Every year, 5 June marks HIV Long-Term Survivors Awareness Day (HLTSAD). This international awareness day honours all long-term survivors of human immunodeficiency virus (HIV) and promotes inclusivity within the global community to keep long-term survivors of HIV and acquired immune deficiency syndrome (AIDS) at the forefront of the ongoing HIV/AIDS conversation. The theme for HLTSAD 2020 had been planned and organised, but the advent of the coronavirus disease 2019 (COVID-19) pandemic led to the creation of a new theme entitled ‘Not Our First Pandemic’ .
The aim of this article is to shine a spotlight on HIV/AIDS and share how the lessons learned from the HIV/AIDS pandemic can be used to save lives in a world that is gripped by the COVID-19 pandemic.
Although unbeknown to the scientific community at the time, the beginning of what later became known as the HIV/AIDS pandemic was marked on 5 June 1981 in the Morbidity and Mortality Weekly Report (MMWR) prepared by the Centers for Disease Control and Prevention (CDC) in the USA. The report detailed five incidences of Pneumocystis carinii pneumonia (PCP) among five young homosexual men in Los Angeles, California, two of which had already succumbed to the disease . All five men tested positive for cytomegalovirus (CMV) and Candida mucosal infections, both of which are associated with a severely weakened immune system [2, 3]. In the days that followed the publication of the report, numerous clinicians across the USA contacted the CDC to report cases of PCP; CMV and other opportunistic infections; and the rare and aggressive cancer Kaposi’s sarcoma in homosexual men . By the end of 1981, over 330 cases had been reported of individuals displaying infectious comorbidities associated with severe immune deficiency .
HIV and disease progression
Nearly 40 years on from the publication of the first report of what is now known as HIV/AIDS, our knowledge of the pathogenesis of the disease has grown tremendously. HIV is a virus that attacks and concurrently weakens the immune system, rendering a patient susceptible to opportunistic infections and diseases that a fully functioning immune system would usually protect against .
Upon binding to specific human cell surface receptors and entering a cell, viral complementary DNA integrates into the host cell genome, resulting in the expression and assembly of viral proteins, which leads to the multiplication of virus particles and the dissemination of HIV within the infected individual . The virus predominantly infects CD4+ T lymphocytes (also known as helper T cells), which form a major constituent of the adaptive immune system. To a lesser extent, the virus also infects antigen-presenting cells, including multiple subtypes of dendritic cells (DCs) . Mature DCs can act as viral carriers within the body, allowing the virus to reach lymphoid organs (including the thymus, spleen, bone marrow, lymph nodes and mucosa-associated lymphoid tissue) where it can then infect additional CD4+ T lymphocytes .
In addition to dysregulating and destroying CD4+ T lymphocytes, HIV also dysregulates other immune cells, including CD8+ T lymphocytes (cytotoxic T cells), B lymphocytes (B cells) and natural killer cells [6, 7]. This leads to the exhaustion of the immune system and the progressive loss of CD4+ T lymphocytes among other immune cells, resulting in affected individuals becoming immunosuppressed . If an HIV infection is left untreated and evolves to a late-stage infection, this can lead to the development of AIDS .
An individual with HIV is considered to have progressed to AIDS when :
- Their CD4+ T lymphocyte count drops below 200 cells per cubic millimetre of blood
- They develop more than one opportunistic infection (regardless of CD4+ T lymphocyte count)
The most common route of HIV transmission is through exposure to cell-free or cell-associated infectious virus during unprotected sexual intercourse. Other common routes of HIV exposure also include infected needles used for intravenous drug administration, infected blood and blood products used in transfusions, and the transmission of the virus from an infected mother to her baby during pregnancy or breastfeeding .
Common symptoms of HIV/AIDS
In the early acute phase of an HIV infection, common symptoms include fever, fatigue, muscle pain and swollen glands, which are often misinterpreted as symptoms of a common cold or flu. As the virus progresses to the chronic phase, patients may experience breathing difficulties, weight loss, diarrhoea and high fever. If a patient’s condition progresses to AIDS, the symptoms tend to be exacerbated and can be accompanied by anal/genital sores, rashes, memory problems and pneumonia . With an inherently weakened immune system because of the virus, the chances of developing comorbidities, including opportunistic infections, increase considerably .
What we have learned from the HIV/AIDS pandemic and how does this relate to the COVID‑19 pandemic
The viruses responsible for AIDS and COVID-19 (HIV and severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], respectively) are of course very different; however, we can take the lessons that we have learned from the ongoing HIV/AIDS pandemic and utilise them to effectively manage the current COVID-19 pandemic. As of September 2019, an estimated 37.9 million people were living with HIV worldwide, which, according to many experts, represents a substantial failure in global health management. It is this kind of failure that we can learn from to prevent COVID-19 from having such devastating and long-lasting effects .
A key lesson we have learned from the HIV/AIDS pandemic is that global health inequalities, including access to care and quality of care, are the prevailing factors when a pandemic persists for years and even decades. Transmission of HIV was enhanced by mobile, well-connected social networks, and in western countries the transmission of the virus among homosexual and other marginalised populations, including the transgender community and sex workers, was largely enabled by people ignoring preventive guidelines and engaging in unprotected sex . In low-income countries, the virus has had a devastating effect on all populations of society; this was principally due to a lack of access to condoms, leading to greater transmission rates in these countries .
