The HIV/AIDS epidemic broke out in the 1980s and continues to impact individuals across the world today. In fact, Ross et al. noted that individuals diagnosed with HIV respond in ways similar to Kübler-Ross’s death and dying because HIV/AIDs was and is to an extent today still a diagnosis that is a threat to one’s life [1]. The immense HIV/AIDs epidemic can be better understood when looked at from the perspective of the patients who are infected and how society responded to these individuals. With this in mind, understanding the origin, transmission, and possible treatments of HIV/AIDs provides background as to nature of the disease and the prognosis that individuals face. Secondly, the prevalence of socioeconomic and minority disparities in HIV diagnosis and treatment contribute to the treatment of these individual patients. Lastly, an ethical perspective can be applied to early HIV testing methods, confidentiality surrounding patient diagnosis and care, and the stigma produced by religious beliefs to help explain the effects of these measures on the treatment of individual patients.

In the 1980s, the world began to see the initial signs of an epidemic. Early in the decade, reports increased of seemingly random and rare infectious diseases across the world, but it was not till the end of 1981 when the first case of HIV was medically diagnosed. These rare infectious diseases became more prevalent due to HIV/AIDS weakening individual’s immune systems. In the beginning, HIV was only understood to be viral, deadly, and highly contagious. Society quickly became aware of this new life-threatening illness and because little was known about the virus panic began to set in. Furthermore, with little information on the transmission of HIV, the rate of infected individuals began to grow exponentially. There were nearly 500 documented cases in 23 states within a year.  By 1993, there was estimated to be around 2.5 million documented cases of HIV/AIDs around the world. Then in 1995, AIDs became the leading cause of Death for Americans for ages 25 to 44 [2] .

Understanding the transmission of the virus was the first step in slowing down the increasing infection rate. Among new cases, there was a higher prevalence of diagnosis in homosexual and needle drug using communities. This clear correlation lead scientists to determine that HIV was spread through blood or bodily fluids [3]. Unprotected sex or sharing needles are two ways that individuals would directly come in contact with bodily fluids and thus increase their chance of being exposed to HIV [2]. Another possibility of transmission includes women who have HIV and them passing it to their baby either during pregnancy or through breast milk [3]. Learning how the virus was transmitted, allowed scientists to isolate the pathogen and perform further studies.

The impact of this virus on a patient’s body was crucial to the understanding the intensity of this epidemic and potentially developing a cure. The virus that causes HIV/AIDs infects the body’s T cells. More specifically, it infects CD4 cells that are responsible for the body’s immune response. These cells are critical in the body’s ability to fight off infection [3]. A lower CD4 count is correlated with a higher probability of infection. Although Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDs) are caused by the same virus, it is important to note that there is a distinction between them. An individual is diagnosed with HIV once the virus can be detected in their system. Without treatment, HIV progresses into the final stage of the disease called AIDS. AIDS is when the body is no longer able to fend off outside diseases and infections. Medically, this is characterized by a patient having one or more infections and a T cell count of less than 200. To compare, a healthy immune system has anywhere from 500 to 1600 T cells [3]. Once the origin of the virus was understood, scientists were able to work on treatments and potential cures to aid individuals living with this terminal illness.

Today, roughly 1.1 million people in the US alone have HIV, and an estimated 162,500 are unaware of their condition [3]. Due to the widespread impact of HIV/AIDS, an effective treatment or potentially a cure is crucial. In 1987, one of the first antiviral drugs called zidovudine (AZT) was approved to successfully treat HIV. Now over 25 antiviral drugs have been developed and approved to prevent transmission and spread of HIV and its progression to AIDS [4].

Figure 1 demonstrates that taking effective HIV treatment can increase HIV positive individual’s life expectancy from 32 years to 71 years. [5]

The root of every successful HIV treatment is to preserve the patient’s immune system. This is done by stopping the rapid replication of the HIV virus within a patient’s T-cells [2]. The virus can be suppressed by combination antiretroviral therapy (cART) that contains three active drugs from two or more different drug classes [4]. Using treatment as prevention approach can significantly decrease the rate of newly infected individuals and as a whole control the HIV epidemic. This system involves frequent universal testing and initiating ART drugs early after diagnosis. Treatment at any stage of the HIV infection significantly decreases the rate of viral load across the population of individuals living with HIV [6].

