thesis statement for hiv research paper

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• Published: 24 November 2021

A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data

• Shobhit Srivastava   ORCID: orcid.org/0000-0002-7138-4916 1 ,
• Shekhar Chauhan   ORCID: orcid.org/0000-0002-6926-7649 2 ,
• Ratna Patel   ORCID: orcid.org/0000-0002-5371-7369 3 &
• Pradeep Kumar   ORCID: orcid.org/0000-0003-4259-820X 1  

Scientific Reports volume  11 , Article number:  22841 ( 2021 ) Cite this article

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Acquired Immunodeficiency Syndrome caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. This study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with the change in awareness level on HIV-related information among adolescents over the period. Data used for this study were drawn from Understanding the lives of adolescents and young adults, a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh. The present study utilized a sample of 4421 and 7587 unmarried adolescent boys and girls, respectively aged 10–19 years in wave-1 and wave-2. Descriptive analysis and t-test and proportion test were done to observe changes in certain selected variables from wave-1 (2015–2016) to wave-2 (2018–2019). Moreover, random effect regression analysis was used to estimate the association of change in HIV awareness among unmarried adolescents with household and individual factors. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2 to 39.1% between wave-1 & wave-2. With the increase in age and years of schooling, the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV. Adolescent boys' paid work status was inversely associated with HIV awareness [Coef: − 0.01; p  < 0.10]. Use of internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness with reference to their counterparts. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups, as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents.

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Introduction.

Acquired Immunodeficiency Syndrome (AIDS) caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. So far, HIV has claimed almost 33 million lives; however, off lately, increasing access to HIV prevention, diagnosis, treatment, and care has enabled people living with HIV to lead a long and healthy life 1 . By the end of 2019, an estimated 38 million people were living with HIV 1 . More so, new infections fell by 39 percent, and HIV-related deaths fell by almost 51 percent between 2000 and 2019 1 . Despite all the positive news related to HIV, the success story is not the same everywhere; HIV varies between region, country, and population, where not everyone is able to access HIV testing and treatment and care 1 . HIV/AIDS holds back economic growth by destroying human capital by predominantly affecting adolescents and young adults 2 .

There are nearly 1.2 billion adolescents (10–19 years) worldwide, which constitute 18 percent of the world’s population, and in some countries, adolescents make up as much as one-fourth of the population 3 . In India, adolescents comprise more than one-fifth (21.8%) of the total population 4 . Despite a decline projection for the adolescent population in India 5 , there is a critical need to hold adolescents as adolescence is characterized as a period when peer victimization/pressure on psychosocial development is noteworthy 6 . Peer victimization/pressure is further linked to risky sexual behaviours among adolescents 7 , 8 . A higher proportion of low literacy in the Indian population leads to a low level of awareness of HIV/AIDS 9 . Furthermore, the awareness of HIV among adolescents is quite alarming 10 , 11 , 12 .

Unfortunately, there is a shortage of evidence on what predicts awareness of HIV among adolescents. Almost all the research in India is based on beliefs, attitudes, and awareness of HIV among adolescents 2 , 12 . However, few other studies worldwide have examined mass media as a strong predictor of HIV awareness among adolescents 13 . Mass media is an effective channel to increase an individuals’ knowledge about sexual health and improve understanding of facilities related to HIV prevention 14 , 15 . Various studies have outlined other factors associated with the increasing awareness of HIV among adolescents, including; age 16 , 17 , 18 , occupation 18 , education 16 , 17 , 18 , 19 , sex 16 , place of residence 16 , marital status 16 , and household wealth index 16 .

Several community-based studies have examined awareness of HIV among Indian adolescents 2 , 10 , 12 , 20 , 21 , 22 . However, studies investigating awareness of HIV among adolescents in a larger sample size remained elusive to date, courtesy of the unavailability of relevant data. Furthermore, no study in India had ever examined awareness of HIV among adolescents utilizing information on longitudinal data. To the author’s best knowledge, this is the first study in the Indian context with a large sample size that examines awareness of HIV among adolescents and combines information from a longitudinal survey. Therefore, this study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with a change in awareness level on HIV-related information among adolescents over the period.

Data and methods

Data used for this study were drawn from Understanding the lives of adolescents and young adults (UDAYA), a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh 23 . The first wave was conducted in 2015–2016, and the follow-up survey was conducted after three years in 2018–2019 23 . The survey provides the estimates for state and the sample of unmarried boys and girls aged 10–19 and married girls aged 15–19. The study adopted a systematic, multi-stage stratified sampling design to draw sample areas independently for rural and urban areas. 150 primary sampling units (PSUs)—villages in rural areas and census wards in urban areas—were selected in each state, using the 2011 census list of villages and wards as the sampling frame. In each primary sampling unit (PSU), households to be interviewed were selected by systematic sampling. More details about the study design and sampling procedure have been published elsewhere 23 . Written consent was obtained from the respondents in both waves. In wave 1 (2015–2016), 20,594 adolescents were interviewed using the structured questionnaire with a response rate of 92%.

Moreover, in wave 2 (2018–2019), the study interviewed the participants who were successfully interviewed in 2015–2016 and who consented to be re-interviewed 23 . Of the 20,594 eligible for the re-interview, the survey re-interviewed 4567 boys and 12,251 girls (married and unmarried). After excluding the respondents who gave an inconsistent response to age and education at the follow-up survey (3%), the final follow-up sample covered 4428 boys and 11,864 girls with the follow-up rate of 74% for boys and 81% for girls. The effective sample size for the present study was 4421 unmarried adolescent boys aged 10–19 years in wave-1 and wave-2. Additionally, 7587 unmarried adolescent girls aged 10–19 years were interviewed in wave-1 and wave-2 23 . The cases whose follow-up was lost were excluded from the sample to strongly balance the dataset and set it for longitudinal analysis using xtset command in STATA 15. The survey questionnaire is available at https://dataverse.harvard.edu/file.xhtml?fileId=4163718&version=2.0 & https://dataverse.harvard.edu/file.xhtml?fileId=4163720&version=2.0 .

Outcome variable

HIV awareness was the outcome variable for this study, which is dichotomous. The question was asked to the adolescents ‘Have you heard of HIV/AIDS?’ The response was recorded as yes and no.

Exposure variables

The predictors for this study were selected based on previous literature. These were age (10–19 years at wave 1, continuous variable), schooling (continuous), any mass media exposure (no and yes), paid work in the last 12 months (no and yes), internet use (no and yes), wealth index (poorest, poorer, middle, richer, and richest), religion (Hindu and Non-Hindu), caste (Scheduled Caste/Scheduled Tribe, Other Backward Class, and others), place of residence (urban and rural), and states (Uttar Pradesh and Bihar).

Exposure to mass media (how often they read newspapers, listened to the radio, and watched television; responses on the frequencies were: almost every day, at least once a week, at least once a month, rarely or not at all; adolescents were considered to have any exposure to mass media if they had exposure to any of these sources and as having no exposure if they responded with ‘not at all’ for all three sources of media) 24 . Household wealth index based on ownership of selected durable goods and amenities with possible scores ranging from 0 to 57; households were then divided into quintiles, with the first quintile representing households of the poorest wealth status and the fifth quintile representing households with the wealthiest status 25 .

Statistical analysis

Descriptive analysis was done to observe the characteristics of unmarried adolescent boys and girls at wave-1 (2015–2016). In addition, the changes in certain selected variables were observed from wave-1 (2015–2016) to wave-2 (2018–2019), and the significance was tested using t-test and proportion test 26 , 27 . Moreover, random effect regression analysis 28 , 29 was used to estimate the association of change in HIV awareness among unmarried adolescents with household factors and individual factors. The random effect model has a specific benefit for the present paper's analysis: its ability to estimate the effect of any variable that does not vary within clusters, which holds for household variables, e.g., wealth status, which is assumed to be constant for wave-1 and wave-2 30 .

Table 1 represents the socio-economic profile of adolescent boys and girls. The estimates are from the baseline dataset, and it was assumed that none of the household characteristics changed over time among adolescent boys and girls.

Figure  1 represents the change in HIV awareness among adolescent boys and girls. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2% in wave-1 to 39.1% in wave-2.

The percenate of HIV awareness among adolescent boys and girls, wave-1 (2015–2016) and wave-2 (2018–2019).

Table 2 represents the summary statistics for explanatory variables used in the analysis of UDAYA wave-1 and wave-2. The exposure to mass media is almost universal for adolescent boys, while for adolescent girls, it increases to 93% in wave-2 from 89.8% in wave-1. About 35.3% of adolescent boys were engaged in paid work during wave-1, whereas in wave-II, the share dropped to 33.5%, while in the case of adolescent girls, the estimates are almost unchanged. In wave-1, about 27.8% of adolescent boys were using the internet, while in wave-2, there is a steep increase of nearly 46.2%. Similarly, in adolescent girls, the use of the internet increased from 7.6% in wave-1 to 39.3% in wave-2.

Table 3 represents the estimates from random effects for awareness of HIV among adolescent boys and girls. It was found that with the increases in age and years of schooling the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV in comparison to those who had no exposure to mass media. Adolescent boys' paid work status was inversely associated with HIV awareness about adolescent boys who did not do paid work [Coef: − 0.01; p  < 0.10]. Use of the internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness in reference to their counterparts.

The awareness regarding HIV increases with the increase in household wealth index among both adolescent boys and girls. The adolescent girls from the non-Hindu household had a lower likelihood to be aware of HIV in reference to adolescent girls from Hindu households [Coef: − 0.09; p  < 0.01]. Adolescent girls from non-SC/ST households had a higher likelihood of being aware of HIV in reference to adolescent girls from other caste households [Coef: 0.04; p  < 0.01]. Adolescent boys [Coef: − 0.03; p  < 0.01] and girls [Coef: − 0.09; p  < 0.01] from a rural place of residence had a lower likelihood to be aware about HIV in reference to those from the urban place of residence. Adolescent boys [Coef: 0.04; p  < 0.01] and girls [Coef: 0.02; p  < 0.01] from Bihar had a higher likelihood to be aware about HIV in reference to those from Uttar Pradesh.

This is the first study of its kind to address awareness of HIV among adolescents utilizing longitudinal data in two indian states. Our study demonstrated that the awareness of HIV has increased over the period; however, it was more prominent among adolescent boys than in adolescent girls. Overall, the knowledge on HIV was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of awareness on HIV among adolescents in this study was lower than almost all of the community-based studies conducted in India 10 , 11 , 22 . A study conducted in slums in Delhi has found almost similar prevalence (40% compared to 39.1% during wave-II in this study) of awareness of HIV among adolescent girls 31 . The difference in prevalence could be attributed to the difference in methodology, study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2 percent of the girls had an awareness of HIV during wave-I, which had increased to 39.1 percent. Several previous studies corroborated the finding and noticed a higher prevalence of awareness on HIV among adolescent boys than in adolescent girls 16 , 32 , 33 , 34 . However, a study conducted in a different setting noticed a higher awareness among girls than in boys 35 . Also, a study in the Indian context failed to notice any statistical differences in HIV knowledge between boys and girls 18 . Gender seems to be one of the significant determinants of comprehensive knowledge of HIV among adolescents. There is a wide gap in educational attainment among male and female adolescents, which could be attributed to lower awareness of HIV among girls in this study. Higher peer victimization among adolescent boys could be another reason for higher awareness of HIV among them 36 . Also, cultural double standards placed on males and females that encourage males to discuss HIV/AIDS and related sexual matters more openly and discourage or even restrict females from discussing sexual-related issues could be another pertinent factor of higher awareness among male adolescents 33 . Behavioural interventions among girls could be an effective way to improving knowledge HIV related information, as seen in previous study 37 . Furthermore, strengthening school-community accountability for girls' education would augment school retention among girls and deliver HIV awareness to girls 38 .

Similar to other studies 2 , 10 , 17 , 18 , 39 , 40 , 41 , age was another significant determinant observed in this study. Increasing age could be attributed to higher education which could explain better awareness with increasing age. As in other studies 18 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , education was noted as a significant driver of awareness of HIV among adolescents in this study. Higher education might be associated with increased probability of mass media and internet exposure leading to higher awareness of HIV among adolescents. A study noted that school is one of the important factors in raising the awareness of HIV among adolescents, which could be linked to higher awareness among those with higher education 47 , 48 . Also, schooling provides adolescents an opportunity to improve their social capital, leading to increased awareness of HIV.

Following previous studies 18 , 40 , 46 , the current study also outlines a higher awareness among urban adolescents than their rural counterparts. One plausible reason for lower awareness among adolescents in rural areas could be limited access to HIV prevention information 16 . Moreover, rural–urban differences in awareness of HIV could also be due to differences in schooling, exposure to mass media, and wealth 44 , 45 . The household's wealth status was also noted as a significant predictor of awareness of HIV among adolescents. Corroborating with previous findings 16 , 33 , 42 , 49 , this study reported a higher awareness among adolescents from richer households than their counterparts from poor households. This could be because wealthier families can afford mass-media items like televisions and radios for their children, which, in turn, improves awareness of HIV among adolescents 33 .

Exposure to mass media and internet access were also significant predictors of higher awareness of HIV among adolescents. This finding agrees with several previous research, and almost all the research found a positive relationship between mass-media exposure and awareness of HIV among adolescents 10 . Mass media addresses such topics more openly and in a way that could attract adolescents’ attention is the plausible reason for higher awareness of HIV among those having access to mass media and the internet 33 . Improving mass media and internet usage, specifically among rural and uneducated masses, would bring required changes. Integrating sexual education into school curricula would be an important means of imparting awareness on HIV among adolescents; however, this is debatable as to which standard to include the required sexual education in the Indian schooling system. Glick (2009) thinks that the syllabus on sexual education might be included during secondary schooling 44 . Another study in the Indian context confirms the need for sex education for adolescents 50 , 51 .

Limitations and strengths of the study

The study has several limitations. At first, the awareness of HIV was measured with one question only. Given that no study has examined awareness of HIV among adolescents using longitudinal data, this limitation is not a concern. Second, the study findings cannot be generalized to the whole Indian population as the study was conducted in only two states of India. However, the two states selected in this study (Uttar Pradesh and Bihar) constitute almost one-fourth of India’s total population. Thirdly, the estimates were provided separately for boys and girls and could not be presented combined. However, the data is designed to provide estimates separately for girls and boys. The data had information on unmarried boys and girls and married girls; however, data did not collect information on married boys. Fourthly, the study estimates might have been affected by the recall bias. Since HIV is a sensitive topic, the possibility of respondents modifying their responses could not be ruled out. Hawthorne effect, respondents, modifying aspect of their behaviour in response, has a role to play in HIV related study 52 . Despite several limitations, the study has specific strengths too. This is the first study examining awareness of HIV among adolescent boys and girls utilizing longitudinal data. The study was conducted with a large sample size as several previous studies were conducted in a community setting with a minimal sample size 10 , 12 , 18 , 20 , 53 .

The study noted a higher awareness among adolescent boys than in adolescent girls. Specific predictors of high awareness were also noted in the study, including; higher age, higher education, exposure to mass media, internet use, household wealth, and urban residence. Based on the study findings, this study has specific suggestions to improve awareness of HIV among adolescents. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents. Investment in education will help, but it would be a long-term solution; therefore, public information campaigns could be more useful in the short term.

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This paper was written using data collected as part of Population Council’s UDAYA study, which is funded by the Bill and Melinda Gates Foundation and the David and Lucile Packard Foundation. No additional funds were received for the preparation of the paper.

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Conception and design of the study: S.S. and P.K.; analysis and/or interpretation of data: P.K. and S.S.; drafting the manuscript: S.C., and R.P.; reading and approving the manuscript: S.S., P.K., S.C. and R.P.

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Srivastava, S., Chauhan, S., Patel, R. et al. A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data. Sci Rep 11 , 22841 (2021). https://doi.org/10.1038/s41598-021-02090-9

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Published : 24 November 2021

DOI : https://doi.org/10.1038/s41598-021-02090-9

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How to write a hiv research paper.

Writing an HIV research paper requires extensive research and understanding of the available data. HIV/AIDS is among the most challenging diseases that humankind has ever faced. When pursuing medical studies, a student will most likely be asked to write a research paper about aids. That’s because educators want learners to understand different aspects of this disease and some of the ways to resolve them.

Researching and writing about HIV/AIDS is not easy. A learner has to search books, journals, and magazines that publish content about the disease to get a paper written . A student has to study the available information thoroughly and analyze it before writing an HIV AIDS research paper. And this is not easy because students have lectures to attend and other assignments to complete while writing research papers.

Why Write an HIV Research Paper

Preparation for writing an hiv research paper, how to write a research paper on hiv, topics for hiv papers.

But, research alone is not enough. Learners should also be persuasive in their writing for their papers to stand out and earn them the top grades. Ideally, a learner should present ideas in a way that convinces the reader that they engaged in a thorough research process before composing the paper. If struggling to compose a strong HIV and AIDS research paper, this guide comprises relevant topics and tips that should guide you.

HIV/AIDS is a preventable disease. When implemented properly, prevention intervention can reduce the transmission of this disease. What’s more, people infected with HIV/AIDS can make behavioral changes and improve their health. Such changes can also reduce the risk of infecting others with the disease.

• When a student engages in research and then writes a paper on HIV AIDS, they learn such aspects of this disease. Ideally, this academic task equips the learner with the knowledge and information required to guide and help people avoid this disease. It also enables them to counsel those living with HIV to lead better lives without transmitting the disease to other people.
• A student will most likely be required to write a research paper about AIDS and HIV when pursuing medical or social science studies. That’s because they will most likely meet people living with the disease or at a higher risk of infection once they venture into the job market. As such, such people will play a significant role in increasing awareness of the disease once they start working. Some individuals are already working while pursuing their studies. Therefore, this assignment equips them with relevant knowledge that they can apply every day at their workplaces.

The reason you’re reading this article is probably that you’ve been assigned a research paper about HIV. However, you don’t know how to complete this task or even where to start. Although you may find a lot of information on this subject online, there are hardly any guides for writing a research paper about it.

To compose a great AIDS research paper, you need to prepare adequately. Here are the three steps to follow when preparing to write an HIV essay paper.

• Choose a topic : You’re supposed to write about HIV/AIDS. However, there are many aspects of this disease that you can write about. Therefore, start by selecting a topic for your research paper. For instance, you can write about the effects of HIV on specific demographics. You can also write about the changes the fight against HIV/AIDS has undergone over the years. Ideally, pick a topic you will be comfortable researching and writing about. Also, make sure that your topic is not too narrow or too broad. That’s because an extremely narrow topic will limit you when it comes to the information you can include in your paper. A broader topic will seem shallow because you won’t cover every aspect of it in your paper.
• Compose a thesis statement : A thesis statement for HIV paper should tell the audience what the paper is about. Your reader should know what to expect in the rest of the paper after reading it in the introduction. Therefore, come up with a clear thesis statement that captures the main theme or idea of your paper. You should compose a thesis statement after conducting preliminary research about your topic.
• Draft an outline : An HIV paper outline is the skeleton of the entire paper. It shows where the information gathered through research will appear in the paper. Ideally, an outline should help with the organization of your ideas and information in the research paper.

Once you’ve chosen a topic, composed a thesis statement, and outlined your paper, you can now proceed to actual writing.

