Chapter 4: HIV Transmission and AIDS Risk Factors - How People Become Infected

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Different groups of people tend to become infected with HIV for different reasons. Children, drug addicts, sexually-active homosexuals, and heterosexual men and women are all developing AIDS in particular ways. Whole family groups are now becoming ill.

How children get infected with HIV

A million children a year get infected with HIV. A preventable tragedy.

1. ´Infection before or during birth

HIV can cross the placenta in the womb, and can also infect during labour, when the baby swallows amniotic fluid and blood - up to 25% of infected mothers will give birth to an infected baby for these reasons. If anti-viral medication is given before birth to mother, and for a short time after birth to baby, the risk of transmission from these causes can fall from to as little as 5 - 8% (results vary according to different studies). There is some benefit from anti-viral therapy even if only started during birth, or only used in the newborn baby. Broadly speaking, anti-viral therapy will more than halve transmission rates if properly used.

Some people used to think pregnancy could shorten the life of a woman with HIV. Doctors now think the risk of rapid deterioration is not very great.

2. ´Infection just after birth

Mother's milk can carry the virus from mother to child. This may account for up to half of all infections from mother to baby. One critical factor may be when the mother becomes infected, since virus levels are highest shortly after infection. The risk of infection to baby could be 29% if the mother is infected while breastfeeding, 10% - 14% additional risk if the mother is infected before delivery. As a result, many hospitals in the United Kingdom have discontinued milk banks for sick babies. Questions have been raised over what advice to give mothers in developing countries. Conventional wisdom is that the risk of death from diarrhoea and vomiting due to contaminated bottle feeds is too great to allow mothers to stop breastfeeding (artificial feeding is a major factor in deaths of 105 million infants a year). The balance of risk may vary according to the individual and the local situation, especially if the mother is known to have HIV.

So if you treat an infected mother before birth, and she does not breastfeed, the combined reduction in risk to the baby is huge: perhaps a fall from as much as 30% down to less than 8%.

3. ´Vaccinations/injections

In Eastern Europe and Africa infection has spread through using the same needles between patients. If there are only a few needles left which are not hopelessly blunt, the temptation is great to immunise a whole clinic with a single needle. Blood from one infected child can spread the disease to others in the group. In some parts of Africa and Eastern Europe many medicines are injected rather than swallowed. Mothers seem to prefer it.

4. ´Transfusions and blood products

Education of health care workers is critically important: to use fewer injections, less blood, and take great care. In most countries today the blood supply is now safe. However there is always a risk because the widely used tests for antibodies to HIV do not pick up recent infection (in many cases 6 weeks or more). Someone could be highly infectious with huge numbers of virus particles in the blood they donate yet test negative.

5. ´Incest/sexual abuse/child prostitution/early teenage sex/drugs

A thirteen-year-old girl shyly came up to me with a friend after a talk I gave to her class. I had to ask her teacher to leave before she could bring herself to speak. She wanted to know if someone could get infected with HIV through being raped. She was thinking of someone in particular. I had to say yes.

One unfortunate trend in high-incidence countries such as Thailand or Uganda has been the targeting of young teenage girls for sex by older men, who hope they will be less likely to be carrying HIV than adult women. This is one reason why the ratio of infected teenage girls to boys can be higher than five to one.

Child prostitution is becoming a global problem. In Taiwan there are an estimated 60--200,000, while around a million children are thought to be traded as sex slaves each year in South East Asia. UNESCO estimates that 800,000 children work as prostitutes in Thailand alone, while child prostitution is also growing in other parts of the world.

How drug addicts get infected with HIV

Drug addiction is a global problem. 8% of the value of all international trade is now illegal drugs according to UNDP. Drug addicts become infected by sharing syringes and needles. A common habit is to rinse the last dregs of drug out of the syringe using your own blood---drawing blood out of your vein and injecting it again. This means the next person injects a lot of virus into the bloodstream if the previous person is infected with HIV. It is far more dangerous than if a doctor pricks himself with a bloody needle. In that case the amount of blood involved would be much less. In Edinburgh, the virus spread from one addict to infect between 1,000 and 2,000 other people in eighteen months. In Thailand, 50,000 drug addicts were infected in two years, with other countries likely to become similarly affected.

