HIV testing in the UK

According to British guidelines, HIV testing should be offered at GUM clinics as part of routine STD screening, regardless of symptoms of disease or risk factors of infection. The guidelines state that everybody taking an HIV test should have a pre-test discussion, and be offered counselling if requested, or if there is a high risk of a positive result.²⁸

The number of people being tested for HIV and other STDs at GUM clinics (where the majority of people are tested for HIV) has risen in recent years. Almost half of sexual health screens in 2003 included an HIV test; this proportion increased to two-thirds for England, Wales and Northern Ireland in 2006. Overall, around 800,000 had an HIV test in a GUM clinic in England, Wales and Northern Ireland in 2007

A major worry is that many people infected with HIV aren’t accessing testing services soon enough. It’s estimated that nearly one third of HIV-positive adults in the UK are diagnosed late, and for heterosexual men this figure rises to 42%.³⁰ It can be difficult to treat someone with HIV if they are diagnosed late, and in some cases late diagnosis leads to death. According to the British HIV Association (BHIVA), at least a quarter of deaths reported in HIV-positive people in the UK between 2004 and 2005 may have been avoided if HIV had been diagnosed at an earlier stage³¹. BHIVA, along with other experts, say that non-HIV clinicians such as General Practitioners (GPs) need to be made more aware of the importance of early diagnosis. They have also called for HIV testing to be made a routine part of more generic healthcare services that aren’t specialised towards HIV or sexual health³². Introducing an opt-out testing policy (whereby everybody attending a GUM clinic is given an HIV test unless they specifically ask not to be tested) may be another way to reduce the number of people diagnosed late. Of previously undiagnosed HIV-infected heterosexual men and women attending GUM clinics in 2006, one quarter left the clinic unaware of their HIV infection in 2006³³.

HIV/AIDS prevention in the UK

HIV prevention in the UK currently includes measures to educate people about HIV/AIDS and how it is passed on so that they can take measures to protect themselves (by using condoms for example); encourage harm reduction measures for drug users (such as needle exchange programmes); and promote HIV testing.

It is widely felt by those working in HIV/AIDS organizations and the healthcare sector that HIV prevention in the UK needs to be stepped up and improved as the number of new infections continues to rise as the level of knowledge of the virus falls.

AIDS & HIV in the UK - the current situation

Although AIDS gets less attention from the media in the UK than it did during the early history of the UK AIDS epidemic, it’s far from a problem of the past. In fact, the epidemic has expanded, with the annual rate of new HIV diagnoses more than doubling between 1999 and 2003, and peaking in 2007.²

HIV prevalence in the UK is relatively low and currently stands at 0.2% of the population³. Statistics show that at the end of 2007 there were an estimated 77,400 people living with HIV in the UK, of whom approximately 20,700 were unaware of their infection. An estimated 7,734 people were newly diagnosed with HIV in the UK in 2007.⁴

Relatively low numbers of people in the UK have died from AIDS in recent years thanks to the availability of HAART (Highly Active Antiretroviral Therapy), which dramatically increases the life expectancy of people living with HIV. In 2007, around 540 HIV-infected persons died, compared to 1,726 in 1995, when antiretroviral treatment for HIV/AIDS was not available. The majority of AIDS related deaths occurred because people were diagnosed late and therefore did not start treatment early enough. In 2007, an estimated 31% of newly diagnosed, HIV-infected adults were diagnosed late.⁵

Although HIV is often perceived to be a ‘gay’ problem, infections acquired through heterosexual sex account for the largest number of HIV diagnoses in the UK. The majority of people who acquired HIV heterosexually were infected overseas but only became aware of their status after being tested in the UK. In terms of HIV infections actually occurring within the UK, gay men (and other men who have sex with men) accounted for two thirds of new cases.⁶

Despite the rising numbers of new HIV infections in the UK, public knowledge of HIV and AIDS appears to have declined. While 91% of people in the UK knew that HIV was transmitted through unprotected heterosexual sex in 2000, by 2007 this figure had fallen to 79%⁷.

Many UK HIV/AIDS organisations are calling for improved sexual health services. The Terrence Higgins Trust, for example, released a 2007 report stating that sexual health services in England remain woefully under prioritised and under funded. It claims that despite the government’s promise of an extra £300 million for sexual health services across the United Kingdom to modernise clinics and reduce waiting times, many GUM (Genitourinary Medicine) clinics remain cramped, out-of-date and understaffed

An overview of AIDS in the Caribbean

Due largely to their close geographic locations, the Caribbean is usually grouped with Latin America in discussions about HIV and AIDS, but the epidemics in these regions are very different. Even within the Caribbean, each country faces a unique situation. The diversity of the region – which is apparent in terms of politics, languages spoken, geographic location and wealth – is reflected in the significantly different ways that countries are affected.

At one extreme, the Bahamas has the highest HIV prevalence in the entire western hemisphere (3%); at the other, Cuba has one of the lowest (0.1%). Haiti (2.2%), Trinidad and Tobago (1.5%) and Jamaica (1.6%) are all heavily affected, while Puerto Rico is the only Caribbean country apart from Cuba where it is thought that less than 1% of the population is living with HIV. ² Other factors, such as AIDS mortality rates and transmission patterns, also vary across countries and areas. ³ See our Caribbean statistics page for more data.

Recent developments have given cause for optimism, with an overall stabilisation in the region. A small number of countries in the Caribbean have even shown signs of a decline in prevalence. In the Dominican Republic prevalence fell from 1% in 2002 to 0.8% in 2007. HIV infection levels have also decreased in Haiti, which has been partly attributed to an increase in condom use and changes in sexual behaviour. ⁴ However, HIV surveillance in the Caribbean is generally considered inadequate, so these reported trends are only vague indicators. Both HIV prevalence and AIDS cases are thought to be widely underestimated in the region. ⁵

Reflecting global patterns, heterosexual sex is now the main route of transmission throughout the region, and it has been established that women and young people are particularly vulnerable. ⁶ Little is known about the role that sex between men plays in the region’s epidemics – it has been estimated that men who have sex with men account for 12% of infections, but it is thought that the actual proportion is higher than this, since the rampant homophobia that exists throughout the region has led to denial and under-reporting.⁷

Despite differences between countries, the spread of HIV in the Caribbean has taken place against a common background of poverty, gender inequalities and a high degree of HIV-related stigma. Migration between islands and countries is common, contributing to the spread of HIV and blurring the boundaries between different national epidemics. ⁸ Additionally, poor availability of HIV and AIDS data makes it difficult to gain a clear picture of each country’s situation.