When writing your research paper, focus on answering the questions that the audience might have after reading your topic. To do this, follow these steps when writing a research paper on HIV AIDS.

• Research your topic extensively : You can find many online sources, journals, books, and magazines with information about HIV/AIDS. Composing a great paper requires you to research your topic extensively. If you’re writing a concept paper on HIV AIDS, ensure that your message comes out. For instance, you can expound on the epidemiological landscape of the disease. This includes the challenges and history of HIV prevention. After research and learning all you can about the topic, analyze your information and then come up with the main points to present in your paper.
• Write the introduction : Start by introducing your topic to the audience. Tell them why you chose this particular topic and why it’s worth exploring. Your intro to a paper about HIV can also provide background information. For instance, you can provide statistics that show the impact of the disease on a specific demographic group. Use a relevant hook in the introduction to capture the audiences’ attention and make them want to read the rest of the paper. Also, include your thesis statement in the introduction. That way, your audience will know what your paper is about after reading the introduction. They also decide whether to read the entire paper or some of its sections.
• Write the body : The body of a research paper on AIDS is where you expound on your main points. For instance, if you want to write about HIV prevention, you can expound on the major prevention measures. Tell your readers what every prevention measure entails and how effective it is. You can include statistics to support your point. Present every point in its paragraph and support it with relevant information.
• Write the conclusion : Compose a conclusion for your AIDS paper by wrapping up your argument nicely. Remind the audience what you set out to do by restating your thesis statement and then show them how you’ve accomplished your mission. You can also leave the audience with something to think about or suggest ideas for further research on your topic.

Writing your paper will be relatively easy if you follow these steps. However, you should pick a good title for AIDS research paper because this will dictate the direction of your research and writing process.

As hinted, choosing the right topic is very crucial because the title of your paper will influence the direction of your research and writing process. HIV/AIDS is a broad subject with many health research topics that learners can research and write about. Here are sample topics to consider when writing a paper about HIV/AIDS.

• How the AIDS virus affects the human immune systems
• How HIV/AIDS compares to most diseases affecting the human DNA
• The most effective methods for curbing the spread of HIV
• The origin of the AIDS pandemic
• Is AIDS a pandemic or epidemic disease?
• Countries with the highest cases of HIV/AIDS and why
• Common myths about HIV/AIDS
• Effects of stigmatization of the people living with HIV/AIDS
• How governments help HIV/AIDS patients
• Why pregnant women undergo HIV/AIDS testing
• How ignorance contributes to the stigmatization of HIV/AIDS patients
• Strides made by medical researchers towards the prevention and possible cure of HIV/AIDS
• How misconception of HIV patients affect their lives
• Common stereotypes about HIV patients in movies
• Factors that accelerate the spread of HIV in developing countries
• How a person’s sexual behavior influence their risk of contracting HIV
• How the struggles of men and women with HIV compare
• Why the world has a hard time preventing the spread of HIV/AIDS among teenagers
• HIV prevention measures- How they compare between the UK and the US
• Common opportunistic illnesses among people with HIV/AIDs

Whether you choose to write an HIV reflection paper or HIV AIDS reaction paper, take your time to conduct extensive research and analyze your information. Also, list down all your sources when researching your topic because you will need them when composing the reference section of the paper. If possible, include in-text citations to help your readers engage in further reading. This will help readers that are interested in a specific aspect of your topic. Also, take your time to research your topic and analyze information before composing your HIV research paper thesis. That way, you will come up with a statement that will reflect what your paper will cover.

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HIV/AIDS epidemiology, pathogenesis, prevention, and treatment

The HIV-1 pandemic is a complex mix of diverse epidemics within and between countries and regions of the world, and is undoubtedly the defining public-health crisis of our time. Research has deepened our understanding of how the virus replicates, manipulates, and hides in an infected person. Although our understanding of pathogenesis and transmission dynamics has become more nuanced and prevention options have expanded, a cure or protective vaccine remains elusive. Antiretroviral treatment has transformed AIDS from an inevitably fatal condition to a chronic, manageable disease in some settings. This transformation has yet to be realised in those parts of the world that continue to bear a disproportionate burden of new HIV-1 infections and are most a% ected by increasing morbidity and mortality. This Seminar provides an update on epidemiology, pathogenesis, treatment, and prevention interventions pertinent to HIV-1.

HIV pandemic

An estimated 38·6 (33·4–46·0) million people live with HIV-1 worldwide, while about 25 million have died already. 1 In 2005 alone, there were 4·1 million new HIV-1 infections and 2·8 million AIDS deaths. 1 These estimates mask the dynamic nature of this evolving epidemic in relation to temporal changes, geographic distribution, magnitude, viral diversity, and mode of transmission. Today, there is no region of the world untouched by this pandemic ( figure 1 ). 2

HSex=heterosexual. MSM=Men who have sex with men. IDU=injection drug users. Based on Joint UNAIDS and WHO AIDS epidemic update December, 2005.

Heterosexual transmission remains the dominant mode of transmission and accounts for about 85% of all HIV-1 infections. Southern Africa remains the epicentre of the pandemic and continues to have high rates of new HIV-1 infections. 3 Although overall HIV-1 prevalence remains low in the emerging epidemics in China and India, the absolute numbers, which are fast approaching those seen in southern Africa, are of concern. 1 Outside of sub-Saharan Africa, a third of all HIV-1 infections are acquired through injecting drug use, most (an estimated 8·8 million) of which are in eastern Europe and central and southeast Asia. 1 The rapid spread of HIV-1 in these regions through injecting drug use is of importance, since it is a bridge for rapid establishment of more generalised epidemics.

A defining feature of the pandemic in the current decade is the increasing burden of HIV-1 infections in women, 4 which has additional implications for mother-to-child transmission. Women now make up about 42% of those infected worldwide; over 70% of whom live in sub-Saharan Africa. 1 Overall, a quarter of all new HIV-1 infections are in adults aged younger than 25 years. 1 HIV-1 infection rates are three to six times higher in female adolescents than in their male counterparts, 1 , 5 – 7 and this difference is attributed to sexual coupling patterns of young women with older men. Population prevalence of HIV-1 infection, concurrent sexual relationships, partner change, sexual practices, the presence of other sexually transmitted diseases, 8 – 11 and population mobility patterns 12 – 14 for economic and other reasons (eg, natural disasters and wars) further increase the probability of HIV-1 acquisition. 3 , 15 Emerging data accord with strong links between risk of sexual HIV-1 acquisition and episodic recreational drug or alcohol use. 16

Although sub-Saharan Africa continues to bear a disproportionate burden of HIV-1 infections, there is now an increasing number of countries reporting stabilisation or declines in prevalence (eg, Zambia, Tanzania, Kenya, Ghana, Rwanda, Burkina Faso, and Zimbabwe). 1 There is some evidence to attribute these reductions to effective changes in sexual behaviour, such as postponement of sexual debut, reduction in casual relationships, and more consistent condom use in casual relationships. 17 , 18 However, increasing morbidity and mortality rates associated with a maturing HIV-1 epidemic need to be considered when interpreting these data. 19 For example, the death of a few high-risk individuals who are key to transmission chains could exert a major effect on sexual networks and result in major reductions in infection rates. 20 Additionally, since most HIV-1 estimates are based on surveys in antenatal populations, increasing morbidity and mortality could cause the numbers of women in this group to decrease, and thus lead to underestimates of the true prevalence in these countries. 19

Although the relative contribution of cell-free virus compared with cell-associated virus in HIV-1 transmission remains unclear, there is growing evidence that viral load is predictive of transmission risk. 21 , 22 The highest levels of viraemia are seen during acute infection and advanced HIV-1 disease. 22 Further, co-infections with other sexually transmitted diseases in asymptomatic HIV-1 infected people can increase viral shedding to levels similar to those seen during acute infection. 23 Thus, sexually transmitted diseases could enhance HIV-1 transmission to rates similar to those seen during primary infection. 24 This observation could help to explain why the efficiency of HIV-1 transmission exceeds, in some settings, the earlier mathematical projections. 25 Thus, identification and treatment of recently infected people is an important means to reduce transmission. However, most people are unaware of their HIV-1 status during these crucial first months of infection. Several screening strategies based on laboratory testing and clinical algorithms are being developed and tested 26 for efficient identification of early infection before antibody development. 27 Additionally, a more aggressive management of sexually transmitted infections in settings with generalised epidemics has the potential to affect current epidemic trajectories. 24

Based on their genetic make-up, HIV-1 viruses are divided into three groups (eg, M [main], N, and O group, figure 2 ). These HIV-1 groups and HIV-2 probably result from distinct cross-species transmission events. 28 Pandemic HIV-1 has diversified into at least nine subtypes ( figures 1 and ​ and2) 2 ) and many circulating recombinant forms, 29 , 30 which encode genetic structures from two or more subtypes (eg, A/E=CRF01; A/G=CRF02). The continuously evolving HIV-1 viral diversity poses an immense challenge to the development of any preventive or therapeutic intervention. 29

The HIV-1 pandemic is largely due to viral isolates belonging to the HIV-1 M-group, with HIV-1 subtype C being the most prevalent (red). Recombinant circulating forms cluster with the M-group but have been omitted for clarity. HIV-1 M group and the contemporary SIV strains identified in wild chimpanzees in Cameroon (SIVcpzLB7/EK5 28 ) are highlighted. HIV-1 sequences cluster closely with SIV from chimpanzees (SIVcpz), whereas HIV-2 resembles SIV from macaques and sooty mangabeys (SIVmac/SIVsm).

In terms of viral diversity, subtype C viruses continue to dominate and account for 55–60% of all HIV-1 infections worldwide ( figure 1 ). 30 Non-subtype B isolates might differ in their virological characteristics from the subtype B isolates (eg, viral load, chemokine co-receptor usage, transcriptional activation in specific biological compartments). 31 – 33 However, the clinical consequences of subtype variations remain unclear.

Infection with two or more genetically distinct viruses could lead to new recombinant viruses. Recombination takes place at a higher rate than initially predicted, 30 and circulating recombinant forms account for as much as 20% of infections in some regions (eg, southeast Asia). 31 These findings are in agreement with the occurrence of co-infections with multiple distinct isolates in a close temporal context. 34 – 36 Further, superinfections in which time points of virus acquisition are months to years apart have been described, although at a much lower frequency than co-infections. 34 , 37 – 39 Collectively, these observations challenge the assumption that HIV-1 acquisition happens only once with a singular viral strain and that, thereafter, the infected individual is protected from subsequent infections. 40 This lack of immunisation has substantial implications for vaccine development. Emerging evidence suggests that clinical progression to AIDS might be more rapid in individuals with dual infections, 35 and encouraging safer sex practices in viraemic HIV-1-infected people might be appropriate to keep recurrent exposure to new viral strains to a minimum.

Pathogenesis of HIV-1

The worldwide spread of HIV-1 indicates that the virus effectively counteracts innate, adapted, and intrinsic immunity. 41 , 42 Despite its modest genome size (less than 10 kb) and its few genes ( figure 3 ), HIV-1 excels in taking advantage of cellular pathways while neutralising and hiding from the different components of the immune system. 43 – 45 Notably, our understanding of pathogenesis is often derived from studies of subtype B viruses and non-human primate studies.

(A) Envelope glycoproteins gp120/41 form the spikes on the virion’s surface. During maturation the gag protein is cleaved and Gag p24 forms the core. The viral genome, viral reverse transcriptase (RT), integrase as well as a number of host proteins are encapsidated. (B) Dir erent steps of the viral life cycle on a cellular level and the potential targets for treatment interventions. (C) HIV-1 has evolved strategies to counteract the restriction factors TRIM5α and APOBEC3G/3F. If left unchecked by HIV-1 Vif, APOBEC3G/3F is encapsidated into the egressing virion, and on infection of a target cell leads to G-to-A hypermutations in the viral genome. Rhesus TRIM5α inhibits HIV-1 replication early after infection of the target cell before the step of reverse transcription.

The HIV-1 life cycle is complex ( figure 3 ) and its duration and outcome is dependent on target cell type and cell activation. 46 In the early steps, HIV-1 gains access to cells without causing immediate lethal damages but the entry process can stimulate intracellular signal cascades, which in turn might facilitate viral replication. 47 , 48 The two molecules on the HIV-1 envelope, the external glycoprotein (gp120) and the transmembrane protein (gp41), form the spikes on the virion’s surface. 49 During the entry process, gp120 attaches to the cell membrane by first binding to the CD4+ receptor. Subsequent interactions between virus and chemokine co-receptors (eg, CCR5, CXCR4) trigger irreversible conformational changes. 49 , 50 The actual fusion event takes place within minutes by pore formation, 50 , 51 and releases the viral core into the cell cytoplasm. After the core disassembles, the viral genome is reverse transcribed into DNA by the virus’ own reverse transcriptase enzyme. 46 Related yet distinct viral variants can be generated during this process since reverse transcriptase is error prone and has no proofreading activity. 46 At the midpoint of infection, the viral protein integrase in conjunction with host DNA repair enzymes inserts the viral genome into gene-rich, transcriptionally active domains of the host’s chromosomal DNA. 52 – 54 An integrase binding host factor, LEDGF/p75 (lens epithelium-derived growth factor), facilitates integration, 55 , 56 which marks the turning point by irreversibly transforming the cell into a potential virus producer. In the late steps, production of viral particles needs host driven as well as virus driven transcription. 46 Viral proteins are transported to and assemble in proximity to the cell membrane. Virus egress from the cell is not lytic and takes advantage of the vesicular sorting pathway (ESCRT-I, II, III), which normally mediates the budding of endosomes into multivesicular bodies. 57 , 58 HIV-1 accesses this protein-sorting pathway by binding TSG101 via its late domain, a short sequence motif in p6 of Gag. 59 , 60 Cleavage of the Gag-Pol poly-protein by the viral protease produces mature infectious virions. 46 , 61

Since cytoplasmic molecules of the producer cell and components from its cell surface lipid bilayer are incorporated into the new viral particle, virions bear characteristics of the cells in which they were produced. 62 Incorporated host molecules can determine the virus’ phenotype in diverse ways (eg, shape the replicative features in the next cycle of infection or mediate immune activation of bystander cells 62 ).

Studies of the early events that happen after HIV-1 breaches the mucosal barrier suggest the existence of a window period in which viral propagation is not yet established and host defences could potentially control viral expansion. 63 The important co-receptors for HIV-1 infection are two chemokine receptors—CCR5 and CXCR4. Independently of the transmission route, most new infections are established by viral variants that rely on CCR5 usage. 64 CXCR4-tropic viruses generally appear in late stages of infection and have been associated with increased pathogenicity and disease progression. 65

Compelling evidence from non-human primate models (eg, simian immunodeficiency virus [SIV] infection of rhesus macaques) suggest that vaginal transmission results in infection of a small number of CD4+ T lymphocytes, macrophages, and dendritic cells located in the lamina propria. 63 Potential pathways for virus transmission involve endocytosis, transcytosis, and virus attachment to mannose C-type lectin receptors (eg, DC-SIGN) located on dendritic cells and macrophages. 66 The initial replication takes place in the regional lymph organs (eg, draining lymph nodes) and is composed of few viral variants, and leads to modest primary amplification. With migration of infected T lymphocytes or virions into the bloodstream, secondary amplification in the gastrointestinal tract, spleen, and bone marrow results in massive infection of susceptible cells. In close temporal relation with the resulting peak of viraemia (eg, 10 6 to 10 7 copies per mL plasma), clinical symptoms can be manifest during primary HIV-1 infection ( figure 4 ). The level of viraemia characteristic for the chronic phase of infection in an individual (viral set point) differs from the peak viraemia by one or two orders of magnitude. This reduction is largely attributed to HIV-1 specific CD8+ responses but target cell limitation could also play a part. The viral population is most homogeneous early after transmission, but as viral quasi-species diversify in distinct biological compartments, mutant viruses that are resistant to antibody neutralisation, cytotoxic T cells, or antiretroviral drugs are generated and archived in long-lived cells (ie, viral reservoirs).

Plasma viraemia (top), and dynamic changes of the CD4+ T-lymphocyte compartments (bottom). Primary infection characterised by high plasma viraemia (red line, top), low CD4 cells (green line, bottom), and absence of HIV-1 specific antibodies (orange line, bottom). Viraemia drops as cytotoxic CD8+ T-lymphocytes (CTL) develop (blue line, bottom) and an individual viral-load set point is reached during chronic infection. Viral set points dir er greatly among individuals (eg, red dotted line, top) and predict disease progression. Viral diversity increases through out the disease (closed circles, top). The risk of transmission is highest in the first weeks when viraemia peaks (closed circles, top). GALT=gut-associated lymphoid tissues.

A pronounced depletion of activated as well as memory CD4+ T cells located in the gut-associated lymphoid tissues has been seen in individuals identified early after infection. 67 The preferential depletion of the CD4+ cells in the mucosal lymphoid tissues remains despite years of antiretroviral treatment, a striking observation that contrasts with the fact that the number of CD4+ T lymphocytes in the peripheral blood can return to normal under antiretroviral treatment.

A gradual destruction of the naive and memory CD4+ T-lymphocyte populations is the hallmark of HIV-1 infection, with AIDS being the last disease stage ( figure 4 ). 68 Despite the frequent absence of symptoms during early and chronic phase, HIV-1 replication is dynamic throughout the disease. The half-life of a single virion is so short that half the entire plasma virus population is replaced in less than 30 minutes, 69 and the total number of virions produced in a chronically infected person can reach more than 10¹P particles per day. 69 , 70 The turnover rates of lymphocyte populations are upregulated many fold during HIV-1 infection, whereas cell proliferation decreases once viral replication is reduced by antiretroviral treatment. 71 , 72 Different depletion mechanisms have been proposed, with an emerging consensus favouring generalised immune activation as cause for constant depletion of the CD4+ cell reservoir. 73

Immune activation predicts disease progression 74 and, thus, seems to be a central feature of pathogenic HIV-1 infections. Recently, Nef proteins from SIV lineages that are non-pathogenic in their natural hosts (eg, African green monkeys) have proved to down-regulate CD3-T-cell receptors, resulting in reduced cell activation and apoptosis. 75 HIV-1 Nef fails to quench T-cell activation, possibly leading to the high degree of immune activation seen in infected people.

Understanding the mechanisms that lead to protection or long-lasting control of infection will guide vaccine development by providing correlates of protection. Natural resistance to HIV-1 infection is rare and varies greatly between individuals. Two groups—long-term non-progressors and highly exposed persistently seronegative individuals—have been studied widely to identify innate and acquired protective determinants ( table 1 ). 76 Host resistance factors consist of human leucocyte antigen (HLA) haplotypes, autoantibodies, mutations in the promoter regions, and coding regions of the co-receptors CCR5 and CCR2, as well as the up-regulation of chemokine production ( table 1 ). 76 , 77 Indeed, individuals encoding a truncated CCR5 version (CCR5Δ32) have slower disease progression (heterozygote) or are resistant to CCR5-using viruses (homozygote). 78 The CCL3L1 gene encodes MIP1α, a CCR5 co-receptor ligand and chemokine with antiviral activity. Recent findings show that CCL3L1 gene copies vary individually and higher numbers of gene duplications result in reduced susceptibility to infection, 77 , 79 possibly by competitive saturation of CCR5 co-receptor. Cytotoxic T-lymphocyte responses, helper T-cell functions, and humoral responses are some of the acquired factors that modulate the risk of transmission in highly exposed persistently seronegative individuals, 76 and could also contribute to spontaneous control of replication in long-term non-progressors. The putative protective role of cytotoxic T-lymphocyte activity has been suggested in seronegative sex workers and in some long-term non-progressors. 76 , 80

Some of the host factors affecting susceptibility to HIV-1 infection

HLA=human leucocyte antigen. CCR5=chemokine receptor 5. CCR2=chemokine receptor 2. CCL3L1=CC chemokine ligand like-1, APOBEC3G/3F=apolipoprotein B mRNA editing complex 3.