The drug addict population is hard to estimate. Addicts do not like to stand up and be counted. Those with children are often scared their children will be taken into custody. Others are just shy of any official contact. I have visited drug injectors in their homes in Manipur, North East India. Villages where up to 8,000 out of 40,000 inject heroin daily, and 4,000 have HIV as a result. The stigma is so great that a villager risks being killed if identified as having HIV.

AIDS has the potential to spread quickly in drug injectors, although in some countries there has been a very encouraging drop in needle sharing, and infection rates among drug injectors have stabilised. A growing number are starting to inject drugs other than heroin, such as amphetamines. The risk is still the same.

Some governments are providing free needles, having found that addicts will be less likely to share them, despite the suggestion that issuing needles may actually accelerate the growth of drug abuse. It certainly makes things hard for the police.

Drug abusers (including alcoholics) have an increased risk of becoming infected with HIV in other ways. When they are `under the influence', judgement is impaired and risks can be taken. Safer sex, discretion and caution can be thrown to the wind. The same with safe injecting practices. Drug addicts are often thought to be hard to educate, not only because they are hard to find and possibly hard to motivate (some addicts can have a kind of death wish), but also because, even if they decide to be careful, they may forget in the rush of the moment. However, education has worked, to the surprise of many.

The third extra risk is that by injecting all kinds of foreign substances---including dirt, germs, and powdered chalk---the immune system is weakened. Addicts frequently come into clinics with huge septic boils, rashes, or strange fevers (septicaemia). Huge chunks of muscle can rot away, especially in drug users living in poorer nations with less access to medical care. They are in no fit state to fight HIV. Infection is more likely and deterioration probably more rapid. An infected addict should be encouraged to stop. However it can be even harder to stop if you know you may be dying anyway.

Drug users may also be at risk of becoming infected when they are in prison. Most addicts end up in prison at some time in their lives. Containing spread in prisons is difficult, with many calls not only for condom issue (could be illegal as prison), but also for needle provision. However, a bloody needle and syringe make a formidable weapon in the hands of someone who may be infected. Prison officers fear attack. In the meantime, injectors may be at greater risk of sharing in prison than in the community. In most prisons a wide range of drugs are freely available from illicit sources. In the absence of needles, even greater risks may be taken. An ACET prison worker recently talked to a man who had shared parts of a ballpoint pen as a `needle' to inject drugs into his neck.

How practising homosexuals get infected with HIV

In America and Europe HIV has spread rapidly through gay communities. Why? There are two reasons. First, it does appear that someone who allows a man to push his penis into his rectum and ejaculate there has a particularly high risk of getting the infection. The lining of the anus is fragile. The lining of the rectum is also likely to bleed during anal intercourse, especially if a pre-sex douche (enema) or a dildo (artificial penis) is used. It is possible that some cells in the rectum have surfaces particularly suited for HIV to latch on to and can become a reservoir for infecting the whole body.

Anal intercourse has always been known to carry a health risk: as we have seen, hepatitis B virus is spread easily by this route and many active homosexuals appear to have chronic low-grade infections of various kinds that may then lower their resistance to HIV. Anal sex is not unusual among heterosexuals in the United States and the United Kingdom. Up to one in ten of women questioned report having had anal as well as vaginal sex in some surveys. Anal sex alone is not the reason for the spread of HIV. The biggest reason of all has to be found somewhere else, which brings us to perhaps the main reason why the gay community is experiencing an epidemic.

If you are an active homosexual, a major predictor of infection has to do with the number of different men you have had intercourse with over the last few years. It is true that some practices carry a particular risk of trauma and infection, eg `fisting', where the hand and sometimes the forearm are inserted into the rectum.

The AIDS epidemic has forced social psychologists to ask some basic questions about human behaviour---questions that may be embarrassing and have been hidden behind closed doors for decades. These questions are extremely hard to get honest answers to, but are important to enable us to predict how the disease might spread in order to plan effective education.