Global health inequalities can be further highlighted by the fact that an overwhelming majority of current HIV cases are reported in low-income countries; this is largely because of the lack of barrier contraceptives and public awareness about the disease . In a similar light, the global burden of the COVID-19 pandemic overwhelmingly affects the elderly and vulnerable populations even more so in low- and middle-income populations . Therefore, in the case of COVID-19, acknowledging and addressing these health inequalities by ensuring any vaccines (when they become available) are shared equally among the global population, focussing efforts in promoting proper hygiene in lower‑income areas, and supporting countries whose healthcare infrastructure may not be as developed as the UK’s should all be of paramount importance in combatting the global COVID-19 pandemic in a timely manner [10, 11].
Behavioural changes are also key to tackling a global pandemic, and in the case of HIV/AIDS these include the use of condoms or abstaining from sex. From the HIV/AIDS pandemic, we have learned that in order to support such behavioural changes, an enabling environment must be created by addressing social and economic structures that prevent the most vulnerable groups/individuals from making safe choices . In the current COVID-19 era, we have learned that social distancing and regular handwashing are the primary preventive behavioural changes that we can adopt while there is no vaccine; this has led to the restructuring of shops, workplaces and public transport systems to create a conducive environment for 2 metre social distancing rules [10, 12, 13]. To combat COVID‑19, we must ensure that those who are most vulnerable to the SARS-CoV-2 virus (elderly individuals and those with comorbidities) are provided with sufficient means to wash their hands and personal protective equipment, alongside additional guidance on how to protect themselves in order to encourage behavioural changes .
The stigma associated with HIV/AIDS was a major obstacle in the prevention, care and treatment of HIV/AIDS in the early years of the pandemic . Soon after the first incidences of HIV were reported in the USA, the virus became widely known as ‘gay cancer’, which led to public belief that HIV/AIDS only affected homosexual men and fuelled the stigmatisation of HIV and those affected by it in an already very homophobic time in US history . This stigmatisation was sustained by an array of factors, including lack of understanding of the virus, misconceptions about the transmission of the virus, damaging media coverage, lack of access to treatment, widespread homophobia, and prejudices against the transgender community and sex workers [14, 15]. Correspondingly, as we face another global pandemic, we must ensure that COVID-19 is not stigmatised in the same way as HIV/AIDS and understand that the viruses that cause both diseases do not discriminate; they affect people of all ages, races, sexual orientations and socio-economic backgrounds .
The final lesson to be taken from the HIV/AIDS pandemic is that governments, researchers and healthcare professionals must work collaboratively to prevent the COVID-19 pandemic from reaching the same scale as the HIV/AIDS pandemic. Novel strategies to combat global pandemics must be utilised effectively in a multidisciplinary manner to allow their effects to have maximum impact on public health. Furthermore, the combined efforts of each country must also be shared globally to allow lessons to be learned from each nation’s approach to the pandemic, thereby allowing us, as a global community, to reap the benefits of successful strategies .
Supporting the HLTSAD campaign
To learn more about the campaign and offer your support, please visit their official website: https://www.hltsad.org/.
- HLTSAD. HIV Long-Term Survivors Awareness Day 5 June 2020: Not our first pandemic. Available at: https://www.hltsad.org/. Accessed June 2020.
- Medium. Why June 5 is HIV Long-Term Survivors Awareness Day (HLTSAD). Available at: https://medium.com/hiv-long-term-survivors-awareness-day-hltsad/about-june-5-hiv-long-term-survivors-awareness-day-hltsad-aba00fb33ad1. Accessed June 2020.
- HIV.gov. Ending the HIV epidemic: A timeline. Available at: https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview/ending-epidemic-timeline. Accessed June 2020.
- HIV.gov. What are HIV and AIDS? Available at: https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids. Accessed June 2020.
- Dutartre H, Clavière M, Journo C et al. Cell-free versus cell-to-cell infection by human immunodeficiency virus type 1 and human T-lymphotropic virus type 1: Exploring the link among viral source, viral trafficking, and viral replication. J Virol 2016; 90 (17): 7607–7617.
- Moir S, Chun T-W and Fauci AS. Pathogenic mechanisms of HIV disease. Annu Rev Pathol 2011; 6: 223–248.
- British Society for Immunology. CD8+ T cells. Available at: https://www.immunology.org/public-information/bitesized-immunology/cells/cd8-t-cells. Accessed June 2020.
- Healthline. A timeline of HIV symptoms. Available at: https://www.healthline.com/health/hiv-aids/hiv-symptoms-timeline. Accessed June 2020.
- UNAIDS. 37.9 million people are living with HIV around the world. Available at: https://www.unaids.org/en/resources/infographics/people-living-with-hiv-around-the-world. Accessed June 2020.
- Hargreaves J, Davey C and Group for lessons from pandemic HIV prevention for the COVID-19 response. Three lessons for the COVID-19 response from pandemic HIV. Lancet HIV 2020; 7 (5): e309–e311.
- World Health Organization. COVID-19 strategic preparedness and response plan: Operational planning guidelines to support country preparedness and response. Available at: https://www.who.int/docs/default-source/coronaviruse/covid-19-sprp-unct-guidelines.pdf?sfvrsn=81ff43d8_4. Accessed June 2020.
- GOV.UK. Working safely during coronavirus (COVID-19). Available at: https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19. Accessed June 2020.
- BBC News. Coronavirus: Supermarkets limit shoppers as rules tighten. Available at: https://www.bbc.co.uk/news/business-52022240. Accessed June 2020.
- UNAIDS. HIV – related stigma, discrimination and human rights violations. Available at: https://data.unaids.org/publications/irc-pub06/jc999-humrightsviol_en.pdf. Accessed June 2020. Accessed June 2020.
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