Mammalian cells are not welcoming micro-environments, but rather deploy a defensive web to curb endogenous and exogenous viruses. HIV-1’s ability to circumvent these defences is as impressive as its efficiency to exploit the cellular machinery. APOBEC3G/3F and TRIM5α are recently described intrinsic restriction factors that are constitutively expressed in many cells. 81 , 82 Both gene loci have been under strong selective pressure throughout primate evolution, 83 indicating an ancient need to neutralise foreign DNA and maintain genome stability that precedes the current HIV-1 pandemic.

APOBEC3 enzymes (A3) belong to the superfamily of cytidine deaminases, 84 a group of intracellular proteins with DNA/RNA editing activity. 84 , 85 Most representatives of the APOBEC3 group have some mutagenic potential and restrict endogenous retroviruses and mobile genetic elements. The deaminases A3G, A3F, and A3B have potent antiviral activity, with the first two being expressed in cells that are susceptible to HIV-1 infection (T-lymphocytes, macrophages). HIV-1 evades APOBEC3 mutagenesis by expressing Vif, which leads to APOBEC3G/3F but not A3B degradation. 42 , 86 – 90

We still need to establish how the mechanisms of DNA editing and antiviral activity are interwoven, since some antiviral activity can be maintained despite defective DNA editing. 91 The early replication block in non-stimulated CD4+ T cells has been attributed to low molecular mass complexes of APOBEC3G. 92 Hypermutated genomes in HIV-1 infected patients 93 and mutations in Vif resulting in abrogated or differential APOBEC3 neutralisation capacity have been described. 94 , 95 The degree to which APOBEC3G/3F mRNA expression predicts clinical progression remains an area of intensive investigation. 96 , 97

Several representatives of the heterogeneous family of tripartite motif proteins (TRIM) inhibit retroviruses in a species-specific manner. 81 , 98 TRIM5α from rhesus macaques and African green monkeys inhibit HIV-1 replication, whereas the human homologue is inactive against SIV and HIV-1, leading to the recorded susceptibility of human cells to both viruses. 81 Rhesus TRIM5α recognises the capsid domain of HIV-1 Gag and manipulates the kinetics of HIV-1 core disassembly within minutes after cell entry. 99 , 100 Thus, experimental approaches to render HIV-1 resistant to rhesus TRIM5α could lead to immunodeficiency viruses capable of replicating in rhesus macaques. Such a non-primate model would allow testing of antiviral treatment and vaccine interventions with HIV-1 viruses instead of SIV or SIV/HIV chimeric viruses.

Clinical management

The diagnosis of HIV-1 infection is based on the detection of specific antibodies, antigens, or both, and many commercial kits are available. Serological tests are generally used for screening. A major advance has been the availability of rapid HIV-1 antibody tests. These assays are easy to do and provide results in as little as 20 minutes, 101 enabling specimen collection and proper diagnosis at the same visit. Rapid tests are important tools for surveillance, screening, and diagnosis, and can be reliably done on plasma, serum, whole blood, or saliva by health-care providers with little laboratory expertise. The two limitations of these serological tests are detection of infection during primary infection when antibodies are absent, and in infants younger than 18 months who might bear maternal HIV-1 antibodies. In these instances direct virus detection is the only option (eg, quantification of viral RNA [standard] or p24 antigen in heat denatured serum [less expensive]).

For staging purposes, measurement of CD4+ cells and viraemia is required. Plasma viral load is widely used to monitor therapeutic success on antiretroviral treatment. Several commercially available tests provide sensitive quantification of plasma HIV-1 RNA copies. The newer versions of the Amplicor and Quantiplex (Roche, Indianapolis, IN, USA, and Bayer Diagnostics, Walpole, MA, USA, respectively) assays have overcome initial suboptimum performance for non-B subtypes. 102 While the viral load determines the rate of destruction of the immune system, the number of CD4+ cells reveals the degree of immunodeficiency and is, therefore, used to assess the stage of infection. CD4+ cell counts together with clinical manifestations (eg, occurrence of opportunistic infections) are key criteria for HIV-1 disease classification. Flow cytometry analysis is the standard method for CD4+ cells quantification.

Standard methods for quantifying viral load and CD4+ cell counts need advanced laboratory infrastructures, and assays require a specimen to be tested within a short time of collection. These requirements pose challenges for resource-constrained settings. The use of dried blood spot specimen has resolved some of the difficulties associated with transportation of samples needed for virological assessments. 103 Measurement of reverse transcriptase activity in plasma samples, simplification of gene amplification methods (eg, Taqman technology), and paper-strip quantification (dipstick assays) might provide cost-effective alternatives for the future. 104 – 106 Similarly microcapilliary flow-based systems, CD4+ chips, or total white counts (panleucocyte gating) provide alternatives for establishment of the level of immunodeficiency in resource-limited settings. 107 – 110

Drug treatment

Antiretroviral compounds.

Antiretroviral treatment is the best option for longlasting viral suppression and, subsequently, for reduction of morbidity and mortality. However, current drugs do not eradicate HIV-1 infection and lifelong treatment might be needed.

20 of the 21 antiretroviral drugs currently approved by the US Food and Drug Administration target the viral reverse transcriptase or protease ( table 2 ). Eight nucleoside/nucleotide analogues and three non-nucleoside reverse transcriptase inhibitors inhibit viral replication after cell entry but before integration. Fixed-dose combination tablets simplify treatment regimens by reducing the daily pill burden, and drugs with long half-lives allow once or twice daily dosing. Eight protease inhibitors prevent the maturation of virions resulting in production of non-infectious particles. The recently approved darunavir (June, 2006) is the first of its class that retains activity against viruses with reduced susceptibility to protease inhibitors. Enfuvirtide targets a gp41 region of the viral envelope and stops the fusion process before the cell is infected. This drug needs to be injected twice daily and its use is reserved for treatment of heavily drug-experienced patients since it can help overcome existing drug resistance. 111 , 112 Development of new antiretrovirals focuses on molecules that target entry, reverse transcription, integration, or maturation. Compounds that have been designed to inhibit resistant viruses are urgently needed since many patients treated during the past decades harbour viral strains with reduced susceptibilities to many if not all available drugs ( table 3 ).

Antiretroviral drugs currently approved by US Food and Drug Administration

Drugs belong to five drug classes and target three dir erent viral steps (entry, reverse transcription, or protease). Availability of these drugs in resource-limited countries is subject to country specific licensing agreements.

Antiretrovirals currently in phase II/III of clinical development

The goal of antiretroviral treatment is to decrease the morbidity and mortality that is generally associated with HIV-1 infection. A combination of three or more active drugs is needed to achieve this aim in most patients. Effective treatment returns to near normal the turnover rates of both CD4+ and CD8+ T-cell populations. 72 Potent but well tolerated drugs with long half-lives and simplified regimens improve the options for first-line and second-line chemotherapeutic interventions.

Combination antiretroviral treatment

High rate of viral replication, low fidelity of reverse transcription, and the ability to recombine are the viral characteristics that lead to the diversity of HIV-1 species (quasi-species) in chronically infected individuals. This high genetic variability provided the rationale for highly active antiretroviral treatments (HAART). By combination of several potent antiretroviral agents, viral replication is suppressed to such low levels that emergence of drug resistant HIV-1 variants was, if not prevented, at least delayed. By doing so, CD4+ T-lymphocyte numbers increase, leading to a degree of immune reconstitution that is sufficient to reverse clinically apparent immunodeficiency. Widespread introduction of HAART in industrialised countries resulted in a striking decrease in morbidity and mortality, putting forward the hope that HIV-1 infection can be transformed into a treatable chronic disease. 113 – 115

A set of criteria composed of plasma viraemia concentration, absolute or relative CD4+ cell counts, and clinical manifestations, is used to recommend initiation of HAART. The benefits of treatment clearly outweigh the potential side-effects in patients with clinical signs of immunodeficiency (eg, AIDS defining illnesses) or with CD4+ numbers less than 200 per μL (recommendation of US Department of Health and Human Services, October, 2005). However, the best time point to begin treatment remains controversial in asymptomatic patients with modest depletion of CD4+ T cells (eg, more than 350 per μL) and modest levels of viraemia (eg, less than 100 000 copies per mL). 116 Studies with clinical endpoints supporting the validity of early versus late interventions in asymptomatic patients are difficult to do and insufficient clinical data are currently available. Early depletion of gut CD4+ T lymphocytes, 117 increasing viral diversity, and the poor regenerative abilities of key populations of the immune system provide arguments for beginning treatment as early as possible. The wide application of this principle is restricted by long-term drug toxicities that lead to reduction of quality of life, and by treatment costs. Toxicities (eg, renal, hepato, mitochondrial), metabolic changes (eg, lipodystrophy, diabetes mellitus), and immune reconstitution disease are some of the long-term problems that complicate decade-long HAART. 118 – 121

One strategy addressing life-long daily compliance to HAART has been structured treatment interruptions. The rationale for this approach was based on the premise that the body’s own immune system could keep the virus in check if exposed to a very modest level of viral replication. If successful, this strategy could limit drug toxicity and reduce treatment costs. 122 Although preliminary findings for this strategy were mixed in terms of benefits, 123 – 125 the recent early closure of the SMART trial was based on increased morbidity and mortality in the treatment interruption arm. 126 Thus, in the absence of clinical benefits, most investigators strongly discourage treatment interruptions except as needed to address treatment intolerance.

HAART in resource-constrained settings

The transformation of AIDS into a chronic disease in industrialised countries has yet to be realised in resource-constrained settings. Access to HAART is an absolute humanitarian necessity to avert mortality in people who are central to the future survival of their countries. 127 Despite restricted health infrastructures and diverse co-morbidities in these regions, remarkable therapeutic success rates have been shown, with adherence rates at least comparable with those reported in industrialised countries. 128 – 131 WHO and UNAIDS treatment guidelines focusing on resource-limited settings suggest use of standard first-line regimen followed by a set of more expensive second-line options 132 and proposes the use of standardised decision-making steps (eg, when to start, to substitute for side-effects, to switch for virological failure). 132 , 133 In many countries, treatment options are limited not only by the costs of HAART but also by restrictive licensing policies, and current estimates suggest that 80% of people infected with HIV-1 with a clinical need for treatment do not yet have access to antiretroviral drugs. 1 Thus, efforts and strategies to further scale up treatment access are crucial, 134 – 137 since antiretroviral treatment is also an effective intervention for prevention. 138

Drug resistance

Emergence of drug resistance is the most common reason for treatment failure. Insufficient compliance, drug side-effects, or drug-drug interactions can lead to suboptimum drug concentrations, resulting in viral rebound. Viral resistance has been described to every antiretroviral drug and therefore poses a serious clinical as well as public-health problem. 139 HIV-1 subtypes differ in the sequence of mutations leading to drug resistance, and some naturally occurring polymorphisms might actually modulate resistance. 140 , 141 Drug-resistant HIV-1 is transmissible and can be detected in up to 20% of newly infected individuals in countries with broad access to antiretrovirals. 34 The prevalence of drug resistance in the untreated population remains low in regions with poor access to treatment. 142

Short-term antiretroviral-based interventions are effective in prevention of mother-to-child transmission. However, these interventions could result in drug resistant viral variants in the mother, baby, or both. 143 Around half the women who received one dose of nevirapine to prevent mother-to-child transmission harbour viruses resistant to non-nucleoside reverse transcriptase inhibitors (NNRTI). 144 , 145 These resistant viruses replicate efficiently and can be transmitted by breast milk, 146 and minor resistant populations present long after the intervention can possibly decrease the effectiveness of subsequent NNRTI-based treatment regimens. 147 The combination of short-course zidovudine, lamivudine, and nevirapine prevents peripartum transmission while reducing the risk of nevirapine resistant viruses. 148

Viral reservoirs

Viral reservoirs consist of anatomical sanctuaries and a small pool of infected long-lived memory T lymphocytes. HIV-1 latency in long-lived cell populations (eg, memory T lymphocytes, macrophages) poses an obstacle to eradication because current antiviral combination treatments fail to eliminate integrated proviruses from resting cells. Different strategies, including immune-modulatory molecules (interleukin 2, anti-CD3 mAb, interleukin 7), have been used to reactivate resting cells in the setting of HAART. Histone deacetylase-1 inhibitors, like valproic acid, release an inherent transcriptional block and by doing so facilitate viral long terminal repeat-driven expression. 149 Augmenting standard antiretroviral treatment with enfuviridine and valproic acid reduced the number of latently infected CD4+ T cells (29–84%), but to establish the relative contribution of each drug with respect to the final outcome is difficult. 150

Mother-to-child transmission

Prevention of mother-to-child transmission has seen advances in both industrialised and resource-constrained settings. 151 – 153 Intrapartum transmission has been reduced by increasing access to interventions such as one dose of nevirapine to mother and newborn baby. 154 Concerns about drug-resistant viral strains have led to several trials with combination treatments to reduce transmission during the intrapartum period. 148 , 152 , 155 In some settings, elective delivery by caesarean section can further reduce HIV-1 transmission during the intrapartum period, but the benefits of the intervention could be countered by post-partum sepsis and increasing maternal mortality. 156

Because HIV-1 can be transmitted by breastfeeding, replacement feeding is recommended in many settings. Poor access to clean running water precludes, however, the use of formula feeding under these circumstances, 157 and exclusive breastfeeding with abrupt weaning is one option for reducing transmission. 158 A potential novel intervention still being tested is the daily use of antiretrovirals during breastfeeding. More attention is starting to focus on the pregnant mother, especially initiation of antiretroviral therapy in mothers with low CD4+ counts during pregnancy and thereafter. 159 , 160 Only limited data are available regarding the health of uninfected children born to HIV-1-positive mothers. 161 In a European cohort of exposed-uninfected children, no serious clinical manifestations were apparent, at least in the short term to medium term (median follow-up 2 years). 162

Sexual transmission

Reduction of heterosexual transmission is crucial for control of the epidemic in many parts of the world. 1 , 163 Prevention is achieved through reduction in the number of discordant sexual acts or reduction of the probability of HIV-1 transmission in discordant sexual acts. The first can be achieved through abstinence and sex between concordantly seronegative individuals. Abstinence and lifelong monogamous relationships might not be adequate solutions for many people and therefore several interventions aimed at lowering the risk of transmission per discordant sexual act are in the process of clinical testing. Male and female condoms provide a proven and affordable prevention option. 164 , 165 In combination, these options are also more commonly referred to as the ABC (abstinence, be faithful, condom use) approach.

Other biomedical prevention interventions include male circumcision, antiretrovirals for prevention (eg, pre-exposure or post-exposure), chemoprophylactic treatment of herpes simplex virus-2 (HSV-2), microbicides, and vaccines. Results from one of three independent phase III male circumcision trials underway in South Africa, Kenya, and Uganda has helped to allay some of the ambivalence around the protective effect of male circumcision. 8 , 166 The findings from the South African trial show a 60% protective effect of male circumcision. 167 The possible mechanism relates to the fact that the foreskin has apocrine glands that secrete lysozymes but also Langerhans cells expressing CD4 and other receptors. 168 , 169 These skin-specific dendritic cells can uptake virus and are believed to play a part in transport of the virus to susceptible T cells. Immunofluorescence studies of foreskin mucosa suggest that these tissues might be more susceptible to HIV-1 infection than cervical mucosa. 170 Findings from this proof-of-concept trial need to be compared with evidence from the two trials still underway in Kenya and Uganda, and to acceptability data, behaviour change after circumcision, surgical complication rates, and logistics of undertaking the procedures before policy formulation and wide-scale access as a prevention strategy. 171 – 173

Since high plasma viraemia increases the risk of transmission by as much as an order of magnitude, 21 does reducing viral load in the infected partner through, for example, antiretroviral treatment reduce the risk of HIV-1 transmission in the uninfected sexual partner? A trial to explore this question is currently being run jointly by the HIV Prevention Trials Network ( www.hptn.org ) and the Adult Clinical Trials Group. Mathematical projections estimate up to 80% HIV-1 reduction, 174 , 175 but scarce observational data currently exist. 176 Post-exposure prophylaxis is recommended after occupational (eg, needle stick) 177 and non-occupational (eg, rape, sexual abuse) 178 exposure, although data for efficacy and optimum drug combinations are few. 179 Some clinical trials assessing the benefits of once daily pre-exposure chemoprophylaxis with antiretroviral compounds with long biological half-life (eg, tenofovir) have been put on hold or stopped. 175 , 180 Neither the overall idea of pre-exposure prophylaxis nor the drug itself, which is well tolerated, was at the root of the protests. Concerns were centred on clinical trials in resource-poor settings and the perceived scarcity of adequate interventions protecting these vulnerable populations.

HSV-2 might increase both the risk of transmitting and acquiring HIV-1. 181 , 182 Antivirals (eg, aciclovir, valaciclovir) are effective in reducing viral shedding 183 – 185 and HSV-2 transmission in discordant heterosexual couples. 182 The future of HSV-2 prevention might reside in the vaccine that is currently under development. 186 Whether prophylactic use of aciclovir in populations with high HSV-2 prevalence and incidence rates results in reduced HIV-1 incidence rates remains unresolved but several trials addressing this issue are underway, including HPTN039.

Gender disparities lie at the centre of women’s vulnerability. Prevention options need to be provided that can be used by women independently of their male sexual partner’s knowledge or consent. 187 Notwithstanding that redressing these disparities is a long-term challenge, several preventive interventions can be implemented in the interim on the basis of our incomplete understanding at a biological level of HIV-1 risk for women. For example, there seems to be a correlation between levels of sexual hormones (eg, progesterone) and transmission risk. 188 Observational studies also highlight the relation between abnormal vaginal flora and increased risk of HIV-1 infection. 189 , 190 The high prevalence of vaginal infections such as bacterial vaginosis (30–50%), vulvovaginal candidosis (10–13%), and trichomonas vaginalis (7–23%) in African women is associated with a substantial risk of HIV-1 acquisition. 189 In addition to increasing access to female condoms and treatment of other sexually transmitted infections, trials are underway to assess the use of other barrier methods such as cervical caps, invisible condoms, diaphragms, and diaphragms combined with micro bicides. 190 The control of vaginal infections is a potentially important method for decreasing HIV-1 acquisition that has yet to be tested. Periodic presumptive treatment for vaginal infections is being explored as an HIV-1 prevention strategy. 191

Microbicides

Microbicides are an additional important biomedical intervention technology that is covert and under women’s control. 192 These topical products potentially could be used to prevent rectal and vaginal transmission of HIV-1, but proof of concept has been elusive. Although the three phase III trial results of the first microbicidal product (nonoxynol-9) done in the mid-1980s and 1990s did not show protective effects, 193 , 194 they have informed the medical knowledge in terms of product selection, clinical testing, and safety assessments. The past 5 years have seen major advances in investment and product development. 66 , 195 , 197 Early clinical testing of multiple products including the launch of advanced clinical trials for five different products is continuing ( table 4 ). The development of antiretroviral gels increased the specificity of these third generation microbicides in relation to surfactants, vaginal enhancers, or entry inhibitors that have dominated the product pipeline so far ( figure 5 ). The first antiretroviral gel to undergo early testing is tenofovir gel, and the findings in terms of safety profile, tolerance, low systemic absorption, and slight adverse events are promising. 192 As with vaccines, a major obstacle is the absence of a surrogate marker of protection. Additional challenges are adherence to product use and the high rates of pregnancy in trial participants.