One of the big surprises to emerge from a recent large and authoritative sexual survey of 18,000 in the UK was how few men said they had homosexual partners. While the famous Kinsey study in the US (1948) had given figures of 37% of men having had a homosexual experience to the point of orgasm, 10% exclusively homosexual for more than three years and 4% lifelong homosexuals, the UK study showed a different pattern. Less than 5% had ever had a homosexual experience, and only 1.7% had had sex in a homosexual relationship in the last five years. When the latter result was separated out, great regional differences were found: 5% in London and only 1% in the rest of the country.

The results caused uproar because they challenged the established view that about one in ten of the male population was a sexually-active homosexual. However, the figures were not so much of a surprise to those running sex disease clinics, or working in the AIDS field. For some time people had been quietly saying that the sexually-active gay community seemed to be far smaller than originally thought. This was vitally important in making forecasts about HIV spread and numbers of AIDS cases. After all, if a London clinic found that a quarter of all gay men attending were HIV-infected, it was vitally important to know if that was a quarter of a total of 2,000 men, or a total of 10,000. Within a few weeks similar surveys were published in France and the US. Both confirmed the basic findings. Most experts on sexual behaviour have now concluded that the Kinsey study was flawed.

One of the things that shows up is that sexual behaviour is far more chaotic than many people imagine. For example, a United States study has shown that possibly one in four men who have sex with men also have sex with women. In the UK, a national sex survey showed that 59% of men having anal sex with men had also had female partners.

Sexual preference sometimes changes with circumstances. A starving man on a desert island will eat strange foods. The reason why there are serious outbreaks of all sexually-transmitted diseases (including HIV and AIDS) in prisons is that many men who behave heterosexually outside prison practise homosexually in prison. In addition, male rape is a common form of initiation bringing fear, humiliation and respect of the boss.

Surveys show that some homosexual men later marry and maintain exclusive heterosexual relationships. However, the most startling fact to emerge from many studies has been the enormous number of different partners some homosexual men used to have in a year. Over half those attending a London clinic said they had had between six and fifty partners in a year. Many had between fifty-one and a hundred, a few reported more than 300. Common meeting places are certain well-known public toilets, gay bars and other venues.

The contrast with the heterosexual group is enormous. Very few men will claim to have slept with more than fifteen women in a year. The vast majority claim to have had only one partner in any year. Incidentally that is still unsafe. Each different partner each year is a new risk---even assuming faithfulness on both sides for twelve months. Serial monogamy is very common and is not the answer to AIDS.

When a prominent churchman was appointed as an Episcopalian bishop recently, he was shocked and outraged by what he found in the gay community. What made people do this? What happened to a sense of belonging or relationship? The answer he discovered was that, in `coming out', many gay men had felt able to leave behind conventional restraints. By deciding to sample `the fruits of the earth', with no relationship ties, many found a new freedom. Even people living together in stable homosexual relationships for years were expected to explore regularly outside that relationship. Public disapproval of gay partnerships also tended to make stable relationships difficult to form and maintain.

Gay people have felt totally ostracised and rejected by society. Beaten up in alleyways, labelled as perverts, and victims of relentless low-grade discrimination, they have often felt misfits. Rejected by family and former close friends, many have found tremendous security and self-acceptance among others who have been through an identical experience. The feeling of togetherness is strong. At last they can be themselves without fear of rejection. This fear is often of heterosexual men. Women are usually more tolerant.

This feeling of intense rejection, isolation, loneliness and vulnerability is then magnified a thousand fold by AIDS. This totally false `gay-plague' label has stuck and reflected on a whole community which has responded with an amazing mobilisation of talent, resources and kindness to support and surround people with AIDS with love. Victims, as they see it, not of AIDS, but of horrendous prejudices and discrimination.

No wonder the gay community is so sensitive to the hostile attitudes of some parts of the church. Many people in the gay community have seen AIDS as something that has generated openness and an unprecedented care and concern from people who are not gay: `Things will never be the same again. However, others have predicted a possible backlash.