Children, HIV and AIDS in South Africa

With many women who are HIV-positive still not receiving drugs that could prevent them passing HIV to their babies, HIV infections are alarmingly common amongst children in South Africa. According to UNAIDS, there were around 280,000 children aged below 15 living with HIV in South Africa in 2007.²⁷

Children who are living with HIV are highly vulnerable to illness and death unless they are provided with paediatric antiretroviral treatment. Unfortunately there is still a shortage of such treatment in South Africa. The AIDS Law Project, an NGO based in Johannesburg, estimated that 50,000 children in South Africa were in need of antiretroviral drugs at the beginning of 2006, but that only around 10,000 were receiving them.²⁸ UNAIDS estimates that at the end of 2005, children accounted for 8% of those receiving antiretroviral drugs in South Africa.²⁹

As well as many children being infected with HIV in South Africa, many more are suffering from the loss of their parents and family members from AIDS. UNAIDS estimated that there were 1.4 million South African children orphaned by AIDS in 2007, compared to 780,000 in 2003.³⁰ Once orphaned, these children are more likely to face poverty, poor health and a lack of access to education.

Gender inequality and sexual abuse in South Africa

Although HIV prevention campaigns usually encourage people to use condoms and have fewer sexual partners, women and girls in South Africa are often unable to negotiate safer sex and are frequently involved with men who have several sexual partners. They are also particularly vulnerable to sexual abuse and rape, and are economically and socially subordinate to men. Police reports suggest that in 2004-2005 there were at least 55,114 cases of rape in South Africa ²³, although the actual figure is undoubtedly higher than this since the majority of cases go unreported. In a 2006 study of 1,370 South African men, nearly one fifth revealed that they had raped a woman.²⁴ Rape plays a significant role in the high prevalence of HIV among women in South Africa.

Women often face more severe discrimination than men if they are known to be HIV-positive. This can lead to physical abuse and the loss of economic stability if their partners leave them. Since antenatal testing gives them a greater chance of being identified as HIV-positive, women are sometimes branded as ‘spreaders’ of infection.

The government has acknowledged that many women face ‘triple oppression’ in South African society – oppression on the grounds of race, class and gender – and has been making efforts to address this problem, through education and skills development schemes.²⁵ In September 2007 rape laws were strengthened to stop judges and magistrates taking into account factors such as a rape victim's sexual history, their apparent lack of physical injury, or the relationship between the victim and the perpetrator, when deciding on the length of the perpetrator's sentence.

HIV testing in South Africa

HIV voluntary counselling and testing (VCT) should be an important part of any country’s response to AIDS. The number of VCT sites in South Africa has increased significantly in recent years, with 4,172 operational by November 2006. Despite this progress, there are concerns about the quality of VCT services in some areas. Reports suggest that counsellors are not always adequately trained, may lack medical knowledge about HIV, and are often overworked.¹⁴

Another problem is that women seem to be accessing testing more readily than men in South Africa. Researchers believe that this is due to fears amongst men that their HIV-positive status will be disclosed through testing, and that stigmatisation will follow. Surveys have also suggested that some men see no value in knowing their HIV status, viewing such knowledge as a burden.¹⁵

HIV treatment in South Africa

South Africa’s national HIV treatment programme has been the topic of much debate. The South African government was initially hesitant about providing antiretroviral treatment to HIV-positive people, and only started to supply the drugs in 2004 – years after many other nations had begun to do so – following pressure from activists. Even since 2004, the distribution of antiretroviral drugs has been relatively slow, with only around 28% of people in need receiving treatment at the end of 2007.¹³

The government was also initially reluctant to provide drugs that could prevent HIV-positive mothers from passing HIV on to their babies, and has been accused of not making enough effort to get these drugs to women that need them.

The slow provision of treatment has been linked to unconventional views about HIV and AIDS amongst the government. Alongside President Mbeki’s questioning of whether HIV really causes AIDS, his health minister Manto Tshabalala-Msimang caused controversy by promoting nutrition rather than antiretroviral drugs as a means of treating HIV. These views attracted widespread criticism, both within South Africa and amongst the international community.

See our AIDS in South Africa: treatment, transmission and the government page for a full account of the issues surrounding antiretroviral drug provision, misinformation, and mother-to-child transmission of HIV in South Africa.

Why did South Africa’s AIDS epidemic go unchecked for so long?

The most rapid increase in South Africa’s HIV prevalence took place between 1993 and 2000, during which time the country was distracted by major political changes. While the attention of the South African people and the world's media was focused on the country's transition from apartheid, HIV was rapidly becoming more widespread. Although the results of these political changes were positive, the spread of the virus was not given the attention that it deserved, and the impact of the epidemic was not acknowledged. It is likely that the severity of the epidemic could have been lessened by prompt action at this time.

The history of AIDS in South Africa

South Africa has had a turbulent past, and this history is relevant to the explosive spread of HIV in the country.

1980s - In 1985, a State of Emergency was declared in South Africa that would last for five years. This was a result of riots and unrest that had arisen in response to Apartheid, the system of racial segregation that had been in place since the 1950s. Apartheid prohibited mixed-race marriages and sex between different ethnic groups, and categorised separate areas in which different races lived. In the same year, the government set up the country’s first AIDS Advisory Group in response to the increasingly apparent presence of HIV amongst South Africans. The first recorded case of AIDS in South Africa was diagnosed in 1982, and although initially HIV infections seemed mainly to be occurring amongst gay men, by 1985 it was clear that other sectors of society were also affected. Towards the end of the decade, as the abolition of Apartheid began, an increasing amount of attention was paid to the AIDS crisis.

1990 - The first national antenatal survey to test for HIV found that 0.8% of pregnant women were HIV-positive.⁹ It was estimated that there were between 74,000 and 120,000 people in South Africa living with HIV. Antenatal surveys have subsequently been carried out annually.

1991 - The number of diagnosed heterosexually transmitted HIV infections equalled the number transmitted through sex between men. Since this point, heterosexually acquired infections have dominated the epidemic. Several AIDS information, training and counselling centres were established during the year.

1992 - The government’s first significant response to AIDS came when Nelson Mandela addressed the newly formed National AIDS Convention of South Africa (NACOSA). The purpose of NACOSA was to begin developing a national strategy to cope with AIDS. The free National AIDS Helpline was founded.

1993 - The National Health Department reported that the number of recorded HIV infections had increased by 60% in the previous two years and the number was expected to double in 1993. The HIV prevalence rate among pregnant women was 4.3%.

1994 - The Minister for Health accepted the basis of the NACOSA strategy as the foundation of the government's AIDS plan. There was criticism that the plan, however well intended, was poorly thought-out and disorganised. The South African organisation Soul City was formed, with the aim of developing media productions to educate people about health issues, including HIV/AIDS.

1995 - The International Conference for People Living with HIV and AIDS was held in South Africa, the first time that the annual conference had been held in Africa. The then Deputy President Thabo Mbeki, acknowledged the seriousness of the epidemic, and the South African Ministry of Health announced that some 850,000 people - 2.1% of the total population - were believed to be HIV-positive.¹⁰

1996 - The HIV prevalence rate among pregnant women was 12.2%.