N9=nonoxonol-9. CS=cellulose sulphate.

Summary of microbicides currently undergoing advanced clinical testing

A safe, protective, and inexpensive vaccine would be the most efficient and possibly the only way to curb the HIV pandemic. 198 Despite intensive research, development of such a candidate vaccine remains elusive. Safety concerns prohibit the use of live-attenuated virus as immunogen. 199 Many different approaches with recombinant technologies have been pursued over the past two decades. Initially, efforts were focused on generating neutralising antibodies with recombinant monomeric envelope gp120 (AIDSVAX) as immunogen. 200 , 201 This vaccine did not induce neutralising antibodies and, not unexpectedly, the phase III trials failed to show protection. 202 , 203 Antibody mediated HIV-1 neutralisation is complicated by the high genetic diversity of the variable Env regions, epitopes masked by a carbohydrate shield (glycosylation), and conformational or energetic constraints. 204 Since CD8 T-cell responses control to some extent viral replication in vivo, recent vaccine development has focused on eliciting cellular immune responses. Overcoming pre-existing immunity against replication incompetent immunogenic vectors (eg, recombinant adenovirus type 5) is one of the challenges. 205 Safety and immunogenicity studies using replication defective vaccine vectors are continuing after preliminary studies in non-human primates showed some protection. 204 The immune system generally fails to spontaneously clear HIV-1 and the true correlates of protection continue to be ill defined. 198 , 206 However, the general belief is that approaches aimed at eliciting both humoral and cell mediated immunity are most promising to prevent or at least control retroviral infection. 198

Conclusions

An important gateway to both prevention and care is knowledge of HIV-1 status. 207 Fear of knowledge of status, including stigma and discrimination, has discouraged many from seeking voluntary counselling and testing services. 208 As access to antiretroviral interventions (prevention of mother-to-child transmission, antiretroviral treatment) increases, the opportunities for HIV-1 testing will grow and create opportunities for a prevention-care continuum, with the voluntary counselling and testing services as a point of entry. These changes will result in a shift in prevention efforts from a focus on individuals not infected with HIV-1 to a more effective continuum of prevention that includes uninfected, recently infected, infected, and asymptomatic people, as well as those with advancing HIV disease and on antiretroviral therapy.

HIV/AIDS is an exceptional epidemic that demands an exceptional response. Much progress has been made in a short space of time, despite many scientific and programmatic challenges ( figure 6 ). In the absence of a protective vaccine or a cure, prevention and access to antiretroviral treatments are the best options to slow down the HIV-1 pandemic. Broad implementation of these principles needs improved infrastructures in resource-constrained regions, which have been and will continue to be most affected. The fact that HIV-1 is predominantly sexually transmitted and disproportionately affects populations that are already socially or economically marginalised, or both, poses many ethical, social, economic, and political challenges.

Estimates place the cross species transmission events leading to the worldwide spread of HIV-1 to the early decades of the 20th century. Numbers circled by a hexagon identify the specific year of an event. PEPFAR=President’s Emergency Plan for AIDS Relief.

In view of the immediacy of the problem, and the fact that both research and programmes are mainly funded by the public sector, there is a greater demand from civil society for co-ownership of research and accountability for use of public funds. On the one hand, this co-ownership defines a changing role and responsibility of science in society, and on the other hand, shows a necessary synergy between activism and science. This partnership has been invaluable for antiretroviral drug development, treatment access in resource-constrained settings, and the scale-up of interventions to reduce mother-to-child transmission.

The increasing number of infected women and the disproportionate burden of infection in resource-constrained settings creates a scientific imperative to ensure research is done for people and in settings who stand to benefit most. The most affected countries face many other economic, political, and development challenges, which have raised issues in undertaking multicentre and multicountry research. Research addressing women-specific topics (such as effect of sexual hormones on transmission and disease progression, viral diversity, and antiretroviral potency) and women-specific prevention interventions including microbicides is crucial. We are probably at one of the most hopeful and optimistic points in our response to the pandemic. There is definitely more attention being directed to HIV-1, more resources ( panel ), more civil society mobilisation, more governments speaking up, more possibilities for treatment, and more evidence about what prevention and treatment strategies will work than in previous years. The unrelenting growth of the pandemic tells us that current strategies are not enough. Clearly, we need to do some things differently, while also increasing the scale and magnitude of current strategies in keeping with the pandemic.

PanelOnline resources

Epidemiology.

http://www.unaids.org/en/HIV_data/default.asp

Treatment recommendations

Centers for Disease Control and Prevention

http://www.cdc.gov/hiv/topics/treatment/index.htm

HIV-1 drug resistance

Stanford University HIV Drug Resistance Database

http://hivdb.stanford.edu/index.html

International AIDS Society–USA

http://www.iasusa.org/resistance_mutations/index.html

Microbicide

Alliance for Microbicide Development

http://www.microbicide.org

HIV Prevention Trials Network

http://www.hptn.org/index.htm

International AIDS Vaccine Initiative

http://www.iavi.org

Search strategy and selection criteria

A comprehensive literature review was undertaken by searching the PubMed database online, for English language publications between January, 2000, and June, 2006. The database search terms included keywords such as “HIV/AIDS”, “epidemiology”, “prevention”, “pathogenesis”, “HSV-2”, “male circumcision”, “PMTCT”, “scaling up treatment”, “resource constrained settings”, “antiretroviral pre-exposure prophylaxis”, “HAART”, “restriction”, “host factor”, “HIV pathogenesis”, “resistance”, “latency”. Various combinations of these words were entered. All duplicate articles were removed. A subset of relevant articles was chosen and full-text manuscripts were summarised.

Acknowledgments

We thank P D Bieniasz, W Cates, L Chakrabarti, C Cheng-Mayer, J Coovadia, H Gayle, P A Fryd, R Gray, S Abdool Karim, L Kuhn, K Mayer, P Mane, L C F Mulder, L Myer, and M Wawer for helpful discussions. M Boettiger and C Baxter assisted with literature searches. This work was supported by NIH grant RO1AI064001 (VS), by grant 1 U19AI51794 (QAK) from CAPRISA that forms part of the Comprehensive International Program of Research on AIDS (CIPRA) funded by the National Institute of Allergy and infectious Disease (NIAID), National Institutes of Health (NIH) and the US Department of Health and Human Services (DHHS) and grant D43 TW00231 (QAK) from the Columbia University-Southern African Fogarty AIDS International Training and Research Program.

Conflict of interest statement

D D Ho sits on the scientific advisory boards for Monogram, Osel, Achillion, Valiant, Oyagen, Lavipharm, and XTL. Products or work from these companies are not discussed in the review. He holds patents on vaccine candidates. The other authors declare no conflict of interest.

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Review article, effectively communicating about hiv and other health disparities: findings from a literature review and future directions.

• 1 Center for Communication Science, RTI International, Durham, NC, United States
• 2 Prevention Communication Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States

Despite significant progress in the prevention and treatment of HIV, disparities in rates of infection remain among key groups in the United States, including blacks and African Americans; Hispanics/Latinos; and men who have sex with men (MSM). The U.S. Department of Health and Human Services' initiative, Ending the HIV Epidemic: A Plan for America , calls for addressing HIV-related disparities and reducing stigma and discrimination associated with HIV. The goal of this literature review was to identify approaches for effectively communicating about health disparities across the HIV care continuum. We reviewed the literature to investigate strategies used to communicate health disparities and to identify potential unintended adverse effects resulting from this messaging. Messages about health disparities often target subgroups at higher risk and can be framed in a variety of ways (e.g., social comparison, progress, impact, etiological). Studies have examined the effects of message framing on the risk perceptions, emotional reactions, and behaviors of individuals exposed to the messaging. The evidence points to several potential unintended adverse effects of using social comparison framing and individual responsibility framing to communicate about health disparities, and visual images and exemplars to target messages to higher-risk subgroups. There is not yet a clear evidence-based approach for communicating about health disparities and avoiding potential unintended effects. However, we offer recommendations for communicating about HIV-related disparities based on our findings. Because we found limited literature that addressed our research questions in the context of HIV, we propose a research agenda to build an evidence base for developing effective messages about HIV-related disparities.

Introduction

Healthy People 2020 defines a health disparity as “a particular type of health difference between individuals or groups that is unfair because it is caused by social or economic disadvantage” ( U.S. Department of Health and Human Services, 2008 ). Despite significant progress in the prevention and treatment of HIV in the United States, disparities remain in rates of infection among racial/ethnic minority groups, with black and African American (hereafter referred to as black) and Hispanic/Latino populations being the most affected subgroups ( McCree et al., 2017 ; U.S. Department of Health and Human Services, 2020 ). Gay, bisexual, and other men who have sex with men (MSM) are also disproportionately affected by HIV, and most MSM diagnosed with HIV are MSM of color. The causes of these disparities are complex and interrelated and can be attributed to multiple individual, social, contextual, and environmental factors ( McCree et al., 2016 ).

Ending the HIV Epidemic: A Plan for America is the U.S. Department of Health and Human Services' cross-agency initiative that aims to reduce new HIV infections in the U.S. by 90% in 10 years by focusing on communities most impacted by HIV ( U.S. Department of Health and Human Services, 2020 ). This initiative highlights the persistence of HIV disparities among racial and ethnic minority groups as well as MSM and the role of stigma in preventing those at risk for HIV or living with HIV from receiving needed health care and services. HIV stigma may be exacerbated in marginalized groups who experience multiple and converging forms of stigma—referred to as intersectional stigma—including stigma related to race, ethnicity, sexual identity, gender identity or expression, illicit drug use, sex work, and incarceration ( Earnshaw et al., 2013 ; Rice et al., 2018 ). Stigmatizing attitudes toward people with HIV or at risk for HIV may lead to delayed HIV testing ( Golub and Gamarel, 2013 ), reduced adherence to antiretroviral therapy ( Sweeney and Vanable, 2016 ), and poorer retention in care ( Yehia et al., 2015 ). Social stigma can also have serious negative consequences for both psychological and physical well-being by decreasing self-esteem and increasing stress responses in stigmatized groups ( Major and O'Brien, 2005 ).

Health communication can play a key role in raising awareness among priority audiences about their risk for getting or transmitting HIV and influencing attitudes, beliefs, and behaviors. However, communicating about health disparities can also result in unintended, adverse consequences. For example, dissemination of information comparing HIV diagnoses by subgroup may result in “blame and shame” and foster helplessness, distress, anger, and mistrust among affected communities ( Friedman et al.'s, 2014 ; Lee et al., 2017 ; Drumhiller et al., 2018 ).

Smith (2007) developed a model of the social and psychological effects of messages that communicate stigma. According to Smith, stigma messages have four characteristics: (1) they distinguish or categorize a group of people, (2) they establish this group of people as a separate social entity, (3) they link the group to a physical or social threat, and (4) they imply that group members are responsible for the threat. Thus, stigma messages encourage stereotyping and the perception of the group as a coherent entity and make social identity salient ( Major and O'Brien, 2005 ; Smith, 2007 ). These messages contribute to the perception of stigmatized individuals as a social threat and as responsible for their condition ( Smith et al., 2019 ). Negative behavioral outcomes of exposure to stigma messages include increased support for interventions that isolate and regulate stigmatized groups, interpersonal disassociation from stigmatized individuals, and the social transmission of stigma messages ( Smith et al., 2019 ). Because HIV and groups at greater risk for HIV are often associated with multiple social stigmas, communication about HIV and disparities in HIV are particularly susceptible to containing characteristics of stigma messages. Consequently, a better understanding of message strategies and features that raise awareness and motivate behavior change while avoiding potential adverse effects is needed.

We designed this literature review to be exploratory in nature. The overarching goal of the review was to identify promising approaches for effectively communicating about disparities across the HIV care continuum. As such, we reviewed the literature to address the following research questions (RQs):

1. What strategies are used to communicate health disparities information?

2. What are the potential unintended adverse effects of messages communicating health disparities, and how do specific message strategies contribute to these effects?

We searched four databases—PubMed, Web of Science, PsycINFO, and Communication Source—using the search terms shown in Table 1 for peer-reviewed literature published between 2011 and 2018. This time frame was selected to focus the review on the most recent literature that addressed our RQs. We also obtained additional articles via the snowball method, which involved reviewing the reference lists of particularly relevant articles and acquiring articles recommended by colleagues with subject matter expertise. Because the number of relevant articles identified by the database search was relatively small, we did not place any limitations on the time frame for articles obtained with the snowball approach.

Table 1 . Literature search overview.

We focused the search on studies conducted in the United States; however, we also included two articles from other countries because they examined RQs closely aligned with those of interest in this review. One study, identified by the snowball method, was conducted in South Korea ( Lee and An, 2016 ) and described a randomized experiment testing the effects of messages about the controllability of a condition (i.e., individual responsibility for the onset of a condition) and group categorization on perceived stigma. The other study, conducted in the United Kingdom, reported results of interviews conducted to learn about the unintended consequences of an intervention targeting a high-risk group ( Sorhaindo et al., 2016 ).

Although we prioritized literature focused on HIV, this body of literature was small. Consequently, we did not limit our search to HIV. We included relevant literature addressing our RQs across health topics, including sexually transmitted diseases (STDs), cancer, mental health, and obesity. Though some higher-risk populations may experience more layers of stigma than others, which could affect responses to messaging, we expected potential responses to messages about health disparities to be a communication phenomenon that would be similar across conditions, rather than entirely condition specific. Thus, we wanted to draw on the body of literature examining this phenomenon.

We were systematic in our approach to identifying relevant literature. However, the goal of this literature review was to be inclusive of relevant studies that addressed our RQs—including both quantitative and qualitative research—to gain an understanding the state of the science. Because the body of literature addressing our RQs was limited, we included a broader range of studies than would be included in a systematic review, which requires that studies meet certain specifications for design and quality. Broadening the body of literature we reviewed also allowed us to better synthesize literature at the intersection of our topics of interest and identify gaps in the existing literature.

We scanned titles and abstracts to identify potentially relevant articles and other documents, which resulted in 89 articles, book chapters, and reports for further review. On the basis of this review, we excluded sources that were not focused on our RQs, such as those that compared gain and loss frames rather than different strategies for framing disparities information. In total, we identified 43 articles and other documents from which we abstracted information that addressed the RQs.

We found limited literature specifically addressing the RQs in the context of communicating HIV-related disparities (11 articles focused specifically on HIV and 3 on other STDs). Research assessing strategies and approaches used to communicate about health disparities often focused on cancer (e.g., Nicholson et al., 2008 ; Landrine and Corral, 2015 ), whereas much of the research about stigmatization and stereotyping focused on mental health (e.g., Corrigan et al., 2012 , 2015 ), and obesity (e.g., Skurka, 2019 ). Only a few studies provided insights into how disparities in STDs and HIV can be presented to promote behavior change and avoid unintended adverse effects ( Friedman et al.'s, 2014 ; Uhrig et al., 2017 ; Drumhiller et al., 2018 ).

We begin by describing strategies used to communicate health disparities. We then discuss potential unintended adverse effects that can result from the use of these strategies.

Strategies for Communicating Health Disparities Information

Targeting and framing are communication strategies often used in messaging about HIV and other health disparities. In this section, we review literature that addresses our first RQ.

Targeting, also referred to as audience segmentation, is a strategy used to increase the effectiveness of health messages and information ( Slater, 1996 ). Targeting involves the decision to direct public health messages to a particular segment or segments of the population (i.e., priority audience), typically groups considered to be at “high risk” ( Kreuter and Wray, 2003 ; Guttman and Salmon, 2004 ). The rationale for developing targeted messages is that they will better address the needs, concerns, beliefs, and values of a particular subgroup; increase the likelihood that the messages will be perceived as relevant; and promote positive behavior change ( Slater, 1996 ; Institute of Medicine, 2002 ; Kreuter and Wray, 2003 ).

Message Framing

Message framing involves “select[ing] some aspects of a perceived reality and [making] them more salient in a communicating text” ( Entman, 1993 ). Entman also describes frames as “defining problems,” “diagnosing causes,” “making moral judgments,” and “suggesting remedies.” The way information is framed is important because it has implications for how people view and understand the topic addressed in the communication ( Entman, 1993 ). Frames can be used intentionally or unintentionally to communicate about health risks in public health messages and in the news media.

Framing is a strategy commonly used in messages about health disparities. We found that messages frame information about health disparities in a number of ways. Social comparison framing typically highlights disparities in disease incidence, risk, or outcomes between racial or other groups; for example, “Blacks are more than twice as likely as whites to be diagnosed with HIV” ( Dunham et al., 2016 ). Progress framing highlights progress made in reducing health disparities, such as “Blacks Making Great Strides Against Colon Cancer” ( Landrine and Corral, 2015 ). Impact framing presents the risks for one subgroup only (e.g., black only or white only). Non-comparative framing presents risks for the population overall (e.g., Americans; often used as a control in studies). Etiological framing or causal framing is when messages are framed to emphasize one or a combination of causal factors.

A small body of experimental studies examined the effects of message frames for communicating about health disparities on the risk perceptions, emotional reactions, behavioral intentions, and behaviors of priority audiences (i.e., those at higher risk) and those outside the priority audience. Table 2 provides an overview of these studies ( n = 13) that address our first RQ. We discuss these studies in more detail below.

Table 2 . Overview of studies testing message framing effects.

Social comparison framing

Several studies have examined the effects of presenting risk information in messages using a social comparison frame vs. messages using a non-comparative frame on participants' risk perceptions, emotional reactions, and other outcomes ( Uhrig et al., 2013 ; Bigman, 2014 ; Dunham et al., 2016 ; Jones et al., 2016 ; Skurka, 2019 ).

In a series of experiments, Bigman (2014) found that social comparison framing (comparing blacks and whites) of STD and cancer risk in mock news articles did not significantly raise risk perceptions among the group at higher risk (i.e., blacks in the case of STDs) relative to non-comparative and impact frames (Americans, blacks only, or whites only) containing equivalent information. However, the social comparison frame had an unintended effect of lowering the risk perception for the group at lower risk (i.e., whites in the case of STDs). Dunham et al. (2016) investigated whether messages about HIV and diabetes using a social comparison frame would increase risk perceptions among blacks (the group at higher risk) relative to non-comparative control messages that did not mention race. The messages using a social comparison frame did not significantly increase risk perceptions among blacks, compared with the non-comparative messages.