In addition, drugs were created in order to protect individuals that were seen as a high risk to exposure to the virus [4].  A drug called Pre-exposure prophylaxis (PrEP) is a daily dose of HIV medications to prevent them from getting infected [3]. Post-exposure prophylaxis (PEP) is an antiretroviral medicine to prevent people from becoming infected after being potentially exposed to HIV. PrEP should be used 72 hours after a recent possible exposure. For all these medications, the treatment is only effective when used exactly as instructed and taken at specific times [2]. The development of these drugs in society have allowed individuals with HIV to live long healthy lives. Furthermore, they have allowed people who do not have HIV to engage in healthy sexual relationships with HIV + people. Although these drugs are available today, universal access to them is not guaranteed.

Unfortunately, there is a correlation in HIV/AIDs diagnosis in those affected and socioeconomic and minority disparities. HIV has frequently been a disease associated with social and economic inequality due to the high proportion of individuals with a lower socioeconomic status having tested HIV positive [7]. For instance, experts claim that “some African American and Hispanic/Latino communities experience high rates of sexually transmitted infections, poverty,  and incarceration as well as low levels of socioeconomic status and education” [8]. This statement attributes that the main disparity between minority groups is due to different socioeconomic status and education. Additionally, it has been confirmed that the individual risk behaviors associated with contracting HIV such as having unprotected sex or multiple sexual partners do not justify the differing percentages of HIV infection in various ethnic groups [8]. This large variation can be attributed to the difference in the social and structural environments in which risk behaviors occur [xx]. Unfortunately, those with constricted economic opportunities are more likely to engage in riskier sexual practices in order to survive making these individuals more at risk for becoming HIV positive [7].

In Figure 2 above, the relationship between HIV prevalence and income is demonstrated indicating a trend. This trend concludes that as an individual’s income decreases HIV prevalence increases [9].

With limited resources, individuals with lower socioeconomic status have limited health care and transportation which contribute to the high percentage of women who are HIV positive [7]. With increased rates of poverty, many individuals are less educated causing them to potentially engage in unsafe sexual habits without the knowledge of how to prevent contracting various diseases [8].

Additionally, due to the association of HIV with different minority groups, many HIV positive individuals who are of racial minorities are challenged with various types of HIV stigma which contribute to increase psychological distress within these individuals [8]. This disease continues to be one of the most “stigmatizing illnesses in the United States” due to “attitudes within and about racial minority communities are typically disparaging of HIV” [8].  In some extreme instances, employers who obtained the knowledge that job applicant had HIV would not hire them due to the belief that they were somehow incompetent and would not be able to fully complete the expectations required of the occupation [7]. This prevents individuals who have HIV from obtaining a job; thereby, worsening their economic situation further which may force them to return to unsafe sexual practices which would continue to spread the disease even further. These stigmas surrounding HIV can be lessened with increased awareness regarding HIV to the public. Another suggestion to improve the treatment of those with HIV is to implement methods to advance viral suppression among minority groups such as African Americans and Hispanics. For example, providing more accessible resources would diminish viral suppression and the likelihood of HIV transmission [8].

Additionally, lower education has been associated with increased HIV; therefore, scholars strive to reduce this by implementing school-based programs that have been proven to reduce risky sexual behavior and prevent HIV in numerous areas [7]. Hopefully, these measures will not only help reduce unfair treatment of those with HIV but also the prevalence of the disease itself due to the fact that “four of the eleven counties in the lowest unemployment quartile had the lowest unemployment rate” implying that as unemployment increases the persistence of HIV increases as well [9].