1997 - The HIV prevalence rate among pregnant women was 17.0%. A national review of South Africa's AIDS response to the epidemic found that there was a lack of political leadership.

1998 - The pressure group Treatment Action Campaign (TAC) was founded, to campaign for the rights of people living with HIV, and to demand access to HIV treatment in South Africa for all those who were in need of it. Deputy President Thabo Mbeki launched the Partnership Against AIDS, admitting that 1,500 HIV infections were occurring every day.

1999 - The HIV prevalence rate among pregnant women was 22.4%.

2000 - The Department of Health outlined a five-year plan to combat AIDS, HIV and STIs.¹¹ A National AIDS Council was set up to oversee these developments. At the International AIDS Conference in Durban, the new South African President Thabo Mbeki made a speech that avoided reference to HIV and instead focused on the problem of poverty, fuelling suspicions that he saw poverty, rather than HIV, as the main cause of AIDS. President Mbeki consulted a number of ‘dissident’ scientists who rejected the link between HIV and AIDS.

2001 - The HIV prevalence rate among pregnant women was 24.8%.

2002 - South Africa's High Court ordered the government to make the drug nevirapine available to pregnant women to help prevent mother to child transmission of HIV. Despite international drug companies offering free or cheap antiretroviral drugs,¹² the Health Ministry, led by Manto Tshabalala-Msimang, remained hesitant about providing treatment for people living with HIV.

2003 - In November, the government finally approved a plan to make antiretroviral treatment publicly available. The HIV prevalence rate among pregnant women was 27.9%.

2004 - The South African government’s treatment program began to take effect in Gauteng in March, followed shortly afterwards by other provinces.

2005 - At least one service point for AIDS related care and treatment had been established in all of the 53 districts in the country by March, meeting the government’s 2003 target. However, it was clear that the number of people receiving antiretroviral drugs was well behind initial targets. The HIV prevalence rate among pregnant women was 30.2%.

2006 – Jacob Zuma, the Former South African Deputy-President, went on trial for allegedly raping an HIV-positive woman. He argued that she had consented to sex and was eventually found not guilty, but attracted controversy when he stated that he had showered after sex in the belief that this would reduce his chances of becoming infected with HIV. Criticism of the government’s response to AIDS heightened, with UN special envoy Stephen Lewis attacking the government as ‘obtuse and negligent’ at the International AIDS Conference in Toronto. At the end of the year, the government announced a draft framework to tackle AIDS and pledged to improve antiretroviral drug access. Civil society groups claimed that this marked a turning point in the government’s response.

2008 – President Mbeki resigned in September 2008 after losing the support of his party. Kgalema Motlanthe took over as interim president and appointed Barbara Hogan as health minister in place of Manto Tshabalala-Msimang. AIDS activists welcomed the changes, anticipating greater government commitment to the AIDS response.

Can a woman become pregnant even if she doesn't have sexual intercourse?

es. Pre-ejaculate (pre-come), the lubricating fluid that leaks out of a man's penis when he's sexually excited, can sometimes contain sperm. If pre-come or semen (come) get inside or around the entrance to the vagina, this can lead to pregnancy. They can also pass on a sexually transmitted infection. Semen and pre-come can be transferred to the vagina on fingers or sex toys, so it's important to make sure they're clean and washed before they go anyway near a woman's vagina.

Which position is best for having sex?

There are quite a lot of different positions for sexual intercourse. One of the most common is the missionary position, where a woman lies on her back and a man lies on top of her. A man and woman might also lie on their sides, the woman may sit on top of the man, or she may kneel on all fours while the man puts his penis into her vagina from behind. If a couple are in a position where the woman's clitoris is not being stimulated, they can do this with their fingers.

What 'counts' as losing your virginity?

Different people have different opinions on this, and some say there are different types of virginity. But most people generally agree that if a man has had penetrative sex with a woman then he (or she) is no longer a virgin.

Does having sex hurt?

Having sex does not usually hurt, though first time sex may be a bit uncomfortable for a woman because her hymen (a thin layer of skin that partially covers the entrance to the vagina) may be stretched or torn. This may cause a little bleeding, but it does not usually last long. Sex is not usually painful for a man.

After the first time, sex should become more comfortable. The vagina is very stretchy and will usually accommodate a penis (even a large one) with ease. However, a woman may experience pain when having sexual intercourse if her vagina does not produce enough natural lubrication. Extra vaginal fluids are usually produced when a woman becomes sexually excited to allow the penis to enter the vagina easily. If a woman is tense or rushing when she has sex, her vagina may not become moist enough to allow the penis to move in and out smoothly. Stress can also cause the muscles in the vagina to involuntarily tense up, making penetration difficult and painful. The best way to ensure pain free sex is for both partners to relax and take their time.

Extra lubrication might also help, and can be bought from many chemists and some supermarkets. When using a condom, it is very important that a water-based lubricant (like KY jelly) is used, as oil-based lubricants like Vaseline can cause the condom to disintegrate.

How to have sex

It depends what you mean by having sex. Sexual intercourse is sometimes called making love or having sex. The most common definition of sexual intercourse is an act that involves a man putting his erect penis inside a woman's vagina. Sexual intercourse might also be used to refer to sex acts between two men or between two women.

Sexual intercourse between a man and a woman starts with them both getting sexually excited. This is sometimes referred to as foreplay, and might involve kissing and cuddling, touching each other and other sexual activities. Foreplay is important as it means a woman's vagina begins to get moist and a man gets an erection. If the woman's vagina does not get moist enough, then having sexual intercourse could be difficult or painful for her.

If a man and woman are having sexual intercourse, then using a contraceptive properly, every time, will prevent the woman becoming pregnant. There is more information on the contraceptive page.

If two people have sex (sexual intercourse) and one of them has a sexually transmitted disease (STD) then they could pass it on to the other person. Using a condom is the best way to prevent any infection from being passed from one person to the other.

If a couple are going to use a condom for protection against pregnancy or infections, they should put it on the man's penis as soon as he gets an erection. Some men say they worry about using condoms in case they lose their erection or have difficulty putting the condom on. You could get some condoms and practice beforehand. Condoms come with instructions in words and pictures which show exactly how to use them.

After the condom is on, the man or woman can guide his penis into her vagina. The couple then move their bodies so that his penis moves up and down inside her vagina. This usually rubs the penis and makes the man sexually excited so that he has an orgasm. The movement might also rub the woman's clitoris (or sensitive areas inside her vagina) so she can have an orgasm. But this depends on the position the couple are in when they have sexual intercourse.