Other studies examined the effects of social comparison frames in the context of cardiovascular disease and obesity. Jones et al. (2016) found that public service announcements (PSAs) using a black-white social comparison frame for presenting cardiovascular disease risk negatively affected task persistence (i.e., completing a health assessment form), especially among blacks, relative to PSAs on neutral health topics (air pollution, forest fires, and wearing seatbelts). Skurka (2019) examined the response to obesity messages that used racial (blacks at higher risk than whites) and geographic (rural individuals at higher risk than urban individuals) social comparison frames. Participants exposed to the racial comparison frame were more likely to accept the accuracy of the information than participants in the non-comparative control condition (i.e., participants who received a message that referenced only “adults”). However, the racial comparison frame had negligible effects on other measures of believability (e.g., agreement that the message is credible, counterarguments to the message), emotions, attributions of responsibility, or policy support, relative to the non-comparative frame. Similarly, relative to the non-comparative frame, the geographic comparison frame decreased the perceived credibility of the message and increased message counterarguing, which was associated with less support for obesity prevention policies.

Social comparison vs. progress and impact frames

Some studies compared the effects of information presented using a social comparison frame to information presented using a progress frame ( Nicholson et al., 2008 ; Landrine and Corral, 2015 ; Langford et al., 2017 ; Lee et al., 2017 ). A few studies also included comparisons to information presented using an impact frame ( Nicholson et al., 2008 ; Uhrig et al., 2013 ).

Landrine and Corral (2015) examined reactions to mock news articles about colon cancer and found that within the group at higher risk (i.e., blacks), exposure to social comparison-framed articles did not increase perceived cancer risk or intention to get screened as compared with exposure to an article using a progress frame, which emphasized a decrease in colon cancer death rates in the black community. Uhrig et al. (2013) compared messages about STD disparities that used a social comparison frame (blacks affected by gonorrhea at higher rates than whites), a progress frame (gonorrhea among blacks has declined over past decade), or an impact frame (gonorrhea affects blacks at a high rate). The progress-framed message was most effective in terms of emotional reaction (less upsetting, more encouraging), and the impact-framed message was most effective in motivating participants to want to get tested for STDs and to talk to family and friends about getting tested.

Langford et al. (2017) compared the effects of a social comparison-framed message (“African Americans die from chronic diseases like diabetes at a much higher rate than whites”) with a progress-framed message (“African Americans are increasing their exercise levels”) on willingness to participate in a diabetes prevention and physical activity study and found that message framing had no effect on blacks' willingness to participate in the study. However, this study did not assess the effects of framing on risk perceptions, emotional reactions, or behavior.

Etiological or causal framing

People often have preexisting beliefs about cause and responsibility for a health condition that can vary by race, gender, income, and age ( Brady, 2016 ). These beliefs about cause and responsibility can be influenced by the way a message is framed. Etiological framing can influence perceptions of responsibility and support for policies to reduce health disparities ( Niederdeppe et al., 2008 ). For example, one study compared the effects of four frames addressing varied causes of anorexia nervosa and found that how the message was framed influenced beliefs about the cause of the condition ( Bannatyne and Abel, 2015 ). The condition was framed as being caused by either biology/genetics, sociocultural factors (e.g., media influence, body image ideals), environmental factors (e.g., sporting pressure, modeling of diet behaviors, trauma), or multiple factors (i.e., the interaction between biological, societal, and environmental factors). Participants who received the biological/genetic frame were more likely to attribute the cause to biology and genetics, those who received the sociocultural frame were more likely to attribute the cause to sociocultural factors, and so on. However, the frames also generated some unexpected effects. Participants in the sociocultural and multiple factors conditions believed individuals to be more responsible and blameworthy for their condition than participants in the other conditions. The authors concluded that attributing the cause to biology and genetics may decrease the level of blame and stigma associated with the condition because biology and genetics are factors over which people have no control.

A common etiological frame used in public health messaging is the individual responsibility frame, which emphasizes factors over which individuals have control, such as behaviors that may increase one's risk of acquiring or developing a disease or health condition ( Guttman and Salmon, 2004 ; Dunham et al., 2016 ; Lee and An, 2016 ). A content analysis of video and print PSAs on a variety of health topics found that 80% used an individual responsibility frame ( Coleman and Hatley Major, 2014 ).

A series of experiments examined message framing in mock news articles about being overweight or obese, comparing an individual responsibility frame (i.e., they described being overweight or obese as controllable and inherently unhealthy, and stigmatization and discrimination as acceptable) to a multiple factors frame (i.e., they described being overweight or obese as uncontrollable and not inherently unhealthy, and stigmatization and discrimination as unacceptable; Frederick et al., 2016 ). These descriptions were based on frames commonly used in news articles about obesity. The researchers found that participants who read articles using an individual responsibility frame expressed more belief in the health risks of being overweight, more belief that weight is controllable, more support for charging obese people more for health insurance, more prejudice against being overweight, more willingness to discriminate against overweight people, and less willingness to celebrate body size diversity. However, they found little or no effect of the individual responsibility frame on support for public policies.

Dunham et al. (2016) found no effect of the individual responsibility frame in messages about HIV and diabetes on risk perceptions, emotional responses, or support for public policy compared with other frames. This study also hypothesized that a combined individual responsibility and social comparison frame would induce denial among the group at higher risk (i.e., blacks) and reduce risk perceptions. Contrary to this hypothesis, a diabetes message using the combined social comparison/individual responsibility frame significantly increased perceived risk among blacks as compared with the control condition. However, an HIV message using this framing did not significantly influence perceived risk among blacks.

Potential Unintended Adverse Effects of Messages Communicating About Health Disparities

Messages about health disparities can have unintended adverse effects both in the short and long term and at the individual and societal levels. The Institute of Medicine (2002) and others have argued that consideration of unintended adverse effects and other ethical issues in health communication is imperative for both moral (i.e., adhering to ethical principles) and practical (i.e., producing the desired impact) reasons. Messages need to balance the potential benefits of presenting health disparities information to raise awareness and promote behavior change with the potential harms, such as stereotyping and stigmatization ( Institute of Medicine, 2002 ; Guttman and Salmon, 2004 ; Coleman and Hatley Major, 2014 ; Keller et al., 2014 ). For example, while targeting is used to increase the relevance of messages to a priority audience, presenting information that links a particular high-risk group with a negative health condition (i.e., highlighting health disparities) can stigmatize the priority audience ( Guttman and Salmon, 2004 ; Friedman et al.'s, 2014 ) and cause them to perceive messages as reinforcing stereotypes ( Sorhaindo et al., 2016 ). Next, we discuss literature addressing our second RQ on the potential unintended adverse effects of communicating about health disparities, including stigmatization and stereotyping, victim blaming, negative emotional reactions, mistrust of health information, and boomerang effects.

Stigmatization and Stereotyping

In stigmatization, certain attributes become associated with negative evaluations and stereotypes that are well-known in a community or culture and become the basis for excluding or avoiding members of the stereotyped group ( Major and O'Brien, 2005 ). Health messages can inadvertently stigmatize and stereotype people based on their health-related behaviors (e.g., smoking, sexual behavior) or health condition (e.g., HIV). These effects are not benign, as they can affect the identity of individuals and groups and influence the way people perceive themselves and how they are perceived by others ( Guttman and Salmon, 2004 ; Guttman, 2017 ). Stigmatized individuals may be feared, avoided, regarded as de via nt, or blamed for their health condition.

Messages that use a social comparison frame can activate a stereotype threat response in individuals exposed to the message, a phenomenon in which these individuals perceive that they are at risk of confirming negative stereotypes about their group ( Cho and Salmon, 2007 ; Inzlicht and Schmader, 2011 ; Lee et al., 2017 ). Stereotype threat is the resulting sense that one might be judged in terms of negative stereotypes about one's group instead of on personal merit. Researchers hypothesize that stereotype threat can adversely affect the attitudes, intentions, and behaviors of the stereotyped group ( Inzlicht and Schmader, 2011 ).

Evidence of these types of unintended effects include anti-tobacco campaigns that stigmatize smokers and people with smoking-related illnesses ( Bayer, 2008 ; Riley et al., 2017 ). Patients with lung cancer report feeling stigmatized because of the association with a behavior (smoking) that is perceived to be personally controllable ( Chambers et al., 2012 ; Shen et al., 2016 ). Lung cancer stigma is associated with negative psychosocial and medical outcomes, including delayed diagnosis, poor quality of life, and poor patient-provider communication ( Riley et al., 2017 ). Additionally, PSAs addressing eating disorders can lead to more negative attitudes and less willingness to interact with individuals with this health condition ( Iles et al., 2016 , 2017 ).

In the context of HIV, research suggests that messages about pre-exposure prophylaxis (PrEP) may contribute to stereotypes and stigma associated with PrEP users ( Thomann et al., 2018 ). For example, in focus groups with MSM and transgender women, some participants expressed negative views of those who use PrEP. Participants suggested that their perceptions of who would benefit from PrEP were derived from PrEP marketing campaigns. They described messages about the benefits of PrEP as contributing to the stereotype that those who use PrEP engage in condomless sex with multiple partners ( Thomann et al., 2018 ). Many participants also said that this negative stereotype and associated stigma influenced willingness to use PrEP.

Populations at higher risk for a stigmatized health condition may oppose health communication interventions that present disparities information because of concern about stigmatization and stereotyping ( Friedman et al.'s, 2014 ; Drumhiller et al., 2018 ). A qualitative study with blacks explored perceptions of STD disparities in the black community and found that participants were reluctant to have STD-related disparities information disseminated to non-black communities. Participants expressed concern that the information would stigmatize blacks, perpetuating racism, and discrimination ( Friedman et al.'s, 2014 ).

Priming stereotypes

Another way in which health messages can perpetuate stereotyping is through the process of priming, which can then influence how people are perceived and the judgments made about them ( Power et al., 1996 ; Roskos-Ewoldsen et al., 2009 ). Priming refers to the automatic activation of representations or associations in memory by exposure to a stimulus, such as a message, which then influences subsequent judgments and behavior ( Bargh and Chartrand, 1999 ; Roskos-Ewoldsen et al., 2009 ).

Stereotypes can be primed through the personality traits and other characteristics used to describe individuals ( Power et al., 1996 ; Wang, 2019 ). Depicting individuals in a small number of stereotypical roles or personality types can prime stereotypes and communicate a message quickly, but can also perpetuate those stereotypes ( Wang, 2019 ). On the basis of a study of stigma and counter-stigma frames, cues, and exemplifications in news coverage of depression, Wang (2019) advised that the use of exemplars (i.e., illustrative cases) can be problematic. Stereotypical exemplars can bias judgment and lead to erroneous generalizations.

Public health messages often use visual images to capture attention, reflect the priority audience, and increase perceptions of the message's relevance. However, visual images can prime stereotypes about race, gender, or other group identities ( Guttman and Salmon, 2004 ; Coleman and Hatley Major, 2014 ; Young et al., 2016 ). Examples include portraying blacks as athletes and women as mothers. Stereotypes can also be primed via cues in the image (e.g., the setting); by emphasizing norms frequently associated with a group or culture, and by music; such as the use of hip-hop in an advertisement targeting a black audience. A content analysis of PSAs on various health topics found that racial and cultural stereotyping primes were present twice as often in visual images than in words (7 and 3%, respectively) ( Coleman and Hatley Major, 2014 ). The content analysis also found blacks were disproportionately represented in HIV-related PSAs; more than half (52.5%) of these PSAs featured blacks.

In a study that tested message concepts for a Centers for Disease Control and Prevention (CDC) HIV testing campaign, black women found a message concept, which was designed to promote HIV testing among black women, to be offensive. They noted that the image called for “women from all walks of life” to get tested, yet the image depicted only black women ( Uhrig et al., 2017 ). Similarly, Drumhiller et al. (2018) examined receptivity to HIV testing campaign messages and found that the participants (black and Hispanic/Latino MSM) objected to images of gay men perceived to be stereotypical (e.g., flamboyant, excessively feminine). The participants reported that stereotypical images of gay men and cues such as the location of campaign materials in “at-risk” neighborhoods made them feel stigmatized because of their race and sexual identity. Images can also influence estimates of rates of disease for specific racial or ethnic groups. In one study, the inclusion of a photograph of a person from a specific racial or ethnic group led to higher estimates of disease risk for that group, even though the text provided no information about the relative risk of disease by race or ethnicity ( Gibson and Zillmann, 2000 ).

Research has consistently found that people tend to remember visual images better than words, referred to as the “picture superiority effect” ( McBride and Anne Dosher, 2002 ). Consequently, the use of images to support frames and the potential for images to prime stereotypes or to promote stigmatization should be carefully scrutinized ( Coleman and Hatley Major, 2014 ). One study that provides support for this conclusion showed participants messages with stigmatizing images of overweight people or non-stigmatizing images and text that emphasized individual or social determinants of obesity ( Young et al., 2016 ). The results revealed a stronger effect of images compared to text. Stigmatizing images influenced behavioral intention among normal-weight participants, even when the text pointed to social determinants. The researchers suggested that the stigmatizing images may have primed an avoidance response in normal-weight participants such that they shifted their behavioral intentions to avoid the stigmatized condition. However, message condition had no effect on the behavioral intentions of overweight participants. The study did not measure emotional response, so it is unknown whether the stigmatizing messages elicited negative emotion or reinforced self-stigma in overweight or obese individuals.

Stereotypic portrayals can influence perceptions about responsibility ( Power et al., 1996 ). One study tested the effects of stereotypic and counter-stereotypic portrayals of blacks and women on attributions or responsibility and perceptions of credibility ( Power et al., 1996 ). The results showed that negative stereotypic portrayals of blacks resulted in more internal or personal attributions of responsibility in subsequent judgments made about blacks. In contrast, positive counter-stereotypic portrayals generated more external or situational attributions of responsibility in subsequent judgments. Stereotypic portrayals of women decreased the perceived credibility of women, whereas counter-stereotypic portrayals increased perceptions of women's credibility. Similarly, another study found that an article depicting suicidal individuals as outgroup members by describing them in stereotypic terms (e.g., insane, unemployed, juvenile delinquents) generated more stigma than an article describing suicidal individuals as ingroup members (e.g., anyone; Lee and An, 2016 ).

Victim Blaming

Health messages framed in terms of individual responsibility can result in victim blaming—identifying the cause of the health problem as being the result of an individual's behavior without recognition of social and environmental forces ( Institute of Medicine, 2002 ; Guttman and Salmon, 2004 ; Cho and Salmon, 2007 ; Coleman and Hatley Major, 2014 ; Riley et al., 2017 ). Linking health with personal responsibility may, by implication, characterize individuals who do not adopt recommended health behaviors as weak or irresponsible. People may react to these types of messages with feelings of guilt, shame, or frustration when they feel they cannot adopt the recommended health behaviors.

In addition to the potential negative emotional effects of presenting information about health disparities using an individual responsibility frame, this frame frequently does not impart a complete understanding of the causes of a disease or condition. In some cases, individual behavior may not actually be responsible for the existence of a disparity. For instance, a disparity in the rate of HIV infection among black MSM compared with other MSM is not the result of black MSM engaging in risky sexual behaviors at higher rates than MSM generally ( Matthews et al., 2016 ). Instead, the disparity in HIV infection rates is the result of a variety of complex, interrelated factors ( McCree et al., 2017 ).

Negative Emotional Reactions

Messages sometimes use negative emotion (e.g., fear, guilt) to communicate a health risk associated with a particular group or identity ( Coleman and Hatley Major, 2014 ; Fairchild et al., 2015 ). Examples include New York City's fear-based tobacco, obesity, and HIV health communication campaigns ( Fairchild et al., 2015 ). An analysis of PSAs on health topics found that the use of negative emotion was the second-most common frame used in PSAs—present in 48% of the sample—after individual responsibility ( Coleman and Hatley Major, 2014 ).

Social comparison framing can elicit counterproductive negative emotional reactions among the population at higher risk. Several studies compared emotional reactions to messages presented using a social comparison frame as compared with other frames. Uhrig et al. (2013) found that communicating about disparities in STD rates among blacks using a social comparison frame was more upsetting and less encouraging relative to using either a progress or impact frame. In another study, blacks exposed to mock news articles about disparities in colon cancer using a social comparison frame (blacks are doing worse than whites) experienced more negative emotional reactions than those exposed to articles using a progress frame (blacks are improving over time) or impact frame (colon cancer strikes blacks at a high rate) ( Nicholson et al., 2008 ). Landrine and Corral (2015) also examined emotional reactions to news articles about disparities in colon cancer and found that blacks exposed to a social comparison frame felt more insulted, discouraged, and angry compared with those exposed to a progress frame.

Lee et al. (2017) examined the effects of messaging about health disparities in the lesbian, gay, bisexual, and transgender (LGBT) community. Participants exposed to the message presented using a social comparison frame reported that it made them feel discouraged, insulted, angry, and significantly less likely to indicate pride in their LGBT identity, relative to the progress-framed message ( Lee et al., 2017 ). When study participants (black men and women) were informed about racial disparities in STD rates in their community within the context of a qualitative study, they often reacted with surprise, sadness, fear, and despair ( Friedman et al.'s, 2014 ).

Mistrust of Health Information

Social comparison framing may increase distrust of health information among the population at higher risk. This is an important concern given the prevalence of medical mistrust among racial and ethnic minorities, which has been found to influence attitudes and behaviors related to HIV prevention and treatment ( Bogart et al., 2010 ; Mimiaga et al., 2016 ; Cahill et al., 2017 ; Thomann et al., 2018 ). For example, among black men, mistrust of PrEP is a barrier to use ( Cahill et al., 2017 ; Thomann et al., 2018 ), and belief in conspiracy theories about antiretroviral therapy is related to treatment non-adherence ( Bogart et al., 2010 ).

Several studies found that social comparison framing was associated with higher distrust, compared with other types of framing. In one study, blacks exposed to news articles about disparities in cancer risk, using a social comparison frame, had more doubts about the veracity of the articles (i.e., they were more likely to agree with the statement, “I wonder if it's true. I am suspicious of the story”), compared with those exposed to non-comparative articles ( Landrine and Corral, 2015 ). Lee et al. (2017) found that study participants exposed to a message using a social comparison frame (“With rates double that of the population, smoking poses a deadly threat to the LGBT community”) or impact frame (“Half of black gay men will get HIV in their lifetime”) had lower agreement with the statement “I believe the message” than those exposed to a message using a progress frame (“LGBT communities are working to address health problems”).

Dunham's study ( Dunham et al., 2016 ) of HIV and diabetes messages found that blacks were significantly less likely to trust the accuracy of “government data” about racial disparities in HIV prevalence when the information was presented with an individual responsibility frame relative to a non-comparative frame (control group). Conversely, white participants were significantly more likely to trust “government data” when presented with a social comparison frame. The findings were mixed for effects of the individual responsibility frame on white participants; this frame significantly decreased trust in the HIV message but significantly increased trust in the diabetes message.

Friedman et al.'s qualitative study ( Landrine and Corral, 2015 ) of perceptions of STD disparities among blacks found that although most participants believed the information, some were skeptical. These participants questioned the objectivity of data sources, suggested the government may inflate or fabricate rates to encourage people to get tested, or disbelieved the lower rates of STDs reported for other racial groups.

Boomerang Effects

A well-recognized unintended consequence of health communication messages is the boomerang effect, which refers to health messages having an effect opposite of the intended effect ( Cho and Salmon, 2007 ). For example, obesity-related messages perceived as stigmatizing have been found to result in increased calorie consumption and decreased motivation to lose weight ( Schvey et al., 2011 ; Puhl et al., 2013 ; Major et al., 2014 ; Young et al., 2016 ).

