CHAPTER 1
• The birth of a new epidemic
- In June 1981, the CDC (Centres for Disease Control and Prevention) reported the occurrence of a rare
pneumonia (Pneumocystis pneumonia or PCP) and a rare cancer, (Kaposi's sarcoma), in 5 homosexual men
in LA.
- Initially thought to only affect homosexuals, it was later diagnosed in haemophiliacs, drug users, and
Haitian immigrants in the USA. The disease was later identified in central Africa.
- This disease which compromised the immune system- severe diarrhoea and weight loss, the disease was
referred to as ‘slim disease’ in Africa.
- Disease was named Aids or acquired immunodeficiency syndrome. - Dr. Luc Montagnier and scientists in
Paris isolated a virus in a patient with lymphadenopathy (swollen lymph nodes).
- Initially, the virus was labelled lymphadenopathy-associated virus or LAV. Now called human
immunodeficiency virus (HIV).
- Aids was first reported in South Africa in 1983 and was initially associated with homosexual men,
haemophiliacs, and blood transfusions. However, HIV spread rapidly in the 1990s, particularly in young
women and older men.
Aids: acquired immunodeficiency syndrome
*Acquired: not inherited. caused by a virus that is outside the body that finds its way into the body.
*Immunodeficiency: inability (or deficiency) of the immune system to defend itself against infections.
*Syndrome: describes signs and symptoms that occur which characterise a particular condition.
Aids is caused by HIV. HIV destroys the body’s ability to fight off infection and disease, which leads to death.
Antiretroviral therapy slows down replication of the virus and can enhance quality of life but doesn’t
eliminate HIV infection.
• The origin of HIV
- Early theories suggested that Aids had been present in central Africa for centuries but remained
unidentified due to lack of diagnostic facilities.
- Some theories blamed the polio vaccine for Aids, claiming it caused the disease due to cell cultures from
the kidneys of the African green monkey.
- Anti malaria medication was also a potential cause.
- Eventually, none of these theories were correct, but the theory that the virus crosses the species barrier
from primates (more specifically, simians) to humans was correct.
• Crossing the species barrier
- HIV and SIV (simian immunodeficiency virus) are found in primates.
- Different SIV strains may have crossed the species barrier to humans, causing different HIV strains.
- HIV-1 group M virus likely originated from interspecies transmission from chimpanzees to hunters (hunter
was either bitten while hunting or cut while butchering the animal).
- Different groups and subtypes which predominates in different parts of the world.
- Group M virus, part of HIV Type 1, dominates the current AIDS epidemic.
- HIV-1 subtype C is currently dominant in South Africa and Southern Africa.
• Urban legends
- Urban legends and conspiracy theories about HIV often blame groups, organizations, or government
agencies.
,- Examples include the FBI's development of the virus to destroy 3rd world countries, it was developed by
the apartheid government, or a New Age movement aiming to destroy a specific population.
- These myths are often rooted in fear and serve to make people feel powerless.
• The global Aids epidemic
- In 1996, HIV spread peaked with 3.5 million new infections worldwide.
- Two decades later, the number of new infections is estimated at about 2 million per year, a 43%
decrease.
- Aids deaths have significantly decreased due to the scale-up and wider accessibility of antiretroviral
therapy.
- Sub-Saharan Africa is the worst-hit region, with nearly 70% of HIV infections occurring in this region.
• HIV incidence
- HIV incidence is the no. of new HIV cases in a specific time period (usually in one year), presented as a %.
- Calculated by dividing the no. of new infections by the no. of previously uninfected people.
- HIV incidence is difficult to measure.
- Longitudinal studies are necessary to observe a group of HIV uninfected people over a specific time
period.
- Estimates are often obtained through mathematical and statistical modelling.
• HIV prevalence
- Defined as the percentage of people living with HIV in a specific population. expressed as a %.
- Described as a snapshot view of the current HIV infection rate.
• How is HIV prevalence measured?
- National HIV prevalence estimates are based on antenatal (pre-birth) prevalence surveys, population and
community-based surveys, studies among key populations at higher risk, and reports of Aids-related
deaths.
- The antenatal surveillance program involves annual testing of blood of pregnant women in the public
health sector. The surveillance is anonymous and blood samples are tested for HIV and herpes simplex
type-2.
- The National HIV Prevalence, Incidence and Behavioural surveys, conducted every three years, involve
testing of blood samples of individuals in households.
- Surveys also provide information on behavioural aspects like condom use, circumcision, sexual debut, and
HIV status awareness.