AIDS treatment in Asia

A major constraint is the high cost of ARVs, as both first- and second-line drugs are still unaffordable to most governments. Cheaper generic drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it’s hoped that this will make it easier for governments to obtain and distribute the drugs. Yet even where drugs are available, the poor state of healthcare in many Asian countries, particularly a shortage of trained doctors, is hindering governments' abilities to organise life-long treatment programmes for millions of people living with HIV
The availability of AIDS treatment has more than tripled in Asia since 2004. At the end of 2007 an estimated 420,000 people in the region were receiving antiretroviral drugs (ARVs). Although this rise is encouraging, access to treatment varies widely across the region. There is evidence that the majority of countries in Central, South and South-East Asia have laws that impede access to HIV services among injecting drug users.²² Overall it is estimated that three quarters of people in need of ARVs in Asia still have no access to them.²³

HIV prevention in Asia

Asia has been the base for some extremely successful large-scale HIV prevention programmes. Well-funded, politically supported campaigns in Thailand and Cambodia have led to significant declines in HIV-infection levels, and HIV prevention aimed at sex workers and their clients has played a large role in these achievements. The Indian state of Tamil Nadu is another area where HIV prevention has had a substantial impact. Here high-profile public campaigns discouraged risky sexual behaviour, made condoms more widely available, and provided STI testing and treatment for people who needed them. These efforts resulted in a large decline in risky sex.¹⁵

Successes such as these prove that interventions can change the course of Asia's AIDS epidemics. As HIV infection rates continue to grow however, it's clear that more needs to be done. The groups most at risk of becoming infected – sex workers, IDUs, and MSM – are all too often being neglected. For instance, although injecting drug use is one of the most common HIV transmission routes in Asia, it is estimated that less than one in ten IDUs in the region have access to prevention services.¹⁶ Similarly men who have sex with men are overlooked and poorly monitored by most governments, even though it is firmly established that this group play a significant role in some countries’ epidemics.¹⁷

Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV testing and counselling services in South-East Asia remains very low. An estimated 0.1% of the adult population in the region received testing and counselling in 2005.¹⁸

Progression is being made in China though where free HIV testing has been made available at more than 3000 sites in all 31 provinces of the country.
Testing services in India have also been expanded recently with about 3600 testing centres now open to the public.¹⁹

Despite efforts being made across the region, more still needs to be done to make testing available to those most at risk.

The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In South-East Asia, less than 5% of pregnant women are offered HIV counselling and testing.²⁰ Across East, South and South-East Asia, the proportion of HIV-infected pregnant women receiving ARVs is just 5%.²¹

See our HIV prevention around the world page for more about efforts to stem the spread of HIV in Asia and other parts of the world.

Overview of AIDS and HIV in Asia

In the early to mid-1980s, while other parts of the world were beginning to deal with serious HIV & AIDS epidemics, Asia remained relatively unaffected by this newly discovered health problem. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries, and by the end of that decade, HIV was spreading rapidly in many areas of the continent.

Today, HIV/AIDS is a growing problem in every region of Asia. East Asia has been identified by UNAIDS as one of the areas of the world where ‘the most striking increases’ in the numbers of people living with HIV have occurred in recent years (along with Eastern Europe and Central Asia).¹ Although national HIV prevalence rates in Asia appear to be relatively low (particularly in comparison with sub-Saharan Africa), the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. The latest statistics compiled by UNAIDS suggest that at the end of 2007, 5 million people were living with HIV in Asia.²

Various factors make Asia vulnerable to the spread of HIV, including poverty, inequality, unequal status of women, stigma, cultural myths about sex and high levels of migration.^{3 4} Some experts predict that Asia may eventually overtake Africa as the part of the world with the highest number of HIV-infected people. Others, however, argue that Asia’s epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely occurring among members of ‘high-risk groups’, unlike Africa where HIV and AIDS are widespread amongst all sections of some countries’ populations.⁵

Although its useful to understand the overall impact that AIDS is having on the Asian region as a whole, there is no single ‘Asian epidemic’; each country in the region faces a different situation.

HIV prevention and affected groups

Thailand once led the way in world HIV prevention, with a series of successful campaigns that helped to reduce the national HIV prevalence. However, in the new millennium there were signs of complacency; prevention programmes received just 8% of the national HIV/AIDS budget in 2000, and by 2001 the level of domestic funding for HIV prevention was half of what it had been in 1997.³⁶ In 2006, UNAIDS reported that Thailand’s government had reduced its HIV prevention budget by two-thirds.³⁷

There were concerns that the declining focus on prevention was putting the public at risk. Reports suggested that condom use had decreased and the rate of STI transmission had risen.^{38 39} Without new prevention campaigns, there was a risk that safe sex messages would be forgotten and a new generation of young people would grow up ignorant of the risks that they face.

In September 2006 following a military coup, a new Thai government was installed. In light of the concerns about a resurgence of the epidemic, the new government decided to increase HIV/AIDS prevention efforts. In 2007 a three-year strategic plan was announced which would focus on those most at risk of HIV infection and difficult-to-reach groups.⁴⁰

The current situation

Thailand Statistics31
Estimated total population, 2008	65,493,000
Estimated number of people living with HIV, end 2007	610,000
Adults (15+)	600,000
Women (15+)	250,000
Children (0-15)	14,000
Estimated adult HIV prevalence	1.4%
Estimated number of AIDS deaths in 2007	31,000

The history of HIV and AIDS in Thailand

Early responses

The first case of AIDS in Thailand occurred in 1984.⁴ For the next few years, gay men, sex workers, injecting drug users and tourists were more commonly affected than other groups. The government took some basic measures to deal with the issue, but an epidemic was not yet apparent. Most of these measures were aimed at high-risk groups, as the government believed that there was not yet sufficient reason to carry out prevention campaigns among the general public.

At the same time, public awareness of the issue was increasing. The case of Cha-on Suesom, a factory worker who became infected with HIV following a blood transfusion, was widely broadcast through the media after he agreed to allow his story and identity to be publicised in 1987. He became well known after appearing on TV shows and in national newspapers, allowing the public to appreciate the human side of the epidemic. Cha-on and his wife had both been fired from their jobs as a result of his HIV-positive status, and the injustice of this situation helped to increase public sympathy for people living with HIV. ⁶

Between 1988 and 1989, the HIV prevalence among injecting drug users rose dramatically, from virtually zero to 40%. The prevalence among sex workers also increased, with studies in Chang Mai, northern Thailand, suggesting that 44% of sex workers were infected with HIV.⁷ The rising level of infection among sex workers led to subsequent waves of the epidemic among the male clients of sex workers, their wives and partners, and their children.⁸

The prevailing view was still that HIV and AIDS had come from abroad and were mostly confined to a few individuals in high-risk groups. It was still not generally recognised that the epidemic would spread more widely. One government official insisted that the situation was under control, and stated that:

“The general public need not be alarmed. Thai-to-Thai transmission is not in evidence.”⁹

Some members of Thailand’s parliament proposed that all foreigners should be required to pass an HIV test before being admitted to the country.¹⁰ In keeping with the view that the threat was limited, the government only spent $180,000 on HIV prevention in 1988.¹¹

HIV testing

One of the main barriers to effective HIV prevention is that the majority of people infected with HIV in China are not aware of their positive status. HIV testing is important so that those found to be infected with the virus can seek treatment and take measures to prevent transmission to others. Little over a quarter of those questioned in a 2008 survey knew where they could get tested.⁷⁴

Until recently people in China were only tested for HIV through voluntary counselling and testing (VCT) schemes. Although these VCT sites still exist, in 2004 the government launched a national programme of ‘active testing’ to seek out certain high-risk groups. Under the new policy, community health leaders initiate outreach schemes to invite members of the targeted groups to be tested. The new policy was launched in Yunnan province in 2004 and found that of the 424,000 people targeted, only 1.3% refused the test. 13,486 people (3.2%) were found to be HIV positive.