Health disparities information may have a boomerang effect if the group at higher risk avoids, devalues, or rejects the information. People may not believe, or may view as prejudiced, information threatening their self-concept or favorable image of their group. Social comparison-framed messages about cancer disparities can have this type of unintended effect ( Nicholson et al., 2008 ). Blacks exposed to mock news articles about colorectal cancer mortality experienced more negative reactions to articles using a social comparison frame compared with those exposed to articles using a progress frame or impact frame, and they were less likely to have screening intentions. Medical mistrust moderated this effect, with the progress-framed articles producing higher intentions to get screened than the social comparison-framed articles among participants with a high level of mistrust. Participants with a low level of mistrust did not differ in terms of their screening intentions across conditions.

Based on our review of the broader body of literature addressing the effects of messages about health disparities, we developed a conceptual framework that presents potential positive and negative effects of communication about HIV-related disparities (see Figure 1 ). Although we hypothesize responses to messages about health disparities to be similar across health contexts, this model will need to be tested empirically in the context of HIV. Next, we discuss implications of the literature that we reviewed and offer recommendations for communicating about HIV-related disparities based on the available evidence. We conclude by proposing a research agenda to fill gaps in the evidence base regarding effective strategies for communicating about disparities across the HIV continuum.

Figure 1 . Positive and negative effects of communication about HIV-related disparities.

The goal of this literature review was to identify promising approaches for effectively communicating about health disparities across the HIV care continuum. Given our RQs, we specifically intended to examine strategies used to communicate health disparities and investigate potential unintended adverse effects of messages communicating health disparities to identify how specific message strategies contribute to the unintended effects. We found limited literature specifically addressing the RQs in the context of HIV. Although there is a substantial body of literature on communication interventions that address HIV (e.g., Noar et al., 2009 ), the body of research focused on examining the effects of messages communicating HIV-related disparities within and outside priority audiences is limited. There are likely multiple explanations for why this body of research is not more developed. One possible explanation may be that focusing on social determinants of health and the social and environmental processes and inequities that contribute to health disparities is still relatively recent in the U.S. ( Braveman and Gottlieb, 2014 ). Increasing attention to these factors has recently contributed to the interest in providing higher-risk groups with more context to help them better understand underlying reasons for the disparities. Additionally, disparities in HIV-related outcomes between some groups, such as blacks and whites, have continued to increase ( Allgood et al., 2016 ). Recent research has also begun to highlight a growing concern that messages about HIV-disparities may have unintended effects (e.g., Lee et al., 2017 ; Thomann et al., 2018 ). Thus, the aim to increase awareness of these disparities while avoiding unintended effects has become more crucial over time.

A common strategy for communicating about health disparities is to use a social comparison frame, which compares the differences in rates of disease or outcomes between a group more at risk and a group less at risk. Although this is an intuitive strategy for attempting to increase risk perceptions within a priority audience, which is an important predictor of health behavior, studies often find that a social comparison frame does not increase risk perceptions in the group more at risk ( Bigman, 2014 ; Landrine and Corral, 2015 ; Dunham et al., 2016 ). Additionally, the evidence points to several potential adverse consequences that can occur with social comparison framing, including stigmatization and stereotyping, negative emotional reactions, and distrust of the information ( Landrine and Corral, 2015 ; Lee et al., 2017 ).

When considering including direct comparisons between racial or other subgroups, as is often done in messages that communicate health disparities, it is important to understand how social psychological processes might influence message effects. Social comparison-framed messages can be perceived as a threat to one's group and individual identity. Social identity theory provides a framework for understanding the relationship between social comparison and intergroup processes ( Tajfel, 1982 ). For a group that suffers from a lower status in society, direct comparisons with a higher-status group can have negative psychological consequences, such as devaluing one's group, engaging in self-hate, and expressing preferences for the outgroup. Alternatively, because people are motivated to maintain a positive social identity and self-image, for members of the lower-status group, social comparisons can also result in attributing the cause of the discrepancy to external factors that are outside of one's control and can generate greater ingroup/outgroup distinctions and ingroup favoritism. Social comparisons also can increase outgroup bias (i.e., negative evaluations of outgroup members) among members of the higher-status group. It is easy to see how these responses are counterproductive to the goals of messages designed to communicate about health disparities and can have detrimental individual and societal effects.

Another framing strategy, the individual responsibility frame, addresses health disparities by emphasizing the role of individuals in both increasing and reducing their risk. This approach can generate negative emotional responses, reinforce stigma, and result in distrust of the information ( Dunham et al., 2016 ). It also places the responsibility for health disparities on the individual, when this is often not accurate ( Matthews et al., 2016 ). Another challenge with this frame is that people have preexisting beliefs about groups and health risks that can influence how they process and respond to messages ( Brady, 2016 ; Calabrese et al., 2016 ; Thomann et al., 2018 ). For example, research in social psychology has identified biases in how social information is processed. One such bias, known as the fundamental attribution error, reflects a tendency when making causal judgments to overestimate the influence of personal factors and underestimate the influence of environmental factors ( Ross, 1977 ). Consequently, messages that focus on individual responsibility as a causal explanation for health disparities serve to reinforce rather than challenge psychological biases.

Communicating about health disparities also has the potential to prime stereotypes via the use of a variety of visual and textual cues. Visual images are particularly influential, and they have the potential to overpower text, reinforce stereotypes, and perpetuate stigma ( McBride and Anne Dosher, 2002 ; Coleman and Hatley Major, 2014 ; Young et al., 2016 ; Uhrig et al., 2017 ).

Thus, messages about health disparities share many of the characteristics that Smith (2007) described as being present in messages that communicate stigma. They draw attention to distinct groups of people defined by racial, social, or behavioral characteristics; they link these groups to a physical threat (i.e., HIV or another health condition); and by using either a comparative or individual responsibility frame, or in some cases both, they suggest indirectly or directly that group members are responsible for the threat. Although the intention behind messages about health disparities is to increase awareness and motivate positive behavior change, the characteristics of these messages can instead generate unintended effects for both the unstigmatized group—including social distancing, negative attitudes, and support for stricter policies—and the stigmatized group.

Unintended effects—such as negative emotional reactions, decreased trust in health information, perceptions of blame, and stereotyping—can cause members of the priority audience to distance themselves from and reject messages about health disparities. Rather than reducing risk and improving health outcomes, these messages can worsen health if they backfire and can also have negative psychological consequences for members of the priority audience. These potential iatrogenic effects are especially important to consider when communicating about HIV-related disparities, as the same groups that experience disparities across the HIV care continuum also experience intersectional stigma ( Earnshaw et al., 2013 ; Rice et al., 2018 ), which could be further exacerbated by the way disparities information is communicated. In addition, medical mistrust among racial and ethnic minorities has been found to influence attitudes and behaviors related to HIV prevention and treatment ( Bogart et al., 2010 , 2011 ; Cahill et al., 2017 ; Thomann et al., 2018 ), and this mistrust could also be perpetuated by the framing of disparities information. As such, messages need to balance the potential benefits of communicating HIV disparities to raise awareness and promote behavior change with the potential harms that may result from the framing ( Institute of Medicine, 2002 ).

It is also critical to ensure that members of priority audiences are involved in message development, pretesting, and implementation of communications. Involving members of the priority audience in these activities is best practice in public health communication. However, it also serves to empower communities that face systemic inequities and foster collective action to reduce disparities and improve health outcomes ( Douglas et al., 2016 ; Thompson et al., 2016 ). Messages and communications that address health disparities with the intention of fostering individual and community empowerment can shift the focus from individual blame to a fuller understanding of the multi-level factors that contribute to health disparities ( Douglas et al., 2016 ). This approach also has the potential to lead to more effective messages and interventions by increasing trust and credibility among the priority audience ( Earnshaw et al., 2013 ).

Recommendations and Agenda for Future Research

Applying the available evidence on message framing to HIV, we offer recommendations for communicating about HIV-related disparities, presented in Table 3 .

Table 3 . Recommendations for communicating about HIV disparities.

Some evidence suggests that using a progress frame to present health disparities information may be more likely to generate positive emotional and behavioral responses than using a social comparison frame ( Nicholson et al., 2008 ; Landrine and Corral, 2015 ; Lee et al., 2017 ). However, the evidence comprises only a handful of studies—some of which compared only a progress frame with a social comparison frame—and even though the progress frame performed better, the extent of its positive effect is unclear. In addition, none of the studies were specific to HIV. Other approaches to message framing, such as using an impact frame, may also be effective for communicating about HIV-related disparities ( Uhrig et al., 2013 ). Furthermore, it is unclear which message framing strategy is most effective when communicating about HIV-related disparities to the general public vs. targeting messages to subpopulations at high risk for getting or transmitting HIV.

Due to the limitations in the existing body of evidence, we propose a research agenda to examine strategies for effectively communicating about HIV-related disparities, while avoiding unintended effects ( Table 4 ).

Table 4 . Agenda for future research on communicating about HIV disparities.

Health communication can play an important role in reducing HIV-related disparities and stigma, which is a central priority of Ending the HIV Epidemic: A Plan for America ( U.S. Department of Health and Human Services, 2020 ). Further efforts are needed to develop and test communication strategies capable of raising awareness of, influencing attitudes and beliefs about, and motivating behavior change necessary to reduce HIV-related disparities without resulting in stigmatization or other unintended adverse effects.

Author Contributions

All authors made substantial contributions to the conception or design of the work, the acquisition, analysis or interpretation of data for the work, drafting the work or revising it critically for important intellectual content, provide approval for publication of the content, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

This study was supported by contract number HHSD-200-2013-M53964B from the U.S. Centers for Disease Control and Prevention (CDC). The findings and conclusions in this article are those of the authors and do not necessarily represent the views of CDC.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: HIV, disparities (health racial), health communication, message framing, stigma, stereotype, targeting, unintended adverse effects

Citation: Peinado S, Treiman K, Uhrig JD, Taylor JC and Stryker JE (2020) Effectively Communicating About HIV and Other Health Disparities: Findings From a Literature Review and Future Directions. Front. Commun. 5:539174. doi: 10.3389/fcomm.2020.539174

Received: 29 February 2020; Accepted: 25 August 2020; Published: 06 October 2020.

Reviewed by:

Copyright © 2020 Peinado, Treiman, Uhrig, Taylor and Stryker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Susana Peinado, speinado@rti.org

This article is part of the Research Topic

Communicating for Social Justice in Health Contexts: Creating Opportunities for Inclusivity Among Marginalized Groups

HIV care linkage, care retention, and viral suppression among persons living with HIV in North Carolina before and after the start of the COVID-19 pandemic

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• Affiliation: Gillings School of Global Public Health, Department of Epidemiology
• Ongoing measurement of HIV care outcomes across the continuum is essential to understanding barriers to care and informing interventions to improve access to and utilization of HIV services. The health care landscape abruptly changed with the onset of the COVID-19 pandemic, substantially altering the manner in which HIV care was accessed and delivered. This dissertation study examines the impact of the COVID-19 pandemic on HIV care outcomes among persons living with HIV in North Carolina (NC), particularly within subpopulations who disproportionately experience social and structural barriers to HIV care. We used statewide HIV surveillance data to assess HIV care linkage and viral suppression before and after the start of the COVID-19 pandemic (March 1, 2020), using HIV laboratory records as proxies for HIV care visits. Among the 4,402 persons newly diagnosed with HIV in NC between January 2018 and August 2021, we found no overall harmful changes in HIV care linkage and viral suppression during the pandemic compared to before. In subgroup analyses we found that Black non-Hispanic, Hispanic, and transgender persons had higher rates of initial HIV care linkage (lab within 30 days of diagnosis) followed by unchanged or lower rates of stable linkage (initial linkage + subsequent lab within 150 days) during versus before the pandemic. Hispanic persons had lower viral suppression (within 180 days of diagnosis) over the course of the pandemic compared to before. Additionally, we identified longitudinal trajectories of HIV care among persons newly diagnosed with HIV between March 2014 and February 2018, and assessed HIV care indicators in the first year of the pandemic according to pre-pandemic care patterns. We observed distinct latent trajectory groups representing consistently high, slowly fluctuating, steadily decreasing, and low U-shape HIV care in six-month intervals from HIV diagnosis up to the start of the pandemic. HIV care outcomes (presence of HIV lab, viral suppression) in the first pandemic year were mostly consistent with pre-pandemic patterns.Our results are reflective of a robust HIV care system in NC overall, however, persons of color and gender minorities may require enhanced ongoing attention in order to rectify recent pandemic harms.
• Epidemiology
• HIV care disparities
• surveillance data
• HIV care continuum
• time-to-event analysis
• group-based trajectory models
• https://doi.org/10.17615/b4sx-ey63
• Dissertation
• In Copyright - Educational Use Permitted
• Powers, Kimberly A
• Pence, Brian W
• Miller, William C
• Norris Turner, Abigail
• Samoff, Erika
• Mobley, Victoria
• Doctor of Philosophy
• University of North Carolina at Chapel Hill Graduate School

This work has no parents.

• UNC-Chapel Hill Coronavirus Research

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264 HIV Essay Topic Ideas & Examples

