (60%).

Same-sex relationships were legal in only 19 of the 44 countries (43%). Just over a quarter of the countries had met the first 90 90 90 target, with 90% of all people living with HIV diagnosed. Most of the countries (31) had generalised HIV epidemics and just over half received PEPFAR funding.

While the national HIV policies of 32 countries included some form of targeted intervention for gay and bisexual men, none included all the WHO-recommended interventions for gay and bisexual men. For instance, while all 32 included condom provision for gay and bisexual men, only 23 provided lubricants for condom use. Nineteen countries included provisions for community-based HIV testing and counselling, while only eight provided guidance on harm reduction interventions.

Overall, 86% of the 3,191 survey participants reported ever testing for HIV, while 66% indicated recent testing. There was strong evidence of a positive association with having ever tested for HIV and the legal status of same-sex relationships, with a 6% increase in ever testing among those in countries where homosexuality was legal. The effect of targeted HIV policies was even stronger: a 14% increase in ever testing among men in countries that provided some form of targeted HIV interventions, compared to those that did not.

For testing in the six months prior to taking the survey, only legal status of homosexuality showed an association: a 3% increase in recent testing for men living in countries where homosexuality is legal.

When accounting for individual-level factors such as income and education that may impact a behaviour such as HIV testing, this pattern still held true for the influence of country-level factors on having ever tested for HIV, but not for recent testing. Thus, men living in countries where homosexuality is legal were twice as likely to have ever tested for HIV (Odds Ratio = 2, 95% Confidence Interval: 1.04 to 3.82) and nearly two and a half times as likely to have ever tested in countries with targeted HIV policies (OR = 2.49, 95% CI: 1.12 to 5.52).

Notably, South Africa stood out among sub-Saharan African countries. It is the only country in the region to have constitutional protections against LGBTQ discrimination, and legal same-sex marriage. This is in stark contrast to some of the other countries included in the analyses, indicating the vast differences in human rights LGBTQ people have in the sub-Saharan African region.

“ Enabling legal and policy environments appear to be important structural factors in shaping the ability of men who have sex with men to initially engage with testing services in sub-Saharan Africa,” conclude the authors.

While these discriminatory laws and policies may not be so important for recent testing, experiences of homophobia and stigma at health facilities and stress may influence men’s decisions about coming back for sexual healthcare services when needed.  HIV vulnerabilities in gay and bisexual men are also influenced by individual socioeconomic factors, such as low educational attainment and poverty, although to a lesser extent than the legal climate, say the authors.

Kalu N et al. Association of same-sex criminalisation laws and national HIV policies with HIV testing in African MSM: an ecological single-level and multilevel cross-sectional study of sub-Saharan African countries . Sexually Transmitted Infections 100: 150-157, 2024 (open access).

https://doi.org/10.1136/sextrans-2023-055964