- National household surveys provide the prevalence of HIV in terms of sex, age, race, and geographical
areas.
• The world’s response to the Aids epidemic
- The world’s initial response to the Aids epidemic was denial, blaming, and moralizing.
- Aids was seen as a 'gay disease' affecting homosexuals.
- Haemophiliacs became infected, dividing the world into 'innocent victims' and 'promiscuous guilty'.
, • South Africa’s response to the Aids epidemic
❖ Inaction and denialism
- The apartheid government viewed Aids as a 'gay' disease, leading to distrust and blame.
- The first Aids Advisory Group was established in 1985, and Aids Training and Information Centres (ATICs)
were introduced in 1991.
- The National Aids Convention of South Africa (NACOSA) was created in 1993, a coordinating body
between apartheid government and anti-apartheid Aids activists.
- Nelson Mandela's government faced numerous challenges, leading to inadequate attention to Aids and
its co-infectant, TB.
- The government's failure to provide AZT to pregnant women in South Africa, despite its success in the
USA, led to an increase in HIV infection rates.
- The Treatment Action Campaign (TAC), led by Zackie Achmat, was established to advocate for HIV
treatment rights.
❖ Our darkest days
- The Mbeki era marked South Africa's worst response to the Aids epidemic.
- The president linked with Aids dissidents who believed Aids was not caused by HIV.
- The minister of health, Manto Tshabalala-Msimang, refused to approve antiretroviral treatment for
pregnant women.
- In 2002, the South African High Court ordered the government to provide nevirapine to prevent mother-
to-child HIV transmission.
- In 2003, the government provided free antiretroviral therapy to all South Africans who visited public
health services.
- Manto Tshabalala-Msimang supported untested and unlicensed 'vitamin' supplements as a cure for Aids.
She also supported vegetables (beetroot, garlic, and lemon) as an alternative for ARV's
- Thabo Mbeki resigned in 2008, and Jacob Zuma took over in 2009.
❖ A new beginning?
- Jacob Zuma, implemented the 5-year National Strategic Plan for both Aids and TB.
- Zuma announced interventions to improve access to antiretroviral therapy for special groups, aiming to
decrease disease burden, improve life expectancy, and address child and maternal mortality.
- New clinical guidelines for managing HIV and Aids in adults, adolescents, and children were implemented
- A major HIV counselling and testing campaign was launched in 2010
- From January 2015, South Africa started treating HIV-infected people earlier than previously, starting ARV
treatment at CD4+T cell counts of less than 500.
- The South African Government removed CD4+T cell count as an eligibility criterion for ARV treatment in
2016.
- The government announced PrEP (pre-exposure prophylaxis) for sex workers participating in sex worker
programmes.
- In 2015, the Medicines Control Council officially registered the use of the antiretroviral drug Truvada® as
PrEP (pre-exposure prophylaxis), which will decrease the chances of HIV-negative people contracting HIV.
• The difference between key populations and vulnerable populations
- Use 'key populations at higher risk' instead of 'high risk groups'.
- 'Key populations' vary across countries.
, - 'key populations' include sex workers, men who have sex with men (MSM), and young women.
- Key populations are crucial to epidemic dynamics and response. (A key response to this situation is
approval of ARV drug Truvada to protect sex workers).
- HIV key populations and vulnerable populations differ; vulnerable populations are influenced by societal
pressures or social circumstances that may make them more vulnerable to exposure to infections.
• Positive worldwide responses
- HIV has led to extensive research and development in the field of HIV and its prevention and treatment.
- AZT was recommended to pregnant women in the USA to reduce HIV transmission from mother to child.
- combination antiretroviral treatment (HAART) was introduced, leading to a decline in HIV-related deaths
in developed countries.
- The '3 by 5' initiative by WHO and UNAIDS aimed to place three million people in low- and middle-income
countries on antiretroviral treatment by 2005.
- Despite not reaching this goal, efforts were made to improve access to treatment
- Efforts were also made to prevent HIV infection, including vaccine research, the development of an
effective microbicide (vaginal cream, gel or ring), and male circumcision research.
- South Africa is leading in the development of a vaginal microbicide to prevent HIV infection in women,
and circumcision research has shown a 60% reduction in HIV infection risk among circumcised men.
CHAPTER 2
• The immune system
The body's immune system has multiple defence lines to counteract pathogens if the 1st line proves
ineffective, allowing for the introduction of additional defence mechanisms.