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• HIV, STI as a Public Health Issue In light of the fact that the HIV/STI development levels remain rather high among the target population, the necessity to educate young people about the threats of HIV/STI, as well as the methods of avoiding […]
• Health Interventions in the AIDS Epidemic This development has created the need for introducing the social-ecological model in curbing the increased rates of HIV infection in some communities. This paper identifies income and stigma as the main social factors that affect […]
• Changes in the Research on AIDS Some of the current researches on this disease include treatment of the disease, the content of Aids protein and the preventive modes.
• The Most Effective Methods of Preventing the Spread of HIV Recent statistics show that in the United States the number of people living with HIV and AIDS is higher among men than women.
• Segregation of HIV-Positive Prisoners The biggest debate on segregation of HIV-positive prisoners surrounds the ethical impact it renders to the inmates. The proponents of segregation of HIV-positive prisoners believe that segregation protects prisoners and the correctional staff from catching […]
• The Problem of Homeless Youths With HIV-AIDS Studies carried out in the city of New York in 2008 showed that 21 percent of homeless youth males and 24 percent of homeless female youths had “more than 100 lifetime partners”. 5 percent of […]
• Country Health Policy Proposal on Improving HIV-AIDS Outcomes in South Africa One of the significant public health problems facing the South African public health system is the high prevalence of HIV/AIDs. Inefficiency of the public health system contributes significantly to the HIV burden in South Africa.
• HIV/AIDS and International Health Community Over the years, the level of people’s awareness about the notion of HIV/AIDS has increased dramatically, yet the health condition itself remains frowned upon and stigmatized by the global community.
• AIDS, Then and Now This view spread to the U.S.culture at large and contributed to an exaggerated representation of the disease as a “gay plague” in the media.
• Film “The Silent Partner: HIV in Marriage” In a region whose fight against HIV is slowed by a lack of awareness, the film shows how traditional ways of fighting the pandemic fail to serve the needs of married women.
• Communicable Disease Health Education Tool: HIV, AIDS The Human Immunodeficiency Virus (HIV) is a contagious that causes a condition known as the Acquired Immune Deficiency Syndrome (AIDS).
• The HIV/AIDS Situation in India Most of the initial cases had occurred through heterosexual sex; but at the end of the 1980s, a rapid spread of HIV was observed among injecting drug users in Manipur, Mizoram and Nagaland. An explosion […]
• HIV, Health & Rights – Sustaining Community Action In general, the strategies are useful since they focus on the existing challenges and address the target population. In conclusion, one can state that the strategic drivers have been successfully developed into the four directional […]
• HIV in Saudi Arabian Children Analysis For a long time, this society has considered those who are suffering from HIV as adulterous and are not living according to the teachings of the Quran.
• Problem of HIV in Saudi Arabian Children Although the rate of HIV infection still remains low when compared to the world’s average, the number has been on the rise over the past five years.
• HIV and AIDS as a Chronic Disease: The Unique Contributions of Nursing Through Philosophical, Theoretical, and Historical Perspectives In most societies across the world, the responsibility of caring for the sick in the community feel on the family and the entire society.
• The Historical and Current Role of Stigma in the Provision of HIV and AIDS Care: The Context of Ghana The paper describes the historical and current role of stigma in the provision and care of people living with HIV and AIDS in the context of Ghana.
• Men Issues With HIV/AIDS in Miami Various men’s issues and social well-being have contributed to the increased rate of infection among men in Miami and Florida. In conclusion, the rate of HIV/AIDS infection in Miami is higher among men than among […]
• From Exceptional to Chronic Illness: New Challenges in HIV Prevention in the UK The current paper is an attempt to analyze the shift in the perception of HIV from an exception to a chronic illness and the new challenges experienced in HIV prevention in the UK.
• Researching HIV, AIDS and Social Justice Disney claims that poverty and social injustice lead to the spread of HIV/AIDS among underprivileged people in all countries. The disease was a kind of stigma and infected people were subjected to discrimination and alienation.
• The Threat of HIV, AIDS and the Means to Avoid It Taking into account the results of the case study conducted by Cornish and Ghosh, instances of people in India becoming infected with the HIV virus have increased recently, which is given as a reason for […]
• The Combivir Medication in HIV, AIDS Treatment Hence by blocking the enzyme the rate of virus multiplication is reduced and consequently the amount of HIV cells in the blood is reduced.
• The Policy Topic on the Impact of HIV/AIDS Pandemic in the USA This paper will discuss the policy topic on the impact of the HIV/AIDS pandemic in the United States and the rest of the world.
• Circumcision of Male Infants as a Way to Combat the HIV Therefore, by circumcising all the men, the rate of heterosexual infections in Australia will reduce considerably as circumcised men are lesser prone to HIV infections than uncircumcised ones.
• Genco Company: A Distribution of HIV-AIDS Drugs in Malaysia The management of Genco Company should be keen on setting out the date of registration because it helps to determine the period, which the business will be legal to operate in the country.
• HIV From a Social Sciences Perspective In the US, the disease was initially associated with gays only but in the recent past, it is has been claiming many lives in the country and other parts of the world. The first social […]
• Microbiological View of HIV Epidemic and Possibility of Discovering Its Cure The glycoprotein facilitates attachment and fusion of the virus to human cell membrane. In Golgi complex it is cleaved by protease and proceased in to human immunodeficiency virus and released.
• HIV (Human Immunodeficiency Virus) Prevention In so doing, they ignore the importance of the community in the prevention of HIV transmission. HIV prevention strategies that focus on the social drivers of HIV transmission are usually very effective.
• HIV/AIDS Pandemic Facing the Female Global Population The questions that arise are; what factors are contributing to the prevalence, who are the most affected and what are the actions taken to mitigate the HIV/AIDS epidemic?
• HIV Transmission From Homosexual Men Receiving Cure The study reaches the following conclusions: In general, male partners to MSM receiving treatment are at risk of contracting HIV virus although the risk is relative to condom use as well as the last time […]
• Hepatitis C and HIV Among Intravenous Drug Users In relation to this health issue of HIV and HCV, the community health nurse has the responsibility of promoting health among intravenous drug users.
• Addressing the Needs of HIV Patients According to the latest report published on the subject matter, the therapy provided to the patients in question implies that the family members should take an active part in the process of managing the disorder […]
• HIV-AIDS in News Reports and Literature The report further shows that the use of ART has led to a reduction in the total cost of managing HIV-related cases annually in low and middle-income countries.
• Decreasing Inflammation in People With HIV: The Efficiency of Low-Dose Methotrexate The principal objective of the research is to obtain a numerical estimate of the issue and the reaction of respondents towards it.
• HIV Pandemic in Africa and the United States However, there is no epidemic of AIDS in the United States due to appropriate measures conducted by the government including the prohibition of the polygamy and anti-drug policy. Additionally, authors regard the role of the […]
• Communicable Disease Control Strategies for AIDS Governments should consider AIDS as a health priority, among the strategies to control the spread of disease are ensuring that public and private sectors are sharing AIDS’ responsibility, provision of enough resources to research on […]
• Guidelines on HIV and Infant Feeding The objective of this guideline was to find ways through which HIV-positive mothers can protect their HIV-free children from a possible infection.
• People Infected With HIV in India The proposed research aims to highlight the particular factors that led to a decrease in the number of people infected with HIV in India.
• Pneumonia Infection & Risk of Mortality in HIV-Infected Children The topic is quite interesting because only a few studies have attempted to focus on the role of HIV infection on the rates of mortality and morbidity rates in pneumonia infections. It is the first […]
• HIV Rates and Infant Mortality: US, UK and Kenya The purpose of this paper is to compare the HIV rates and infant mortality cases of the United States with the situation in a developed country such as the United Kingdom) and a developing nation […]
• Disclosure of a Physician’s HIV Status The addition of another corpus that needs the disclosure of HIV/AIDS status to partners is as important as it is harmful if done without prior consent.
• AIDS: The Legal Rights and Responsibilities of Employees and Patients It is the responsibility of employees to adhere to adjusted schedules and to maintain high productivity and efficiency. Employees also have a right to assess information on HIV and AIDS in the workplace.
• Late Phase of HIV Type 1 Replication The Late Phase of HIV type 1 replication involves the assembly of Gag proteins with the plasma membrane of hematopoietic cells.
• Baby With HIV Is Deemed Cured After reading the article, the first question I asked myself was whether it is possible for a baby with HIV to be cured without medication.
• Routes of HIV Transmission Based on the NACO annual report, it can be seen that the primary drivers of the HIV epidemic in India are commercial female sex workers, drug use and unprotected sex between homosexuals and heterosexuals.
• Health Services Research: AIDS-Related Stigma The information obtained from the analysis of the research findings are used by the healthcare organizations and policy makers to improve on the delivery of quality healthcare services to the people.
• HIV Intervention in Gay Community The AIDS scourge is at the center of this study because this paper seeks to address AIDS as a special health concern affecting the gay community in the Montrose area, with a clear aim of […]
• Risks for HIV&AIDS in Juvenile Detention The participants in this study willingly shared their perceptions and experience of risk for HIV/AIDS within the context of their social and ecological environments and, in so doing, embodied other models of interaction and behavior […]
• The Impact of HIV and AIDS Epidemic on Women In the anatomy while having intercourse the vagina is very susceptible to tears and irritations when engaging in sex and thus with the tears and the irritations the exposed flesh offers a good penetrating surface […]
• The Impact of Social Determinants of Health in the HIV-AIDS Efforts have been made to contain the pandemic but in vain, and that is why researchers are concentrating on the social determinants of health in the context of HIV/AIDS.
• The Social Environments and the Effectiveness of Youth HIV Prevention It is saddening that most of the youth view sex education negatively since their elders have socialized them to view it as a curse.
• Combining Efforts to Combat HIV and AIDS The difference in health care systems and standards of health care resources available in different parts of the world, greatly affect the course of the disease in individuals and groups.
• HIV Testing of High School Seniors Should Not Be a Mandatory Requirement for Graduation Still if a policy like mandatory HIV screening of students is formulated by the governing body of the University it is the indication of a serious lack of proper understanding of HIV/AIDS and the rights […]
• Research Into the Causes of HIV Though HIV is still incurable in modern days, one of the problems that people in slow developing countries face is high death rate from HIV due to the lack of funds for purchasing effective medication […]
• The Problem of HIV & AIDS in Spain: The Leading Rate of Infection in Europe Considering the fact that Spain has the leading number of the homosexual in Europe, the rate of the infections in this group stands at 10%.
• HIV and People Who Use Drugs: Cases of Infection Caused by Injection Drug Use The existing condition of the epidemic in a certain region can be termed as low-level, concentrated, or generalized depending on the prevalence levels of the virus in the specified demographic.
• Concepts of Culture and Disease Paper: AIDS However, in general, African governments and non-governmental organizations with the help of the United Nations Department of AIDS, UNAids, continue to educate Africans on the spread, symptoms, and other AIDS factors. In sub-Saharan Africa, numerous […]
• AIDS and Its Trends: An Infectious Disease That Causes the Vulnerability of the Human Internal System These facts address the query of the author having the valid experience to make writings regarding the Disease, it is clear that he had first-hand experiences. The disease is manageable with the use of drugs […]
• Effects of HIV and AIDS on Young Children and Women The hypothesis of this study is to establish the prevalence of HIV and AIDS on the general population this is with particular attention to the young children and the women who are more vulnerable.
• HIV Counseling and Testing: Lifetime Treatment Program Some of the possible intervention that can be adopted by the clinicians in order to improve adherence include the encouragement of the patients to be in contact with people of their age who will encourage […]
• Epidemiological Analysis of the Acquired Immune Deficiency Syndrome (AIDS) The virus is found in most of the body fluids of the infected person; and this is the main route of infections.
• Drugs for the Treatment of HIV Infection: Over 30 Antiretroviral Drugs to Counter the Effects of the Deadly AIDS Virus By the latest study, the Food and Drug Administration has approved 30 antiretroviral drugs to counter the effects of the deadly AIDS virus According to the National Institute of Allergy and Infectious Diseases, the drugs, […]
• Health Care Management: HIV and AIDS Prevention and Treatment To define the measurement system, and define the failure or success of HIV/AIDS treatment it is necessary to give the image of the situation in general.
• HIV, AIDS Health Determinants in Africa: The Research and Development in Curative and Preventive Medicare Emphasis was laid on the research and development in curative and preventive Medicare so that the members of the society lived a healthy life. This is compared to a total of between 130,000 and 180,000 […]
• HIV Crisis in Africa: Review of Major Public Health Concerns on the Continent The paper will examine the issue of HIV/AIDS in Africa, focusing on the effects of the disease, procedures of its containment, and the prevention tactics used by the African public.
• The Spread of HIV and AIDS in Prisons: Causes and Measures of Control Other causes of the spread of the disease include overcrowding and lack of education on the danger of the virus. At-risk individuals need to be sensitized about the devastating consequences of this virus and the […]
• ART HIV Medicine Saves Lives: Maintains Functions of the Immune System and Prevents Opportunistic Infections The goal of the essay is to increase the level of awareness of readers on the importance of ART. A brief overview of HIV treatment programs should also be included in the essay to support […]
• HIV: Overview of the Clinical Manifestations of Infection and Symptoms and Known Cases of Complete Cure The information includes detailed information about the molecular structure of the virus, the form of the genome, and the mechanism of self-reproduction within a targeting cell.
• Faith-Based Organization Services as the Best Means to Prevent HIV and AIDS in Southern Cameroons The HIV/AIDS issue was complicated by the fact that at the moment of this research, there was no cure and the only way of addressing the infection spread was through prevention and ensuring that people […]
• HIV & AIDS: Role of Healthcare Professionals and Patient Education It is also vital to stress that non-adherence leads to the return of the symptoms and the development of HIV-related diseases that could lead to death.
• HIV & AIDS Diagnosis and Treatment Measures After decades of its first appearance, the human immunodeficiency virus, which causes AIDS at a more severe stage, continues to be a major threat to human health and searches for developments in diagnosis and treatment.
• Breast Cancer and AIDS: Significant Issues in the United States in the Late 20th Century Thus, the given paper is going to explain why these activists challenged regulatory and scientific authorities and what they demanded. That is why the enthusiasts challenged their practices and made specific demands to improve the […]
• The Effect of HIV Treatment on Individuals and Contributing to a Longer Life of the Patients As a result, better treatment of the illnesses globally and especially in Africa has contributed to a longer life expectancy of the patients.
• Male Circumcision for HIV Prevention in South Africa The primary purpose of this study is to determine the cost-effectiveness of the use of circumcision and if this practice is appropriate.
• Misinform Partner’s HIV-AIDS Status: How to Prevent From Being Misinformed However, I believe that the key to avoiding the issue of the HIV growing epidemic does not lie in the doctor’s duty to anonymously inform one’s sexual partners.
• The Issue of HIV-AIDS-Positive Status Disclosure Whereas at the beginning of the epidemic, the therapists felt it was their duty to inform the patient’s surroundings of the issue, the introduction of the HIV/AIDS Confidentiality Act turned this duty into a forthright […]
• Global Health Issue Analysis: HIV – A Relatively New Disease Rapid detection and treatment are crucial to limit the spread of HIV and limit the patient’s effects. As the frequency and intensity of symptoms vary from person to person, testing is the only clear way […]
• High Risk of HIV Among Injection Drug Users The aim of this Health Promotion Plan is to improve the situation with infection diseases spreading among the injection drug users due to the social importance of this problem and the high level of mortality […]
• Childhood Sexual Abuse and HIV Risk in San Salvador Still, the women interviewed presented a peculiar layer of the society that made it possible to understand the clear connection of the CSA to HIV/AIDS and drug addictions.
• New Directions and Strategies for Current and Future Research in HIV The authors therefore are in agreement that future research paradigms focusing on HIV should lay much focus on developing an efficacious vaccine to curtail further spread of the virus.
• Health and Health Policy of HIV and AIDS: Physical and Psychological Wellbeing Health is defined and understood as the state of full physical and psychological wellbeing, and not just the absence of diseases in the body, while a health policy is the plans, strategies and actions undertaken […]
• Bubonic Plague and AIDS: Differences and Similarities Transmission of the diseases is also another area that generated debate in the entire course of The Plague and during the initial stages of AIDS.
• Pricing AIDS Drugs Sold to Developing Countries The majority of the world’s HIV/AIDS cases are in Africa particularly the sub-Saharan and many of the infected have been faced with a huge challenge to live a normal life due to limitations in access […]
• HIV-AIDS and Male Circumcision: The Cases of Kenya and Sri Lanka In India, religion and culture have been identified as impediments to the fight and prevention of HIV-AIDS. Religion as the main basis of culture has resulted in the entrenchment of the ban on circumcision to […]
• Does Black America Need White Support in Order to Combat HIV, AIDS Epidemic? The economic instability, the lack of education and improper health care facilities all attribute to the spread of the epidemic in the black community which is set to rise in the coming years.
• Women With AIDS in Africa: Treatment Possibilities Starting with the economical issues, the countries of Africa are the countries of the third world and the economy is very weak in the area.
• The Relationship Between the High Rate of Urbanization in Africa and AIDS Spread This movement results in to increase in the number of people in the towns and cities in a particular year. The increased social interaction of people in towns has led to increased HIV/AIDS infections in […]
• Language and Stigmatization: Cancer, HIV, and AIDS Much has been written concerning the alarming spread and effects of HIV/AIDS in the society and the effects of cancer and the position of its victims and how to care for them.
• HIV and AIDS in Adolescents The teenagers in America and the world are a group that is constantly at risk of infection with the Human-Immunodeficiency-Virus and developing the Acquired-Immune-Deficiency-Syndrome, the disease condition that eventually results; this is stemming mainly from […]
• The Human and Economic Effects of AIDS on the United States The social impact of HIV has been well documented and widely distributed which has served to educate the public and acted to stem the tide of the epidemic.
• Workplace Stereotypes About People With HIV: Business Ethics After analyzing the every angel of the case, it can be said that this is the picture of the stereotyping prejudice of people with AIDS.
• Capitalism and Industrialization as a Cause of AIDS Spread Population growth rates are the highest in most of Asia, Africa, and Latin America due to the high degree of fertility and the dramatic decrease in mortality following World War II.
• The Pharmaceutical Industry Faces AIDS in Africa Food insecurity in these countries has to lead to the quick progression of patients to full brown AIDS and completely worsened the immunity of the patients.
• HIV, AIDS and the Social Environment The obvious place to start is to find out the sociological impact of HIV/AIDS with regards to the infected person. Thus, there is a tendency to concentrate on the scientific aspect of the disease as […]
• African Gold: Ethics and AIDS in the Workplace The issue that is troubling the management of the organization in the case, African Gold is that of the costs, medical costs and disability programs as a result of the rising workforce succumbing to the […]
• Center for Disease Control and HIV Prevention Goals The first short-term mission of the CDC Preventions is to increase the percentage of those HIV-affected people who indulge in such activities which alleviates the risks or dangers of HIV transmission.
• AIDS Infection in Europe Statistics: A National Disaster in Many Countries Most of these young men and women that engage in this business are end up being infected with HIV virus since they do not have the power to negotiate for safe sex and especially the […]
• Rational System of HIV Disclosure Laws Since the start of HIV pandemic, the humanity aimed to regulate and minimize the spread of the infection. The people, who became the victims, as they were unaware of the danger of the infection, finally […]
• World AIDS Day Celebration: Increasing the Awareness of the People About the Disease The World AIDS Day is not just celebrated in the United States, Europe, or Asia, it is observed all over the world because the disease does not only affect this part of the globe, but […]
• Public Policy Development. AIDS.gov Benefit Types CDC is a premier public health agency which undertakes the control and prevention of AIDS in US, and their mission is to promote health and quality of life.
• Public Policy. Eligibility Rules Used by AIDS.gov There are no restrictions that prohibit the tailoring of health care programs by clients and using various services and providers that are eligible for meeting the health care needs of individuals.
• HIV/AIDS and Orphans in Sub-Saharan Africa On the choice of orphans in sub-Saharan Africa as the topic for this research, it aims at addressing the cause of overwhelming numbers of orphans in the region and how this impacts society.
• Social Networks of People Living With HIV and AIDS The purpose of the study was to compare the social networks of younger patients with the older ones. The convoy theory of social support lent credence to the research.
• Changes in Prostitution and AIDS Epidemic in Thailand This provided information on commercial sex trends such as the types of CSEs in existence, the number of sex workers, and the price of sex. However, the decline in the number of sex workers was […]
• How AIDS.gov Fund Its Programs to Respond to the Impact of the Epidemic on Ethnic and Minority Populations Transportation costs to go to the clinic and lost wages should be accounted for and records kept acting as evidence of how the funds were used.
• The Pharmaceutical Industry and the AIDS Crisis in Developing Countries One of the reasons of this difference is that excise and custom duties that are responsible for the unaffordable prices of medicines have been avoided by the developed countries by the creation of pharmaceutical industries, […]
• Advancements in AIDS Research: A Potential Advancement in the Attempt to Cure HIV Infection After HIV’s genetic code is altered from a single thread to a double-strand by the reverse transcriptase enzyme, it gets included in the genetic code of the infected cell.
• Ethics of Leukemia Treatment With Disabled HIV Cells In recent years, the medical community has pondered the radically new approach to cancer treatment, which is isolating and collecting T-cells from the patient.
• AIDS: Emergence Factors of Infectious Disease Emerging diseases refer to the newly identified pathogens that have been recognized in the past few decades that lead to a new manifestation of diseases.
• AIDS and Its Impact on Humankind: The Leading Killer Disease in the World From these statistics, it is easy to deduce the effect of the disease of humankind. At the international level, more and more funds have been committed to the treatment of AIDS.
• AIDS in a Different Culture Review: Cultural Differences, Prejudice, and Racism Now, gay youth and men face the possibility of HIV infection in the course of sexual relationships. The pejorative view of gay men prevalent in some black and Hispanic communities can inhibit they are coming […]
• Lewis’ Race Against Time: Curbing HIV&AIDS in Africa Lewis points out that, “HIV/AIDS has sabotaged all of the socioeconomic indices, and the continued damaging western policies in trade and aid and debt, serve to drive the nails into the coffins”.
• Community Health. HIV/AIDS Prevention for the 50+ The specificity of the paper is that it relates the issue of HIV prevention for the people over 50. It is necessary to mention, that: 10% of all AIDS cases in the USA are people […]
• Microbiology. AIDS Vaccine Studies: Different Developments Strategy So far there is no practical hope that ongoing AIDS vaccine development will produce tangible results, According to one of the leading AIDS vaccine expert Mr. Clinical trials will have to continue as they will […]
• Medical Anthropology. HIV&AIDS Preventive Measures Since the detection of the first case of HIV in India, the government introduced both surveillance and preventative plans to reduce the risk of the disease spread.
• HIV and AIDS in the Era of Antiretroviral Therapy To lower the complacency of people to HIV/AIDS and change the perceptions about the condition for individuals with and without HIV/AIDS, health care professionals should focus on such aspects as safety, responsibility, and stigma.
• Descriptive and Analytical Epidemiology: Tuberculosis and HIV The establishment of trends in the epidemic process for the rapid introduction of adjustments helps optimize preventive and anti-epidemic measures alongside the evaluation of the effectiveness of the activities.
• AIDS and Its Related Aspects The report aims to show that clinicians and nurses should discuss AIDS and associated risks with their patients to enhance individuals’ health outcomes and eliminate the prevalence of the disease.
• Anti-HIV Nonprofit’s Organizational Design Particularly, three areas of concern are of the primary interest: the design and functional characteristics of NGOs, the problem of HIV in the context of NGOs, and differences between organic and mechanistic organizational structures.
• HIV and AIDS: Legal and Ethical Conduct During the conversation, I would inform the patient about his HIV status, focusing on the potential health effects of this condition and the types of contacts that may cause the further transmission of the virus.
• OraQuick Home HIV Test and Its Pros & Cons The inventors or other technologists can work on reducing the time people have to wait for the results. It reduces the time people spend visiting the doctor.
• Female HIV-Positive Patients’ Medication Adherence The author presents the results of the study concerning barriers to medical help-seeking behavior objectively and proves that the results are reliable. Finally, the limitations and implications are remarkable.
• Immunology and Virology of HIV Infection The HIV attacks the body in the form of mRNA, which attacks the nucleus of the T cells and immediately replicates its DNA using the material in the host cells.
• Mandatory HIV Screening: Ethical Issues
• Spreading and Dying From AIDS and the Increasing Spread of the Disease
• Health Fraud: HIV/AIDS and Sexual Enhancement Scams
• HIV and AIDS Early History and Risks
• HIV Prevention Programs in Africa
• HIV and AIDS Infection Levels and Their Social Effects
• HIV Prevalence Among American Queer Communities
• HIV Testing Among African American Women
• HIV Rates Among African American Women
• HIV Prevention Policy Development for Chicago
• HIV Prevention Among Young Adults in Chicago
• Techniques for Helping Women With HIV
• Group Policy Regarding the HIV/AIDS Transmission Issue
• Pharmacology: HIV Drug Resistance
• HIV Prevention in Youth: Public Health Campaign
• HIV/AIDS as a Long-Wave Event in Politics
• Act Up Movement for Surviving HIV/AIDS Plague
• HIV/AIDS Activism in “How to Survive a Plague”
• HIV/AIDS Prevention by Anti-Retroviral Drugs
• The Impact of AIDS and Reasons Behind the Outbreak
• HIV/AIDS Policies in India and Antropological Study
• AIDS in New York in “How to Survive a Plague” Film
• ”The Cure for AIDS” by Apoorva Mandavilli and Various Ethical Issues
• Qatari Laws: HIV/AIDS Visitors, Pets, Dressing Code
• Legal Ethics, Patients’ Rights, and HIV/AIDS
• HIV/AIDS as a Communicable Disease
• Ancillary Services for HIV/AIDS Patients
• HIV/AIDS Patients: Legal Ethics and Patient Rights
• Medicine: HIV/ AIDS Campaign Slogan
• Medicine: HIV/AIDS as the Key Threat for the Kenyan Population
• HIV and AIDS in Kenya
• HIV/AIDS in Kenya: Evaluation Plan
• Health Promotion Program HIV/AIDS in Kenya
• HIV Among Adolescents – Treatment and Prevention
• HIV/AIDS Definition, Prevention and Treatment
• Medical Issues: HIV in the U.S.
• 5 Years Strategic Plan for HIV Prevention in Swaziland
• HIV and AIDS Prevention Among the Youth in Asia
• STD/HIV Health Promotion Evaluation Plan
• HIV and AIDS: an Evolving Global Response
• HIV Epidemic in Enrique’s Native Country
• AIDS: From the Perspective of Sociology
• Critical Analysis of Avahan – the India AIDS Initiative
• HIV/AIDS by Allan Whiteside
• Thailand Issues: Environment, Child Prostitution, and HIV/AIDS
• The Rate of Smoking Among HIV Positive Cases.
• Critical Review of Chapter 5 and 6 of the Book HIV/AIDS
• AIDS Combating in the 21st Century: Issues and Challenges
• HIV/AIDS in the UK
• History of Treatment the HIV/AIDS
• Pathology of HIV and AIDS
• How the AIDS Epidemic Has Affected the World on a Political, Social, Economical Way
• The HIV and AIDS Problem Between Educated and Non-Educated Children in Uganda
• Implementation of AIDS Control Policies in Australia and South Africa
• HIV/AIDS Among African Americans
• AIDS: The Guilt and Failure of the West in a Spread of the Disease
• AIDS as an Epidemic of Signification: A Globally Potential Threat
• Key Drivers of HIV/AIDS in Sub Saharan Africa and in San Francisco
• Key Drivers of HIV and AIDS in Sub-Saharan Africa and in San Francisco and Church’s Response to the AIDS Pandemic
• Drivers of HIV and AIDS in Sub-Saharan Africa and San Francisco
• Impact of HIV/AIDS on Microeconomics
• Why Lack of Awareness Leads to the Spread of HIV/AIDS in New York Prisons
• Theory, Methodology and Human Development: HIV/AIDS and Education in African Countries
• Vital Signs: HIV Testing and Diagnosis Among Adults – United States, 2001-2009
• Community HIV/AIDS Mobilization Project (CHAMP)
• HIV/AIDS Stigma in Tanzania
• Communicable Diseases: HIV and AIDS
• Why HIV/AIDS Crises Are High in African-American Community
• A Project on Establishment of Jousing Flats Voluntary Counselling and Testing Centers in Njoro Area to Reduce Prevalence of HIV/AIDS and Provide Nutritional Support Among the Youths Aged Between 16-35 Years
• HIV/AIDS Issues in African Women
• AIDS in Lesotho, Africa: The Highest Prevalence Rate of HIV Infections in the World
• Prevention of HIV/AIDS in Rural Ethiopia: Identifying Risks
• Is Being HIV Positive a Disability?
• Why Does the Immune System Weaken With HIV Infection?
• What Is the Main Cause of HIV?
• How Does HIV Gain Entry Into the Cells It Attacks?
• What Can Gamma Delta T Cells Contribute to an HIV Cure?
• What Are the 4 Stages of HIV Infection?
• What Are the 5 Symptoms of HIV?
• Does the HIV Virus Evolve?
• What Is the Good News for HIV-Positive Patients?
• What Is the Impact of HIV on Society?
• What Are the Symptoms of HIV/Aids?
• How Long Will HIV Take to Show Up?
• Can Mosquitoes Transmit HIV?
• How Can You Get HIV?
• How Fast Does HIV Spread in the Body?
• What Can the Government Do to Stop HIV?
• When Did HIV First Arise?
• Why Are Child Victims of Sexual Abuse at Greater Risk of HIV?
• How Long Do HIV Symptoms Last?
• Will There Be a Cure for HIV by 2030?
• Can You Survive HIV-Positive?
• How Many Teenagers Are Affected by HIV?
• Is There Currently a Cure for HIV?
• What Age Group Has the Highest HIV Infection Rate?
• How Long Can You Live After Having HIV?
• What Are the Three Biggest Risk Factors for HIV?
• Which Antibody Functions Are Important for an HIV Vaccine?
• Can You Drink When HIV Positive?
• Why Is HIV Research Important?
• What Resources Are Available for HIV Patients?
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Bibliography