Although the Chinese government consider outreach ‘active testing’ to be successful for the increased number of people identified as HIV positive (in Yunnan the number of people found to have HIV was equivalent to the total number identified through voluntary testing in the previous 18 years) some experts have voiced concern over the human rights of those being tested. There is unease that ‘active testing’ may be placing community protection over individual rights. The tests may not be entirely voluntary due to the significant social pressure to be tested. Additionally social marketing campaigns promoting HIV awareness and addressing misconceptions are often used in place of individual pre- and post test counselling⁷⁵.

Routine testing (whereby people are tested as part of an annual medical check up) has also been introduced in institutional settings such as prisons and government offices⁷⁶. This method of HIV testing has also provoked criticism as individuals consent to health examinations that include an HIV test, rather than directly agreeing to the test itself⁷⁷.

In the first seven months of 2008, China conducted random HIV tests on some 756,000 travellers at border crossings. HIV positive foreigners are generally barred from entering China, though it is expected that this ban may be lifted in 2009⁷⁸.

HIV sub-epidemics in China

The AIDS epidemic in China consists of several different sub-epidemics that often overlap and intersect with each other. High prevalence groups in China include injecting drugs users, men who have sex with men, former plasma donors, commercial sex workers and migrant workers. UNAIDS predicts that amongst these sub-populations, there are an estimated 30–50 million people who are at risk of exposure to HIV²³.

Although it is customary to associate HIV/AIDS in China with these high-risk groups, boundaries are becoming increasingly blurred as the virus finds its way into the general population, and sex becomes the dominant transmission route²⁴.

Injecting drugs users

In 1989 HIV was detected amongst injecting drug users (IDUs) in Yunnan province²⁵. Needle sharing drove the epidemic and HIV spread rapidly to IDUs in neighbouring cities and along drug trafficking routes. By 2002 HIV was present amongst IDUs in all mainland Chinese provinces. It is believed that IDUs may have been the core source for all later sub-epidemics in China

In 2007 there were a reported 937,000 registered injecting drug users in China²⁷, although unofficial estimates put the number closer to three or four million.

A zero tolerance attitude to drug use meant that the government was slow to implement HIV prevention and control measures for IDUs. Prevention activities tended to focus on posters outlining the harmful effects of drug use, or concentrated on reducing supply and demand.

In the late 1990s the Chinese government began to show a change in attitude towards preventing HIV transmission among injecting drug users²⁸.

A pilot began in Guangdong in 2000. After initial positive results showed that participants were almost three times less likely to have shared needles in the past month, the programme was scaled up to approximately 92 sites in high prevalence regions²⁹. China now has more drug replacement clinics and needle social marketing programmes than any other country in Asia³⁰.

Further interventions for IDUs were also explored and in 2004 a methadone maintenance treatment programme was piloted. The programme found that the rates of heroin use, intravenous injection and crime related to drug use decreased in the pilot areas³¹. By September 2006 there were 307 methadone clinics in China, covering two thirds of the country's provinces.

Current estimates

Current estimates by UNAIDS estimate that 700,000 people were living with HIV in China in 2007²⁰. This figure is lower than the previously published estimate of 840,000 in 2003. This is not because prevalence is falling, but is due to better data and improved methods of estimation. However, massive under reporting, especially in the rural areas, means that even the revised figures may be inaccurate.

UNAIDS and other organisations had previously estimated that by 2010 there could be a generalised epidemic with between ten and twenty million HIV positive Chinese²². Although this is no longer anticipated there is still potential for a severe epidemic in China.

The history of AIDS in China

n 1989, 146 injecting drug users (IDUs) in Southwest Yunnan were identified as HIV positive. By the end of the year the total number of infected people was reported as 153 Chinese and 41 foreigners¹⁰. At that time AIDS and drug addiction were seen as consequences of contact with the West, and AIDS was known as aizibing, the "loving capitalism disease"¹¹.

By late 1994 it was clear that the reported AIDS cases amongst IDUs in Yunnan had signalled the beginning of an epidemic amongst drug users. National figures for HIV infection were growing quickly – in 1996 the Minister of Health, Chen Min-Zhang, put the number of infections at between 50,000 and 100,000¹² - and new cases were being reported in more regions. By 1998, HIV infections had been reported in all 31 provinces, autonomous regions and municipalities, with drug users accounting for 60-70% of reported infections¹³.

The sharp increase in AIDS cases in China in the 1990s was also attributed to a large number of people infected through blood donation, which was widely reported by the western press, as well as transmission through heterosexual sex, which increased steadily to represent 7% of all HIV infections¹⁴.

There was a notable shift in government response to the epidemic in the new millennium. On World AIDS Day 2001, stories and testimonials of those infected with HIV alongside a television drama about AIDS reflected a far greater willingness to discuss the emerging epidemic

he same year, the "China Plan of Action to Contain, Prevent and Control HIV/AIDS (2001-2005)" was published, which included plans to screen all blood for clinical use for HIV¹⁶.

In 2003, the Health Minister’s change in attitude was evident, it is widely felt that the 2003 SARS epidemic prompted the change as it demonstrated to the government the impact public health could have on social and economic stability. He described the fight against AIDS as a "long-term war" and, as well as showing a new willingness to accept overseas assistance, requested that China’s AIDS budget of US$12.5 million be doubled.¹⁷.

On World AIDS Day 2003, Wen Jiabao became the first Chinese premier to shake hands with an HIV-positive person

The history of AIDS in China

China’s first AIDS case was reported in Beijing in 1985⁶. In the following five years a small number of further cases were reported among foreigners and Chinese, who were infected overseas or by imported blood products⁷.

