40. Acquired Immune Deficiency Syndrome (AIDS)

During the 1980s the acquired immune deficiency syndrome (AIDS) emerged as a major public health problem. AIDS was originally described in 1981 when a type of chest infection (pneumocystis carini pneumonia) and a type of cancer (Kaposi sarcoma) were noted to occur in homosexual men and intravenous drug abusers. In 1983, it was discovered that AIDS was caused by a retrovirus, the human immunodeficiency virus (HIV). Subsequently, it became evident that HIV caused a spectrum of disease, including a symptom free carrier state, the AIDS-related complex (ARC), and AIDS itself.

HIV has been documented to infect the brains of patients with AIDS. It is thought that HIV infection of the brain is responsible for the 'HIV brain disturbance' clinical picture often seen among AIDS patients.

The hallmark of the immunodeficiency in AIDS is that the virus kills body cells that are normally used by the body to create resistance to infection - the immune response. When AIDS interferes with this response by killing cells responsible for generating that immune response, that results in a profound immune (or resistance) deficiency, leading to the life-threatening opportunistic infections characteristic of AIDS. They are called opportunistic infections because they take the opportunity of the lack of immunity in the body to multiply and cause disease. If the body had its normal immune (defence or resistance) mechanism such infections would not take root. The body creates enough defences to kill off the invading organisms.

Presentation

The clinical picture of AIDS consists of the occurrence of recurrent, severe opportunistic infections or unusual tumours.

AIDS is now diagnosed (deemed present) when an individual presents with one or more "indicator diseases". These indicator diseases are indicative of an underlying immunodeficiency (lacking in the defence mechanism), and the most common presentations are pneumonia and a tumour known in the medical world as Kaposi sarcoma.

AIDS represents the most severe end of the spectrum of HIV infection. With acute infection with HIV there is a transient illness. Patients may then enter a prolonged symptom-free carrier state. Limited symptoms in AIDS-related complex include fever, weight loss, chronic (long standing) diarrhoea, mouth infection and isolated swelling underneath the skin in various parts of the body (lymphadenopathy).

Progress and treatment

Currently AIDS is an incurable and fatal disease. Approximately 60 percent of all cases have died, and the mortality approaches 100 per cent within ten years after the diagnosis of AIDS. There are a number of drugs in use in AIDS patients. Most of them decrease mortality by controlling opportunistic infections or weakening the virus, but they do not cure AIDS.

Global picture of HIV/AIDS

Among HIV-infected persons, World Health Organisation (WHO) estimates that close to 4.0 million AIDS cases may have occurred in adults worldwide by the end of 1995, of which 60-80 per cent have died. More than half a million childhood AIDS cases, resulting from maternal transmission before or during birth, may have occurred. Thus, WHO estimates that the cumulative global total of AIDS cases by 1993 stood at over two million , somewhere between 2.5 and 3.0 million.

During the 1990s, 10-20 million new HIV infections may be expected in adults. During the same period, WHO projects that 5-10 million children will have been born with HIV, the majority of them in sub-Saharan Africa.

Regional trends

In East and Central Africa, between one-quarter and one-third of all adults aged 18-50 living in some large urban centres had been infected with HIV by 1992. Initially, infections were concentrated in urban populations. Epidemic spread of HIV is increasingly being documented in rural areas, where most people live.

Heterosexual transmission of HIV continues to be the predominant mode of spread. As with other sexually transmitted infections there is a slight excess of women infected with HIV, the male to female ratio is approximately 1:1.2. Transmission of infection by pregnant mothers to their unborn babies (perinatal transmission) is a widespread and increasing problem. It is estimated that about 1.5 million HIV-infected infants had been born in Africa by 1994, and the projected total by the end of the 1990s is 4-8 million.

Counselling

Informing symptom-free HIV patients of their status is difficult at the best of times given public reaction, but set against the African attitude to marriage it becomes almost impossible. In a culture where the woman is frequently blamed for any serious illness affecting her child, counselling a couple together has to be done with much caution and after much careful thought. In Africa most married women are faithful to their husbands. However, when they are asked whether their husbands are faithful to them, they just laugh. The women are nearly always afraid of rejection by their husbands, and will do anything humanly possible to keep them happy, whilst the husbands rarely accept that they may be the source of the problem, even when they know deep in their hearts that the fault lies with them. A common scenario is for the wife to be rejected and for the husband to take another wife whom he will also infect. The former wife may return to her aging parents and turn to affairs with one or more men for income. Clearly counselling to the couple, preferably before they separate, becomes paramount.