The large disparities between socioeconomic groups and the association of HIV positive individuals have created a cultural gap due to the different ways in which people from various social classes think [10]. In essence, class plays a huge role in the development of specific cultures. Culture can be de defined as “the values, rules, norms, religions, scientific theories, and symbols that can be identified in a society”; therefore, socioeconomic divisions strongly influence a society’s culture and must be considered when analyzing different cultures [11]. When there are large disparities in the prevalence of a disease between socioeconomic groups, assumptions begin to arise between the two social classes conveying a sense of resentment or dislike [13]. In order to reduce the stigma associated with HIV positive individuals, one must consider how the culture of that particular society influences the way in which different social classes not only interact but also think. HIV needs to be made more aware of in communities which would help reduce the cultural connotation implied when discovering that an individual has aids. Additionally, there continues to be a disparity in the availability of HIV testing resources that contribute to the growth of stigmatization within certain underprivileged socioeconomic groups.

Due to the stigmatization of the disease, in part related to the socioeconomic divisions, many people avoid being tested due to the lack of resources that are available within certain socioeconomic groups and due to the psychological factors associated with the diagnosis. However, slightly less than half of those infected with HIV are unaware of their status, so early HIV testing has become increasingly more important in our society today, even if it may cause damage to one’s social relationships [13]. Current legislation in Connecticut and New York requires mandatory testing for HIV in newborns, which indirectly reveals the mother’s status with respect to the disease [14]. This legislation brings forward an ethical debate over whether testing should be mandatory at birth due to the severity of the disease. Even though mandatory testing is a part of the law, it is still a breach of the individual’s informed consent because children may be tested without the parents’ knowledge or consent. Testing after birth provides the parents with knowledge about the baby’s HIV status, allowing them to immediately begin treatment to help their children live healthier and longer lives if their child is HIV positive. However, there is no universal cure for the disease and the knowledge that a child is HIV positive can be burdensome on the parents, who may not wish to care for or may not have the resources to properly care for a child with a terminal illness. Recommended testing for pregnant women would resolve the majority of these issues. If HIV testing were to become a routine part of prenatal care, women would not be required to specifically consent to the HIV test, but they would still be informed that the test would be conducted [15]. Early diagnosis of the disease leads to a better response to treatment and a reduced chance of transmission to others [13]. Thus, the parents and the child could benefit from prenatal testing instead of testing after birth. Also, if tests were performed prenatally, the parents of the child would be able to decide if they wanted to go through with or terminate the pregnancy. Many ethical issues can be raised in relation to recommended testing for HIV. If the screenings become frequent and routine, the woman may not realize she has the autonomy to opt out [15]. Additionally, routine testing raises issues of confidentiality over the baby’s and mother’s HIV status, which could result in social or marital isolation due to the stigmatization of the disease. However, due to the severity of the disease, many the US Public Health Service (USPHS) and many physicians recommend that prenatal testing for HIV become a routine part of prenatal screening [15].

Figure 3 shows that mothers who discussed HIV testing with their prenatal care doctor, were more likely to receive testing before or after birth [16].

The psychological factors associated with the disease result from the stigma surrounding the disease that affects the individual. Stigma surrounding HIV has existed since the initial outbreak when the disease became known as “gay-related immune deficiency” because members of the gay community made up the majority of those infected with HIV [18]. Not only is the gay community affected by the disease, but many other marginalized social groups that face the greatest discrimination are greatly affected by the disease. Many scholars believe religion is the driver of the marginalization of these communities affected by HIV [18]. This raises the question – can religion ethically be used as a morally sound basis for discrimination toward those infected with HIV? After the initial outbreak, many religious leaders immediately identified HIV with the gay community and took the position that God was punishing them for their sins associated with being homosexual [19]. Even though there was significant evidence that the disease could be spread by heterosexuals, many religions saw the disease as a way to marginalize homosexuals and to communicate that being homosexual was a sin according to God [19]. These religious leaders used the moral principle of fidelity to demonstrate how their hatred toward the gay community stemmed from their faith in God. However, these leaders lacked the moral principle of veracity because they denied that heterosexuals were also affected by the disease, even though there was sufficient evidence to support this fact. Even though these religious leaders adhered to some of the basic moral principles, they lack support from ethical principles like nonmaleficence, which suggests that one should inflict the least amount of harm possible. The religious leaders and their followers created a stigma for HIV/AIDS that continues to cause harm to marginalized communities. Many people refuse to get tested because of the social implications that become associated with the individual who has the disease and others keep their diagnosis a secret in fear of becoming a social outcast.