IvyPanda . "264 HIV Essay Topic Ideas & Examples." February 29, 2024. https://ivypanda.com/essays/topic/hiv-essay-topics/.

• Communicable Disease Research Topics
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How to write a thesis statement + examples

What is a thesis statement?

Is a thesis statement a question, how do you write a good thesis statement, how do i know if my thesis statement is good, examples of thesis statements, helpful resources on how to write a thesis statement, frequently asked questions about writing a thesis statement, related articles.

A thesis statement is the main argument of your paper or thesis.

The thesis statement is one of the most important elements of any piece of academic writing . It is a brief statement of your paper’s main argument. Essentially, you are stating what you will be writing about.

You can see your thesis statement as an answer to a question. While it also contains the question, it should really give an answer to the question with new information and not just restate or reiterate it.

Your thesis statement is part of your introduction. Learn more about how to write a good thesis introduction in our introduction guide .

A thesis statement is not a question. A statement must be arguable and provable through evidence and analysis. While your thesis might stem from a research question, it should be in the form of a statement.

Tip: A thesis statement is typically 1-2 sentences. For a longer project like a thesis, the statement may be several sentences or a paragraph.

A good thesis statement needs to do the following:

• Condense the main idea of your thesis into one or two sentences.
• Answer your project’s main research question.
• Clearly state your position in relation to the topic .
• Make an argument that requires support or evidence.

Once you have written down a thesis statement, check if it fulfills the following criteria:

• Your statement needs to be provable by evidence. As an argument, a thesis statement needs to be debatable.
• Your statement needs to be precise. Do not give away too much information in the thesis statement and do not load it with unnecessary information.
• Your statement cannot say that one solution is simply right or simply wrong as a matter of fact. You should draw upon verified facts to persuade the reader of your solution, but you cannot just declare something as right or wrong.

As previously mentioned, your thesis statement should answer a question.

If the question is:

What do you think the City of New York should do to reduce traffic congestion?

A good thesis statement restates the question and answers it:

In this paper, I will argue that the City of New York should focus on providing exclusive lanes for public transport and adaptive traffic signals to reduce traffic congestion by the year 2035.

Here is another example. If the question is:

How can we end poverty?

A good thesis statement should give more than one solution to the problem in question:

In this paper, I will argue that introducing universal basic income can help reduce poverty and positively impact the way we work.

• The Writing Center of the University of North Carolina has a list of questions to ask to see if your thesis is strong .

A thesis statement is part of the introduction of your paper. It is usually found in the first or second paragraph to let the reader know your research purpose from the beginning.

In general, a thesis statement should have one or two sentences. But the length really depends on the overall length of your project. Take a look at our guide about the length of thesis statements for more insight on this topic.

Here is a list of Thesis Statement Examples that will help you understand better how to write them.

Every good essay should include a thesis statement as part of its introduction, no matter the academic level. Of course, if you are a high school student you are not expected to have the same type of thesis as a PhD student.

Here is a great YouTube tutorial showing How To Write An Essay: Thesis Statements .

Think of yourself as a member of a jury, listening to a lawyer who is presenting an opening argument. You'll want to know very soon whether the lawyer believes the accused to be guilty or not guilty, and how the lawyer plans to convince you. Readers of academic essays are like jury members: before they have read too far, they want to know what the essay argues as well as how the writer plans to make the argument. After reading your thesis statement, the reader should think, "This essay is going to try to convince me of something. I'm not convinced yet, but I'm interested to see how I might be."

An effective thesis cannot be answered with a simple "yes" or "no." A thesis is not a topic; nor is it a fact; nor is it an opinion. "Reasons for the fall of communism" is a topic. "Communism collapsed in Eastern Europe" is a fact known by educated people. "The fall of communism is the best thing that ever happened in Europe" is an opinion. (Superlatives like "the best" almost always lead to trouble. It's impossible to weigh every "thing" that ever happened in Europe. And what about the fall of Hitler? Couldn't that be "the best thing"?)

A good thesis has two parts. It should tell what you plan to argue, and it should "telegraph" how you plan to argue—that is, what particular support for your claim is going where in your essay.

Steps in Constructing a Thesis

First, analyze your primary sources.  Look for tension, interest, ambiguity, controversy, and/or complication. Does the author contradict himself or herself? Is a point made and later reversed? What are the deeper implications of the author's argument? Figuring out the why to one or more of these questions, or to related questions, will put you on the path to developing a working thesis. (Without the why, you probably have only come up with an observation—that there are, for instance, many different metaphors in such-and-such a poem—which is not a thesis.)

Once you have a working thesis, write it down.  There is nothing as frustrating as hitting on a great idea for a thesis, then forgetting it when you lose concentration. And by writing down your thesis you will be forced to think of it clearly, logically, and concisely. You probably will not be able to write out a final-draft version of your thesis the first time you try, but you'll get yourself on the right track by writing down what you have.

Keep your thesis prominent in your introduction.  A good, standard place for your thesis statement is at the end of an introductory paragraph, especially in shorter (5-15 page) essays. Readers are used to finding theses there, so they automatically pay more attention when they read the last sentence of your introduction. Although this is not required in all academic essays, it is a good rule of thumb.

Anticipate the counterarguments.  Once you have a working thesis, you should think about what might be said against it. This will help you to refine your thesis, and it will also make you think of the arguments that you'll need to refute later on in your essay. (Every argument has a counterargument. If yours doesn't, then it's not an argument—it may be a fact, or an opinion, but it is not an argument.)

This statement is on its way to being a thesis. However, it is too easy to imagine possible counterarguments. For example, a political observer might believe that Dukakis lost because he suffered from a "soft-on-crime" image. If you complicate your thesis by anticipating the counterargument, you'll strengthen your argument, as shown in the sentence below.

Some Caveats and Some Examples

A thesis is never a question.  Readers of academic essays expect to have questions discussed, explored, or even answered. A question ("Why did communism collapse in Eastern Europe?") is not an argument, and without an argument, a thesis is dead in the water.

A thesis is never a list.  "For political, economic, social and cultural reasons, communism collapsed in Eastern Europe" does a good job of "telegraphing" the reader what to expect in the essay—a section about political reasons, a section about economic reasons, a section about social reasons, and a section about cultural reasons. However, political, economic, social and cultural reasons are pretty much the only possible reasons why communism could collapse. This sentence lacks tension and doesn't advance an argument. Everyone knows that politics, economics, and culture are important.

A thesis should never be vague, combative or confrontational.  An ineffective thesis would be, "Communism collapsed in Eastern Europe because communism is evil." This is hard to argue (evil from whose perspective? what does evil mean?) and it is likely to mark you as moralistic and judgmental rather than rational and thorough. It also may spark a defensive reaction from readers sympathetic to communism. If readers strongly disagree with you right off the bat, they may stop reading.

An effective thesis has a definable, arguable claim.  "While cultural forces contributed to the collapse of communism in Eastern Europe, the disintegration of economies played the key role in driving its decline" is an effective thesis sentence that "telegraphs," so that the reader expects the essay to have a section about cultural forces and another about the disintegration of economies. This thesis makes a definite, arguable claim: that the disintegration of economies played a more important role than cultural forces in defeating communism in Eastern Europe. The reader would react to this statement by thinking, "Perhaps what the author says is true, but I am not convinced. I want to read further to see how the author argues this claim."

A thesis should be as clear and specific as possible.  Avoid overused, general terms and abstractions. For example, "Communism collapsed in Eastern Europe because of the ruling elite's inability to address the economic concerns of the people" is more powerful than "Communism collapsed due to societal discontent."

Copyright 1999, Maxine Rodburg and The Tutors of the Writing Center at Harvard University

25 Thesis Statement Examples

A thesis statement is needed in an essay or dissertation . There are multiple types of thesis statements – but generally we can divide them into expository and argumentative. An expository statement is a statement of fact (common in expository essays and process essays) while an argumentative statement is a statement of opinion (common in argumentative essays and dissertations). Below are examples of each.

Strong Thesis Statement Examples

1. School Uniforms

“Mandatory school uniforms should be implemented in educational institutions as they promote a sense of equality, reduce distractions, and foster a focused and professional learning environment.”

Best For: Argumentative Essay or Debate

Read More: School Uniforms Pros and Cons

2. Nature vs Nurture

“This essay will explore how both genetic inheritance and environmental factors equally contribute to shaping human behavior and personality.”

Best For: Compare and Contrast Essay

Read More: Nature vs Nurture Debate

3. American Dream

“The American Dream, a symbol of opportunity and success, is increasingly elusive in today’s socio-economic landscape, revealing deeper inequalities in society.”

Best For: Persuasive Essay

Read More: What is the American Dream?

4. Social Media

“Social media has revolutionized communication and societal interactions, but it also presents significant challenges related to privacy, mental health, and misinformation.”

Best For: Expository Essay

Read More: The Pros and Cons of Social Media

5. Globalization

“Globalization has created a world more interconnected than ever before, yet it also amplifies economic disparities and cultural homogenization.”

Read More: Globalization Pros and Cons

6. Urbanization

“Urbanization drives economic growth and social development, but it also poses unique challenges in sustainability and quality of life.”

Read More: Learn about Urbanization

7. Immigration

“Immigration enriches receiving countries culturally and economically, outweighing any perceived social or economic burdens.”

Read More: Immigration Pros and Cons

8. Cultural Identity

“In a globalized world, maintaining distinct cultural identities is crucial for preserving cultural diversity and fostering global understanding, despite the challenges of assimilation and homogenization.”

Best For: Argumentative Essay

Read More: Learn about Cultural Identity

9. Technology

“Medical technologies in care institutions in Toronto has increased subjcetive outcomes for patients with chronic pain.”

Best For: Research Paper

10. Capitalism vs Socialism

“The debate between capitalism and socialism centers on balancing economic freedom and inequality, each presenting distinct approaches to resource distribution and social welfare.”

11. Cultural Heritage

“The preservation of cultural heritage is essential, not only for cultural identity but also for educating future generations, outweighing the arguments for modernization and commercialization.”

12. Pseudoscience

“Pseudoscience, characterized by a lack of empirical support, continues to influence public perception and decision-making, often at the expense of scientific credibility.”

Read More: Examples of Pseudoscience

13. Free Will

“The concept of free will is largely an illusion, with human behavior and decisions predominantly determined by biological and environmental factors.”

Read More: Do we have Free Will?

14. Gender Roles

“Traditional gender roles are outdated and harmful, restricting individual freedoms and perpetuating gender inequalities in modern society.”

Read More: What are Traditional Gender Roles?

15. Work-Life Ballance

“The trend to online and distance work in the 2020s led to improved subjective feelings of work-life balance but simultaneously increased self-reported loneliness.”

Read More: Work-Life Balance Examples

16. Universal Healthcare

“Universal healthcare is a fundamental human right and the most effective system for ensuring health equity and societal well-being, outweighing concerns about government involvement and costs.”

Read More: The Pros and Cons of Universal Healthcare

17. Minimum Wage

“The implementation of a fair minimum wage is vital for reducing economic inequality, yet it is often contentious due to its potential impact on businesses and employment rates.”

Read More: The Pros and Cons of Raising the Minimum Wage

18. Homework

“The homework provided throughout this semester has enabled me to achieve greater self-reflection, identify gaps in my knowledge, and reinforce those gaps through spaced repetition.”

Best For: Reflective Essay

Read More: Reasons Homework Should be Banned

19. Charter Schools

“Charter schools offer alternatives to traditional public education, promising innovation and choice but also raising questions about accountability and educational equity.”

Read More: The Pros and Cons of Charter Schools

20. Effects of the Internet

“The Internet has drastically reshaped human communication, access to information, and societal dynamics, generally with a net positive effect on society.”

Read More: The Pros and Cons of the Internet

21. Affirmative Action

“Affirmative action is essential for rectifying historical injustices and achieving true meritocracy in education and employment, contrary to claims of reverse discrimination.”

Best For: Essay

Read More: Affirmative Action Pros and Cons

22. Soft Skills

“Soft skills, such as communication and empathy, are increasingly recognized as essential for success in the modern workforce, and therefore should be a strong focus at school and university level.”

Read More: Soft Skills Examples

23. Moral Panic

“Moral panic, often fueled by media and cultural anxieties, can lead to exaggerated societal responses that sometimes overlook rational analysis and evidence.”

Read More: Moral Panic Examples

24. Freedom of the Press

“Freedom of the press is critical for democracy and informed citizenship, yet it faces challenges from censorship, media bias, and the proliferation of misinformation.”

Read More: Freedom of the Press Examples

25. Mass Media

“Mass media shapes public opinion and cultural norms, but its concentration of ownership and commercial interests raise concerns about bias and the quality of information.”

Best For: Critical Analysis

Read More: Mass Media Examples

Checklist: How to use your Thesis Statement

✅ Position: If your statement is for an argumentative or persuasive essay, or a dissertation, ensure it takes a clear stance on the topic. ✅ Specificity: It addresses a specific aspect of the topic, providing focus for the essay. ✅ Conciseness: Typically, a thesis statement is one to two sentences long. It should be concise, clear, and easily identifiable. ✅ Direction: The thesis statement guides the direction of the essay, providing a roadmap for the argument, narrative, or explanation. ✅ Evidence-based: While the thesis statement itself doesn’t include evidence, it sets up an argument that can be supported with evidence in the body of the essay. ✅ Placement: Generally, the thesis statement is placed at the end of the introduction of an essay.

Try These AI Prompts – Thesis Statement Generator!

One way to brainstorm thesis statements is to get AI to brainstorm some for you! Try this AI prompt:

💡 AI PROMPT FOR EXPOSITORY THESIS STATEMENT I am writing an essay on [TOPIC] and these are the instructions my teacher gave me: [INSTUCTIONS]. I want you to create an expository thesis statement that doesn’t argue a position, but demonstrates depth of knowledge about the topic.

💡 AI PROMPT FOR ARGUMENTATIVE THESIS STATEMENT I am writing an essay on [TOPIC] and these are the instructions my teacher gave me: [INSTRUCTIONS]. I want you to create an argumentative thesis statement that clearly takes a position on this issue.

💡 AI PROMPT FOR COMPARE AND CONTRAST THESIS STATEMENT I am writing a compare and contrast essay that compares [Concept 1] and [Concept2]. Give me 5 potential single-sentence thesis statements that remain objective.

Chris Drew (PhD)

Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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• Chris Drew (PhD) https://helpfulprofessor.com/author/chris-drew-phd/ What is Educational Psychology?

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