During the early stages of the AIDS epidemic the Health Ministry concentrated its prevention efforts on the risk of infection from abroad. In 1986 it announced that it planned to test all foreign students for AIDS who had been in the country for more than a year, and students entering China would require a certificate from their country of origin testifying that they were not infected with HIV⁸. Although a National Programme for AIDS Prevention and Control was set up in 1987, the Public Health Authorities reported that AIDS would not become established as homosexuality and "abnormal" sexuality - thought to be the main causes of the spread of HIV - were a "limited" problem

Testing

The general consensus among those fighting AIDS worldwide is that HIV testing should be carried out voluntarily, with the consent of the individual concerned. This view has been supported by the Indian government and NACO, who have helped to establish hundreds of voluntary counselling and testing (VCT) centres in India. By the end of 2005 there were 873 VCT centres in India, compared to just 62 in 1997. ⁴¹ These centres tested 225,600 people for HIV during 2005. ⁴² In 2007 there was a dramatic scale-up - 4245 testing and counselling centres were in operation by December 2007

Although voluntary testing is officially supported in India, some states have tried to implement policies that would force people to be tested for HIV against their will. In Goa, the state government recently planned to make HIV tests compulsory before marriage, and in Punjab it has been proposed that all people wishing to obtain or retain a driver’s license should be tested for HIV. ⁴⁴ Neither of these plans has come to pass, but they have concerned activists, who argue that HIV testing should never be imposed on people against their wishes.

Unfortunately, cases of people being tested without their consent or knowledge are common in Indian hospitals. In one 2002 study, it was suggested that over 95% of patients listed for surgical procedures are tested against their will, often resulting in their surgery being cancelled. ⁴⁵ Hospital staff and health professionals, much like the rest of the Indian population, are often unaware of the facts about HIV. This leads to unnecessary fears and, in some cases, causes them to stigmatise HIV positive people and discriminate against them, including testing them without consent.

Who is affected by HIV and AIDS in India?

eople living with HIV in India come from incredibly diverse backgrounds, cultures and lifestyles. The vast majority of infections occur through heterosexual sex, and most of those who become infected would not fall into the category of ‘high-risk groups’ - although members of such groups, including sex workers, men who have sex with men, truck drivers and migrant workers, do face a proportionately higher risk of infection.

Nagaland

Nagaland is another small northeastern state, with a population of two million, where injecting drug use has again been the driving force behind the spread of HIV. In 2006, the HIV prevalence at antenatal clinics was 0.93%, and the rate among female sex workers was 16.40%.

Manipur

Manipur is a small state of some 2.2 million people in the northeast of India. The nearness of Manipur to Myanmar (Burma), and therefore to the Golden Triangle drug trail, has made it a major transit route for drug smuggling, with drugs easily available. HIV prevalence among injecting drug users is around 20%, and the virus is no longer confined to this group, but has spread further to the female sexual partners of drug users and their children. ³² The HIV prevalence at antenatal clinics in Manipur has exceeded 1% in all recent years. The 2005-2006 survey found that 1.13% of the general population was infected - the highest of all states surveyed.

Tamil Nadu

When surveillance systems in the southern Indian state of Tamil Nadu, home to some 62 million people, showed that HIV infection rates among pregnant women were rising - tripling to 1.25% between 1995 and 1997 - the State Government acted decisively. Funding for the Tamil Nadu State AIDS Control Society (TANSACS), which had been set up in 1994, was significantly increased. ³⁰ Along with non-governmental organisations and other partners, TANSACS developed an active AIDS prevention campaign. This included hiring a leading international advertising agency to promote condom use for risky sex in a humorous way, without offending the many people who do not engage in risky behaviour. The campaign also attacked the ignorance and stigma associated with HIV infection.
he HIV prevalence at antenatal clinics in Tamil Nadu was 0.25% in 2006, though several districts still have much higher rates. The general population survey of 2005-2006 found a rate of 0.34% across the state. Prevalence among injecting drug users was 24.20% in 2006 - the highest of all states and union territories

Maharashtra

Mumbai (Bombay) is the capital city of Maharashtra state and is the most populous city in India, with around 14 million inhabitants. Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The HIV prevalence at antenatal clinics in Maharashtra was 0.75% in 2006, and surveys of female sex workers have found around 20% to be infected. Similarly high rates are found among injecting drug users and men who have sex with men. The 2005-2006 survey found an infection rate of 0.62% in the general population of Maharashtra. This state is home to around one in five of all people living with HIV in India.

Karnataka

Karnataka - a diverse state in the southwest of India - has a population of around 53 million. In Karnataka the average HIV prevalence at antenatal clinics has exceeded 1% in all recent years. Among the general population, 0.69% were found to be infected in 2005-2006. Districts with the highest prevalence tend to be located in and around Bangalore in the southern part of the state, or in northern Karnataka's "devadasi belt". Devadasi women are a group of women who have historically been dedicated to the service of gods. These days, this has evolved into sanctioned prostitution, and as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. ²⁹ The average HIV prevalence among female sex workers in Karnataka was 8.64% in 2006, and 19.20% of men who have sex with men were found to be infected.

Goa

Goa is a very small state in the southwest of India, and is best known as a tourist destination. Tourism is so prominent that the number of tourists almost equals the resident population, which is about 1.3 million. The HIV prevalence at antenatal clinics was found to be 0.50% in 2006. Prevalence at STD clinics was 8.6% in 2006, indicating that Goa has a serious epidemic of HIV among sexually active people.

Andhra Pradesh

ndhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live in or around the city of Hyderabad. The HIV prevalence at antenatal clinics was 1.26% in 2006 - higher than in any other state - while the general population prevalence was 0.97% in 2005-2006. The vast majority of infections in Andhra Pradesh are believed to result from sexual transmission. HIV prevalence at STD clinics was 24.4% in 2006.

The HIV/AIDS situation in different states

The vast size of India makes it difficult to examine the effects of HIV on the country as a whole. The majority of states within India have a higher population than most African countries, so a more detailed picture of the crisis can be gained by looking at each state individually.

The HIV prevalence data for most states is established through testing pregnant women at antenatal clinics. While this means that the data are only directly relevant to sexually active women, they still provide a reasonable indication as to the overall HIV prevalence of each area. ²⁷ Data for six states are also available from a survey of the general population. ²⁸

The following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) clinics over recent years.

Current estimates

In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there were more people with HIV in India than in any other country in the world. ¹⁷ However, NACO disputed this estimate, and claimed that the actual figure was lower. ¹⁸ In 2007, following the first survey of HIV among the general population, UNAIDS and NACO agreed on a new estimate – between 2 million and 3.6 million people living with HIV. The figure was confirmed to be 2.4 million in 2008. This puts India behind South Africa and Nigeria in numbers living with HIV.^{19 20}

In terms of AIDS cases, the most recent estimate comes from August 2006, at which stage the total number of AIDS cases reported to NACO was 124,995. Of this number, 29% were women, and 36% were under the age of 30. These figures are not accurate reflections of the actual situation though, as large numbers of AIDS cases go unreported. ²¹

Overall, around 0.3% of India’s population is living with HIV. ²² While this may seem a low rate, India’s population is vast, so the actual number of people living with HIV is remarkably high. There are so many people living in India that a mere 0.1% increase in HIV prevalence would increase the estimated number of people living with HIV by over half a million.