The health professional’s duty to keep patient information about HIV diagnosis secret has created some ethical dilemmas about confidentiality. Currently, HIPAA (Health Insurance Portability and Accountability Act of 1996) governs the rules about HIV testing and treatment confidentiality [19]. However, there are issues with HIV-infected patients refusing to disclose their condition to their partners, and health professionals are legally required to refrain from intervening. In one example, a 37-year-old man infected with HIV was having unprotected sex with his 17-year-old girlfriend. When a clinic worker attempted to convince him to tell his girlfriend, the man responded that telling her would destroy his dream of getting married and having children [19]. Under the ethical principles of beneficence and nonmaleficence, the health professional should have been able to inform the man’s girlfriend of his condition so that she and her potential children would not be affected by the severe disease. Unfortunately, health professionals are not always able to act strictly on ethical principles because of certain laws and regulations.

Through the progression of our scholarly analysis, it becomes evident that HIV/AIDS is a complex disease. A consideration of the scientific, social, and ethical factors surrounding the disease allows us to gain a complex understanding of the HIV/AIDS epidemic as it pertains to the individual. Although HIV/AIDS is a terminal diagnosis that an individual face, the initial outbreak, and resulting repercussions impact society as a whole. Furthermore, these effects and implications of the disease are still prevalent in our society today. In the future, it will require widespread support in order to reduce the number of transmissions and stigmatizations associated with infected individuals.

Sabrina Deweerdt

Elena Wilson

Hannah Weisbecker

 

[1] Schweitzer, Ana-Maria. Mizwa, Michael. Ross, Michael. “Psychosocial Aspects of HIV/AIDS: Adults,” In HIV Curriculum for Health Professional, 334-349. Baylor College of Medicine, 2010.

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[3] NIDA. “Drug Use and Viral Infections (HIV, Hepatitis).” National Institute on Drug Abuse, April 23 2018, https://www.drugabuse.gov/publications/drugfacts/drug-use-viral- infections-hiv-hepatitis

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[3] NIDA. “Drug Use and Viral Infections (HIV, Hepatitis).” National Institute on Drug Abuse, April 23 2018, https://www.drugabuse.gov/publications/drugfacts/drug-use-viral- infections-hiv-hepatitis

[3] Ibid.

[3] Ibid.

[3] Ibid.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[5] The Center for Disease Control.Web. HIV Medicines Help People with HIV Live Longer (Average Years of Life). January 2019. https://www.cdc.gov/hiv/library/infographics/index.html.

[2] Public Health. “HIV and AIDS: an origin story.” https://www.publichealth.org/public-awareness/hiv-aids/origin-story/

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[6] Wilson, David P. 2012. “HIV Treatment as Prevention: Natural Experiments Highlight Limits of Antiretroviral Treatment as HIV Prevention.” PLoS Medicine 9 (7) (07): e1001231. doi:http://dx.doi.org/10.1371/journal.pmed.1001231.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[6] Wilson, David P. 2012. “HIV Treatment as Prevention: Natural Experiments Highlight Limits of Antiretroviral Treatment as HIV Prevention.” PLoS Medicine 9 (7) (07): e1001231. doi:http://dx.doi.org/10.1371/journal.pmed.1001231.

[4] Cihlar, Tomas. Fordyce, Marshall “Current Status and Prospects of HIV treatment,” Current Opinion in Virology, vol. 18, 50-56, (June 2016), https://doi.org/10.1016/j.coviro.2016.03.004

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[8] Ibid.