How women get infected with HIV

Women become infected in several ways. Historically in many societies women have been disadvantaged sexually and vulnerable to sexual abuse. It is still true today that it is very difficult for women in many parts of the world to protect themselves against HIV from a dominant male partner.

In African countries such as Malawi or Kenya, the majority of infected women in some groups have been celibate before marriage and monogamous since, yet have been infected because of the unfaithfulness of their partners, or because partners were infected before marriage . Some experts have expressed concern at the effect of new Western influences, undermining traditional family values in developing countries, and encouraging higher rates of partner exchange.

Long-term relationships can also clearly carry a great risk where no precautions are taken. Often women may have no idea their husbands are infected, but even if they suspect so, they may be unable to do anything about it. One woman I spoke to after an open-air presentation on AIDS in Uganda told me she was certain her husband was infected because he was continually unfaithful with a large number of partners, but she was unable to make him change to using a condom with her. She was powerless and lived in fear of her life. These are important issues in prevention, but may lead to confronting cultural norms in a way which could be accused of imperialism. Sensitivity is needed (see Chapter 14).

Sensitivity is also needed to tackle dangerous traditional practices in some countries, such as widow cleansing, where the brother of a man who dies is required to have sex with the widow. This is hazardous if the man died of AIDS after infecting his wife with HIV.

Women can be at risk through anal sex, which is far more common among heterosexuals than many people realise. As we have seen, a number of Western nation surveys of young women have suggested that up to one in ten have experienced anal intercourse at least once. This carries possibly twice the risk associated with vaginal intercourse, partly because of the possibility of trauma to the delicate anal and rectal lining, but also because there are cells in the wall of the rectum that have receptors for HIV, so can be infected directly.

Women are at high risk as commercial sex workers, particularly as clients may insist that no precautions are taken, or may indulge in violent sex or anal intercourse.

Their main risk in low incidence countries is sleeping with a man who has had sex at some time in the last fifteen years with another man, or who has injected drugs, or who has had sex with women in nations with a higher incidence of HIV. Once may be enough for him and for her. They will probably never know because the man will never say. The average interval between marriage and the wife discovering her husband's homosexual preferences is between five and fifteen years. Women can also become infected from a heterosexual man who has been infected by another woman---commonest in developing nations---or who is a drug addict. Very rarely a woman can catch HIV from nursing her child with AIDS.

Lesbians are one group of people, apart from those who are celibate, where HIV infection is almost unknown. I know of only one or two cases where a lesbian woman has infected another. However, there may be many more infected who are as yet unknown. Lesbians are at risk if they inject drugs and have heterosexual relationships as well.

How heterosexual men become infected with HIV

A heterosexual man becomes infected by having sex with a woman who injects drugs, by injecting himself, or by sleeping with a woman who has previously had an infected partner, the latter being the commonest reason worldwide. You will never know unless she tells you. Sex on a single occasion with an infected partner can be enough to infect you, although the risk from a single act is very small - probably less than one in 200 for non-traumatic vaginal intercourse unless there is some other factor like another sex disease. (see Chapter 6).

In some developing countries initiation rites such as male circumcision with a communal knife or ritual mutilation can risk HIV spread. Such practices need to be discussed sensitively. Circumcision reduces risk of HIV transmission, probably because the risk of other sexually transmitted diseases is lower.

AIDS and the church

Some churchgoers contracted HIV before they became Christians. It can surface after they have begun new lives and are happily married, infecting their wives and possibly their children as well. Others who regularly attend church lead double lives: a person can pretend to be one thing for an hour or two a week, and probably at work too, while beneath the respectable veneer he has a drug problem or is sleeping around with men or women. The result may be AIDS.

For some today there is no double life. The risky lifestyle is maintained openly in defiance of traditional church teaching, perhaps in a church led by someone with liberal views. And tragically, as we will see in Chapter 14, a small but increasing number of church members are becoming infected while serving as doctors and nurses in high incidence countries where they are exposed frequently to medical hazards.

The Truth About AIDS


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March 14, 2012 - 22:23
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