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Male Circumcision
Studies have shown that the mucosal surface of the male foreskin
contains a greater number of HIV target cells (known as Langerhans
cells) than the skin along the penile shaft. The foreskin
is also more sensitive and fragile and more easily torn during
sexual activity, again increasing the risk of HIV entry with
exposure. During male circumcision, the foreskin or the prepuce
of the penis is removed.
Results of studies in Africa and Asia have shown promising
results. Overall, male circumcision has reduced HIV infection
rates by 44 - 71% in areas where the circumcision rate for
men is less than 20%. Following male circumcision, there were
also reductions in rates of genital ulcer disease, chlamydia
and penile cancer (Weiss et al., 2006).
CDC is currently reviewing data in order to make recommendations
on circumcision for men living in the U.S. Preliminary data
has shown decreased rates of HIV transmission during penile-vaginal
sex (more common in Africa/Asia), but not penile-anal sex
(more common in US). Additionally, more US males were circumcised
as infants than in many other countries bringing into question
the cost effectiveness and risk ratio of the surgical procedure
as an adult. Regardless of future recommendations, it is important
to stress the fact that circumcision should not be considered
an effective barrier to HIV infection, but rather used in
conjunction with other barriers or abstinence (CDC, 2010).
HIV Vaccine Development
There continues to be much interest and research in the development
of a vaccine for HIV. In the past decade, numerous vaccines
have been trialed to some extent in the US and in developing
countries with limited success. Scientists have learned valuable
information from the trials, but to date, no effective vaccine
has been developed.
The process of HIV vaccine development has been difficult
in many ways. First, the virus mutates rapidly, making it
a sort of "moving target." Next, clinical trials are expected
to be conducted safely without placing participants at unnecessary
risk. With the HIV vaccine, failure could lead to infection
with an incurable disease. Finally, there are ethical issues
related to developing countries and the benefit and risk of
trialing the vaccine.
There is no cure and no approved HIV vaccine today, but hopefully
the future will hold both. Future research may include gene
therapy to mitigate target cells and receptor cells on the
surface of the CD4 cells of the immune system.
Topical Antiviral Agents
The use of a vaginal cream or gel to prevent HIV infection
in women has been a consideration for several years. This
year, there was finally a report from a clinical trial using
a tenofovir gel in South Africa that showed a 54% reduction
in HIV infection among women in the study who were adherent
with the gel application. Lower, but still improved rates
of infection were reported for women with lower adherence
rates. This was a breakthrough in prevention and may prove
to be a safe and cost effective method of HIV prevention in
years to come, especially in populations where condom use
is infrequent. Gel application allows women to protect themselves
when their partners refuse to use barriers in a way that is
not obvious.
HIV and the Aging Population
The number of new cases of HIV infection among people age
50+ has continued to rise steadily since 1997. In addition,
due to the effectiveness of ART, the number of people who
are living with HIV/AIDS at age 50+ continues to climb. Currently,
about one of every five persons with HIV/AIDS in the US is
age 50+ (Shah & Mildvan, 2010). The older HIV population has
problems that are specific to their age cohort including:
- Lack of knowledge of HIV/AIDS risk behaviors
- Denial of risk
- Later diagnosis, often with AIDS
- Naturally decreasing immune system
- Social isolation
- Financial Hardships
- Stigma: HIV and ageism
- Drug/drug interactions related to multiple medical conditions
Care and treatment of this population may need to be modified
to assist with these issues. Affordable safe housing, proper
nutrition, transportation to and from medical appointments,
availability of medications and other issues must be discussed
prior to staring ART to assure the best possible outcome.
Social support is also very important, and seniors should
be encouraged to participate in social activities with family
and friends regardless if they choose to disclose their HIV
status or not. Many older adults are afraid of the stigma
associated with HIV infection and become more isolated at
a time when social support is important. HIV education is
important, since many older adults choose not to be around
loved ones because they fear infecting them with the virus.
Older adults who understand HIV transmission and risk factors
will be able to continue in relationships without the worry
of accidental transmission.
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Case Study
#2
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Cathy is a 64 year old woman. Her husband died 4 years
ago and she has been very lonely. One day neighbor and
friend introduced her to her brother, who recently moved
nearby to be closer to family. Ed retired from the military
and had traveled all over the world. Several weeks later
he invited her out to dinner and a movie. She had not
dated since her husband's death, but felt like it would
be ok since it was her friend's brother. When she got
ready to leave for the evening his sister said jokingly,
"Be careful, he's always been a real ladies man."
Her date acted like a gentleman all evening. He opened
doors, pulled out her chair, and told non-stop accounts
of his exciting life in the military. His last post
before retiring was Bangkok. He made it sound beautiful
and mysterious. Cathy asked if he ever married and he
said no, but he had been in several long-term relationships.
He was easy to be with, and soon she was in a serious
relationship.
- Identify clues that Cathy might have been putting
herself at risk for HIV/AIDS.
- What questions could she have asked?
- What else could they have done?
- In your opinion this your case out of the ordinary
or do you think that it is common behavior?
Cathy may be at risk for HIV infection. Ed has been
in the military and traveled to many different countries.
Like others their age, ED and Cathy may have limited
knowledge of HIV risk factors. Ed has had multiple long
term relationships, and may also have had other sexual
partners. Thailand has a brisk prostitution trade and
a high prevalence of HIV/AIDS. As their relationship
progressed, Cathy should have asked about other sexual
encounters, STDs, and if he had been tested for HIV.
Although Cathy had been in a monogamous relationship,
they should go together to be tested for HIV. This case
is common, especially among older people. Many are not
well informed about the risks associated with HIV/AIDS,
and consider barrier use necessary only for protection
from contraception (Lindau et al, 2007).
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