[8] Ibid.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[9] CDC Study Reports Poverty Among Minorities Doubles HIV Infection Rate. Figure 2. July 18, 2018. Web. Conference Report. http://www.natap.org/2010/IAS/IAS_04.htm

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[8] Ibid.

[8] Ibid.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[8] McCree, Donna H. et al. “An Approach to Achieving the Health Equity Goals of the National HIV/AIDS Strategy for the United States Among Racial/Ethnic Minority Communities” Sage, [no. 4]. https://www.jstor.org/stable/44297663.

[7] Tenkorang, Eric Y., and Maticka-Tyndale, Eleanor. “Individual- and School-Level Correlates of HIV Testing among Secondary School Students in Kenya” Population Council, [no. 2].  https://www.jstor.org/stable/23408618

[9] Fede, Ana L. et al. “Spatial Visualization of Multivariate Datasets: An Analysis of STD and HIV/AIDS Diagnosis Rates and Socioeconomic Context Using Ring Maps” Sage, [no. 3]. https://www.jstor.org/stable/41639311

[10] “Social Class as a Culture” Association for Psychological Science. https://www.psychologicalscience.org/news/releases/social-class-as-culture.html

[11] Gabrenya, W. K., “Culture and Social Class” Research Skills for Psychology Majors: Everything You Need to Know to Get Started. http://my.fit.edu/~gabrenya/social/readings/ses.pdf

[12] “HIV/AIDs and Socioeconomic Status” American Psychological Association. https://www.apa.org/pi/ses/resources/publications/hiv-aids

[13] Evangeli, Michael, Kirsten Pady, and Abigail L. Wroe. “Which Psychological Factors Are Related to HIV Testing? A Quantitative Systematic Review of Global Studies.” AIDS and Behavior 20, no. 4 (2015): 880-918. doi:10.1007/s10461-015-1246-0.

[14] Wolf, Leslie E., and Bernard Lo. “Comprehensive, Up-to-date Information on HIV/AIDS Treatment and Prevention from the University of California San Francisco.” Ethical Dimensions of HIV/AIDS. (2001). http://hivinsite.ucsf.edu/InSite?page=kb-08-01-05#S3.2X.

[15] Hlongwa, P. “Current Ethical Issues in HIV/AIDS Research and HIV/AIDS Care.” Oral Diseases 22 (2016): 61-65. doi:10.1111/odi.12391.

[13] Evangeli, Michael, Kirsten Pady, and Abigail L. Wroe. “Which Psychological Factors Are Related to HIV Testing? A Quantitative Systematic Review of Global Studies.” AIDS and Behavior 20, no. 4 (2015): 880-918. doi:10.1007/s10461-015-1246-0.

[15] Hlongwa, P. “Current Ethical Issues in HIV/AIDS Research and HIV/AIDS Care.” Oral Diseases 22 (2016): 61-65. doi:10.1111/odi.12391.

[15] Ibid.

[16] The Center for Disease Control. Figure 1. May 21, 1999. Web. Prenatal Discussion of HIV Testing and Maternal HIV Testing — 14 States, 1996-1997. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4819a4.htm.

[17] Courtenay–Quirk, Cari, Richard J. Wolitski, Jeffrey T. Parsons, and Cynthia A. Gómez. “Is HIV/AIDS Stigma Dividing the Gay Community? Perceptions of HIV–positive Men Who Have Sex With Men.” AIDS Education and Prevention 18, no. 1 (2006): 56-67. doi:10.1521/aeap.2006.18.1.56.

[18] Blevins, John B., Mohamed F. Jalloh, and David A. Robinson. “Faith and Global Health Practice in Ebola and HIV Emergencies.” American Journal of Public Health 109, no. 3 (2019): 379-84. doi:10.2105/ajph.2018.304870.

[19] Heimer, Carol A. “‘Wicked’ Ethics: Compliance Work and the Practice of Ethics in HIV Research.” Social Science & Medicine 98 (2013): 371-78. doi:10.1016/j.socscimed.2012.10.030.

[19] Ibid.

[19] Ibid.

[19] Ibid.