AIDS to Resolution:

An Article By

Dr. Marguerite Barnette

©Marguerite Barnette 2001

This segment reflects the interest and belief that Dr. Barnette and her learned colleagues share regarding the importance of heightened education as a means of resolving the worldwide AIDS epidemic.

AIDS to Resolution: An Introduction

When I was a second year surgical resident, the Center for Disease Control published, in the June 5th 1981 issue of Morbidity and Mortality World Report, the first report of a new disease among gay men. In the twenty years since the recognition of AIDS, the severity of the epidemic has matched the glummest predictions. Unfortunately, here in North America, it is clear that we are still in the early phases of the epidemic. As any good infectious disease doctor will tell a medical student, the time to make a difference in terms of lives saved and disease averted is in the early stages of an epidemic, not when it has run its course. Yet apart from a flurry of articles marking the milestone of two decades with a renewed interest in the disease's devastation in Africa, AIDS has all but dropped off the radar screen in the US. The question "Why?" has many answers, but there are no excuses. AIDS is and will continue to be a clear and present danger to all sexually active individuals. The emphasis on sexual activity is no accident. Worldwide over 80% of all cases are heterosexually transmitted.

For those of us who have forgotten "ancient" history, a brief recounting is in order. Early on it was clear that AIDS was an infectious disease. At first believed unique to homosexuals, it was rapidly identified in other groups such as intravenous drug users and Haitians. This early stratification of risks, along with the lack of cure, led to much hysteria surrounding the disease and a great stigma associated with it. Many Americans paid little attention to AIDS until reports of disease transmission from blood transfusions began to surface. The ensuing outcry led to the development of unparalleled safety features around transfusions and an astounding decrease in all blood-borne diseases. Transmission from transfusions is almost unheard of today in the United States.* Campaigns to prevent infection were begun in communities at risk; education in safe sex practices combined with screening slashed rates of infection in the homosexual population during the late 80s and early 90s; needle-exchange programs for IV drug users lowered the rate of infection in NYC from 50% before 1990 to less than 20% in 2000 and dropped the annual infection rate from 4% to 1%; prenatal screening programs combined with maternal antiviral treatment and avoidance of breast feeding when the mother is infected has dropped new infections in children (most of which are maternal-to-child transmission) from 945 in 1992 to 155 in 1999.

Also, for those who are unclear on the basics, I'll provide a brief overview. (For those who would like to know more, there are literally thousands of excellent sites on the Web; my server found nearly three million hits when I typed in AIDS. One of my personal favorites is www.thebody.com. It has links to many other sites.) AIDS stands for Acquired (meaning can be caught) ImmunoDeficiency(weakness of the disease fighting system of the body) Syndrome(group of health problems that make a disease). It is caused by the Human Immunodeficiency Virus or HIV.** People infected with the virus begin to produce antibodies against it. The HIV test looks for these antibodies and that is what it means if one is HIV positive. Being HIV positive is not the same as having AIDS. Many people harbor the virus for years before they get sick.

This virus is an interesting type of virus known as a retrovirus; this means it can insert its own genetic material into the DNA of the infected person. This allows it to hide efficiently. It preferentially targets the immune system; one measure of this is the CD4+ cells (helper cells). Normally there are 500-1500 such cells in a milliliter (drop) of blood. Without antiviral treatment, as these cells are destroyed, symptoms such as fever, night sweats, swollen glands or diarrhea develop. One officially has AIDS when the CD4+ cell count is less than 200, or one develops an opportunistic infection such as candida (a fungal infection of the throat or vagina), pneumocystis carnii (a lung infection), cytomegalovirus (CMV which may affect the eyes or brain) or Kaposi's sarcoma (a skin cancer). An opportunistic infection is one caused by an organism (virus, fungus, bacterium or parasite) that normally does not cause a problem but can when the immune system is weakened.

Bodily fluids of people infected with HIV carry the virus even if the person does not look ill. In fact, healthy appearing individuals are probably more likely to pass on the virus as their viral loads are often higher than really ill people. Most people get HIV from exchanging body fluids with an infected person: by having unprotected sex, sharing needles, or being born of and/or breast feeding from an infected mother. There have been no reports of infection from fluids such as tears, but it is possible to acquire HIV from oral sex if there are sores or cuts in the mouth. Up to one third of people infected with HIV do not know they are infected; symptoms may be so mild. And since it may take weeks or months for the body to begin producing antibodies to the virus, an individual may be infected and infectious without testing positive! To repeat, A NEGATIVE HIV TEST IS NO GUARANTEE THAT A PERSON DOES NOT CARRY THE VIRUS! One cannot rely on a negative test until it has been repeated after a six-month interval, and if the partner has sex with someone else in the interim, the clock gets reset!