The national HIV prevalence rose dramatically in the early years of the epidemic, but a study released at the beginning of 2006 suggests that the HIV infection rate has recently fallen in southern India, the region that has been hit hardest by AIDS. ²³ In addition, NACO has released figures suggesting that the number of people living with HIV has declined. ²⁴

Researchers claim that this trend is the result of successful prevention campaigns, which have led to an increase in condom use.

The History of HIV/AIDS in India

At the beginning of 1986, despite over 20,000 reported AIDS cases worldwide ², India had no reported cases of HIV or AIDS.³ There was recognition, though, that this would not be the case for long, and concerns were raised about how India would cope once HIV and AIDS cases started to emerge. One report, published in a medical journal in January 1986, stated:

Later in the year, India’s first cases of HIV were diagnosed among sex workers in Chennai, Tamil Nadu. It was noted that contact with foreign visitors had played a role in initial infections among sex workers, and as HIV screening centres were set up across the country there were calls for visitors to be screened for HIV. Gradually, these calls subsided as more attention was paid to ensuring that HIV screening was carried out in blood banks. ^{5 6}

In 1987 a National AIDS Control Programme was launched to co-ordinate national responses. Its activities covered surveillance, blood screening, and health education. ⁷ By the end of 1987, out of 52,907 who had been tested, around 135 people were found to be HIV positive and 14 had AIDS. Most of these initial cases had occurred through heterosexual sex, ⁸ but at the end of the 1980s a rapid spread of HIV was observed among injecting drug users in Manipur, Mizoram and Nagaland - three north-eastern states of India bordering Myanmar (Burma). ⁹

At the beginning of the 1990s, as infection rates continued to rise, responses were strengthened. In 1992 the government set up NACO (the National AIDS Control Organisation), to oversee the formulation of policies, prevention work and control programmes relating to HIV and AIDS. ¹⁰ In the same year, the government launched a Strategic Plan for HIV prevention. This plan established the administrative and technical basis for programme management and also set up State AIDS bodies in 25 states and 7 union territories. It was able to make a number of important improvements in HIV prevention such as improving blood safety. ¹¹

A human daisy chain on World Aids Day in India, December 2004.

By this stage, cases of HIV infection had been reported in every state of the country. ¹² Throughout the 1990s, it was clear that although individual states and cities had separate epidemics, HIV had spread to the general population. Increasingly, cases of infection were observed among people that had previously been seen as ‘low-risk’, such as housewives and richer members of society. ¹³ In 1998, one author wrote:

“HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread… it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.”¹⁴

In 2001, the government adopted the National AIDS Prevention and Control Policy. During that year, Prime Minister Atal Bihari Vajpayee addressed parliament and referred to HIV/AIDS as one of the most serious health challenges facing the country. The Prime Minister also met the chief ministers of the six high-prevalence states to plan the implementation of strategies for HIV/AIDS prevention. ¹⁵

HIV had now spread extensively throughout the country. In 1990 there had been tens of thousands of people living with HIV in India; by 2000 this had risen to millions.

Creative visualization

Thirteen years ago, on her 28th birthday, Claire Celsi smoked herself sick. "I puffed 10 cigarettes in one hour," she says. Afterward, she crumpled up her almost-empty pack, threw it away, and never lit up again. She found the strength for this drastic move with something decidedly healthier -- visualization.
Four months before that smoky birthday, Claire started using a technique she had read about in "Creative Visualization," a book by Shakti Gawain. First thing in the morning and whenever she caught a quiet moment, she imagined a huge cigarette wearing boxing gloves, bullying her. Next, she visualized being equals and punching back. Finally, she pictured herself growing larger than the cigarette -- she was wearing the gloves, knocking it out. "The technique took only a few minutes and helped me realize that I was in control, not my cravings," she says.
By the time her birthday arrived, Claire felt so confident that once she stubbed out her last cigarette, that was that. She's never smoked again.

Taking a class, and help from the patch

Natasha Gruppo loved lighting up. "Cigarettes were always there for me," she says. "Fortunately, I realized that smoking was really like having a friend who's holding a gun behind her back."
She got her wake-up call two years ago when a severe asthma attack sent her to the ER. "I thought, 'How far does this have to escalate for me to stop?'" she says.
Soon after, she saw an advertisement about a smoking-cessation class in the employee newsletter published by the university where she works as a finance counselor. Natasha figured trying to quit in a group would provide her with some much-needed support, so she joined. In the classes she learned about nicotine-replacement-therapy options and strategies for coping with withdrawal. She started wearing the patch and quit along with her classmates, who kept her accountable. And when cravings hit, she used a breathing technique she'd learned: "I closed my eyes and inhaled and exhaled three times," she says. "When I opened my eyes, the desire had passed." (Deep breathing is a craving-busting technique recommended by the American Cancer Society.) Eight weeks later, Natasha started forgetting to put on her patch

Why it worked

Liz's tactic of cutting back is an effective way to break free of smoking routines and eventually stop altogether, according to a University of Vermont review of 19 studies. The hard part is staying committed. But Liz knows that's doable -- she hasn't smoked in 10 years. "I used to love it, but now the smell makes me sick," she says. "It's not who I am anymore

Weaning away

Liz Marr smoked off-and-on throughout her 20s and picked it up again in her early 30s. "I didn't smoke all the time," she says. "Usually, only while socializing with other smokers."
But then she fell in love with mountain-biking and cross-country skiing. After all, Liz lives near Boulder, Colorado, and could literally walk out her door to go mountain-biking. "Trust me," she says, "you can't smoke and ride a bike up a mountain!"
Rather than stop cold turkey ("That all-or-nothing mind-set made me want to smoke more," she says), Liz gradually tapered off by avoiding the situations that made her want to smoke. "For a while, I actually stopped hanging out with friends who smoked," she says. Liz built activities into her life where smoking wouldn't fit: exercising, going to smoke-free restaurants, hanging out with her son. "Within a year I naturally drifted into a nonsmoking lifestyle

How four women quit smoking -- and you can too

Everybody knows that smoking isn't good for you. But if you're a woman? "Hands down, smoking is the absolute worst thing you can do to your body," says Phyllis Greenberger, president and CEO of the Society for Women's Health Research in Washington, D.C.
In fact, new research shows that the carcinogens in cigarettes, while harmful to everyone, are more dangerous for women, who are three times as likely as men to get aggressive forms of lung cancer and more likely to develop it at an earlier age. They're also more likely to die of lung cancer than breast cancer.
So why, oh, why do 20 million American women still light up?
Because quitting, as we also know, is really, really hard -- so hard that, while roughly two-thirds of all current smokers want to quit, only 5 percent actually succeeded last year, says the Centers for Disease Control and Prevention. And women, it turns out, have an even harder time quitting than men: They seem to experience stronger withdrawal symptoms, perhaps because of hormones or the bigger nicotine dose delivered to smaller female bodies.
The news isn't all bad, though. In spite of the challenges, some women are finding creative ways to kick the butts for good. We have four of their inspiring stories here, along with a list of some of the newest stop-smoking tricks And if you need company to help you or someone you know quit?

What do HIV+ people think of animal testing?

Many HIV positive people condone, or remain neutral on animal testing because they are aware that the drugs they take to keep them alive have very likely been tested on animals at some point in the past.
in September 2005, six well-known AIDS organisations in the USA got together to form ‘Patient Advocates Against PETA’ (PAAP), a group that opposed the strong anti-animal testing stance of People for the Ethical Treatment of Animals (PETA) ⁹. Formed of ACT UP DC, ACT UP Southern California, AIDS Healthcare Foundation, AIDS/HIV Health Alternatives, AmASSI and the HIV Incarcerated Task Force, PAAP argued that PETA’s constant high-profile protests were hindering scientists in their search for effective HIV vaccines.

Their work was however opposed by a number of HIV positive individuals, who declared they were strongly opposed to animal testing, and did not condone PAAP’s actions. A consensus amongst HIV positive people themselves on the benefits of animal testing is obviously not very forthcoming.

General research

As well as the testing of new drugs and other products, animals may also be used for more general research that aims to gain a greater understanding of a disease. Rhesus macaques, chimpanzees and even cats (who can get Feline Immunodeficiency Virus) may be used as human substitutes to see how HIV-like viruses operate within the body.

They can also be used to study natural phenomena such as transmission or disease progression, and the effects of non-therapeutic substances on HIV.

One example would be a study carried out in Rhesus macaques in 2006 ⁶. Scientists looking at the effects of alcohol on SIV found that feeding the monkeys large quantities of alcoholic beverages over a short space of time (effectively making them ‘binge’ drink) could significantly speed up the rate at which HIV progressed to AIDS. This may well lead to a greater emphasis on moderate drinking amongst HIV positive people, and a reassessment of safe levels of alcohol. However, whether the results of this experiment could have been recreated using methods that didn’t involve animals is open to debate.

Efficacy trials

While all drugs and vaccines have to be tested on animals to establish their safety, testing them to establish their effectiveness is a different matter.

HIV is a retrovirus specific to humans (hence the name ‘Human Immunodeficiency Virus’), which means it is not naturally found in any other animal. Some African primates, such as chimpanzees and a few species of monkey, are naturally infected with SIV (Simian Immunodeficiency Virus), which is believed to be the virus from which HIV originated. Chimpanzees can also be artificially infected with HIV in a laboratory. However most monkeys and chimpanzees have very efficient immune responses to SIV (and HIV), and do not develop AIDS, even after many years of infection. This can make it very difficult to assess whether a drug or vaccine actually works, so primates are not used as widely as human substitutes as they once were.

This said, there is one primate still commonly used to conduct efficacy testing: the Rhesus macaque monkey. Because Rhesus macaques originate from Asia, rather than Africa, they have never been exposed to SIV, and thus have no natural immune responses to it. A Rhesus macaque that is infected with SIV will therefore develop AIDS type illnesses in a relatively short time ².

For this reason (and because they are not an endangered species like some other Asian primates), macaques are often used in HIV research. A few HIV drugs, such as AZT and tenofovir (see our Introduction to Antiretroviral Treatment page for more information about these), have been tested on macaques for efficacy, though stricter rules on the use of primates in animal testing, and greater knowledge of HIV, mean that more modern antiretrovirals are generally only tested on animals for safety reasons.

Vaccine development on the other hand makes extensive use of primates. Because it could be seen as unethical to give a healthy human a vaccine, and then expose them to HIV to see if the vaccine works (if it doesn’t, they’ll end up with HIV), animals can be used as substitutes to establish whether a vaccine is effective or not. This method can also be used to test the usefulness of current AIDS drugs (such as tenofovir) in preventing HIV infection. Such work of course raises significant questions over whether it is any more ethical to give a monkey HIV than a human, when it too may become sick with AIDS and die.

A fundamental problem with using macaques in vaccine research has been that they have different immune systems to humans. This means they cannot be infected with HIV-1 (although they are susceptible to certain strains of HIV-2), however they can be infected with SIV, or an SIV-HIV combination (‘chimeric’ virus) known as SHIV. A drug or vaccine that is effective in Rhesus monkeys infected with SIV or SHIV may not therefore be effective in humans with HIV. Conversely, a drug or vaccine that may be effective in an HIV positive human may be dropped because it appears ineffective in animals. Scientists have now constructed a simian strain of HIV-1 that differs from the human virus by only one gene and mimics early HIV infection, however the infected macaques did not develop AIDS³. Further research on this genetically engineered virus is necessary, however if successful this may make testing vaccines in primates potentially more reliable.

Monkey research has yielded significant discoveries about HIV in recent years⁴, including major findings that have strengthened understanding of early SIV and HIV infection

Safety trials

Animal safety tests usually come at the end of a long process of safety data collection that may include testing the product ‘in vitro’ (i.e. in a test-tube) and using a computer program to simulate what might happen to the drug inside the body. The regulations on what safety data is required for a new product vary from country to country (and also from drug to drug), but most drug authorities require all three types of data - animal, in vitro and computer- generated - for trials to be allowed to continue.

All this means that at some point, all (anti-AIDS) drugs will have been tested on animals for safety.

There is an argument however that animals are actually fairly poor substitutes for humans and that some compounds that may well cause no harm to a mouse, could kill a human being. This is particularly the case for drugs that interact with the complex human immune system, such as the anti-inflammatory drug that caused major organ failure in six men involved in a trial at Northwick Park Hospital in London, England in 2006. However, such occurrences are rare.

Safety trials

n many countries it is a legal requirement that all drugs and vaccines (not just for HIV) are tested on animals to ensure safety. In the United Kingdom for example, the Medicines Act of 1968 ¹ states that all new pharmaceutical products must be tested on at least two different species of live mammal, one of which must be a large non-rodent. This legislation was introduced shortly after the discovery that the drug Thalidomide could cause serious physical deformities in babies born to mothers who had taken it during pregnancy. Thalidomide was not thoroughly tested on animals (particularly pregnant animals) before it was prescribed to women, and this case is the root of many countries’ animal testing safety laws today.

Why are tests performed on animals?

There are three reasons why animals may be used in scientific experimentation. The first is to ensure the safety of new drugs and other pharmaceutical products. The second is to see whether such products might be effective in humans. The third is for general research into the biology of an animal, or the function and action of certain diseases within its body.