Unfortunately, no cure has yet been found. Antiviral therapies have been available since the 80s but they can only slow down the progression of the disease and, other than in the transmission of HIV from mother to child, have not been shown to effectively prevent infection. The introduction of HAART (highly active antiretroviral therapy) in 1996 slashed the death rate from AIDS by nearly 70% but it is only a temporary breather; rates of infection in high risk groups, which had been falling in the 90s, are now rising—presumably because as people lose the fear of dying from AIDS, they begin to engage in risky behavior again. These therapies are expensive and toxic, requiring a mind-boggling adherence to schedules of multiple drugs. Further, the virus is quite adaptable, mutating every time it replicates (every 8 hours) so that it has the ability to easily develop drug resistance. No good vaccine is yet on the horizon, in part because of the unique ability of the virus to hide and mutate; 77 potential vaccines have been tried to date with only two reaching final clinical trials. Neither of the two is expected to perform well. This is after over $800 million has been spent by the government alone on AIDS research.

To summarize some glum statistics: There has been an estimated 60 million individuals infected with HIV in the last twenty years; 22 million have died. There are 15,000 new infections daily, 95% of them in the developing countries. In the US 800,000 individuals are HIV positive; 300,000 of them living with AIDS. 440,000 have died from AIDS (one sixth in NYC). There are 40,000 new infections in the US annually. In the absence of a cure, ultimately, the vast majority of these persons will be expected to die from AIDS. Historically 70% of these have been men but the demographics of those infected are changing. The highest rates of infection are now in minorities, women, and those under 25 years of age. If this trend continues, we will develop a picture closer to that seen in other countries, in which women comprise half of those infected. Younger women especially are more vulnerable to infection due to immaturities of the reproductive tract. Minorities will make up larger shares of those infected. While the percent of the population infected is around 1% in North America and Western Europe, rates are as high as 40% in parts of Africa (46% in Kwazulu Natal province of South Africa). Rates of infection continue to mushroom in India, China, SE Asia, and the former Soviet Union. At these rates, it is estimated that in another twenty years there will be 200 million people living with HIV (currently there are 36 million).

I know of no other devastating epidemic with such a high rate of infection, except perhaps the plague of the Middle Ages; the consequence of such devastation was long-term destabilization, politically and economically, of an entire world, leading to the Dark Ages. This is already occurring in Africa which has over 5000 AIDS deaths daily and a projected number of 13 thousand daily by 2005. In ten years there will be 40 million AIDS orphans in Africa—will be, not might be. Even if antivirals are given to these countries free of charge, the infrastructure is lacking to deliver them and provide the intensive support necessary to keep them working.

What do these alarming figures mean to those of us who live in the relative comfort and safety of the United States? It means that we cannot continue to live in denial of the existence of this disease, its modes of transmission, and the economic and political reasons fueling its rapid spread in certain areas. I believe we have a moral obligation to provide assistance to those countries suffering the devastation of this disease, as well as financial and political reasons to do so. The plague was contained centuries ago by quarantines, which allowed the disease to run its course; we can no longer have such luxury in the global village of today. For example, my transcription in the office this week was handled by a company in India; I placed an order from a catalog last night that was handled by another company not on this continent; I have, within arm's reach, at least five essential items, parts of which were either made or assembled on four different continents, and my refrigerator contains foods not grown in the United States.

We must increase funding to continue looking into basic science as so many questions are unanswered: Why are some people able to live with HIV with a minimum of symptoms for years and others succumb rapidly? How is the virus able to cause its damage and how can we prevent that? What are the most cost-effective ways of containing the epidemic? Future articles will deal with these and other issues.

The next article will be from a local physician who is at the forefront of the AIDS war in Sarasota County, Florida. Our community has a surprisingly high number of HIV positive individuals, and here, as well as in any other area, the admonishment to think globally, act locally, holds.

In the twenty years since I was that young resident who realized this disease would have an impact on my future practice, I have seen the silver lining to a dark cloud. Sagas of incredible heroism have been superimposed over those of great tragedy and horror. I have seen patients become empowered activists—no longer victims. I have seen new understandings and treatments of this disease benefit patients with other diseases . But I have seen that all this is not enough.

I welcome comments and suggestions for further articles.

Dr. Marguerite Barnette

*This is true only for the US and developed nations. Less than 10% of blood transfusions worldwide are screened for HIV. Last year contaminated S. African blood was confiscated in China, India and England, and in 1996 Austria seized several thousand liters of contaminated blood that was being shipped to Third World countries.

**There has been some debate in the past over whether HIV is the true cause of AIDS. These debates are chronicled at several Internet sites. The vast majority of experts do not dispute that HIV is the cause of AIDS. What causes confusion is the different ways the disease can express itself. But this has been true of all disease processes and is a function of an individual's genetics, the organism's genetics and socioeconomic factors that influence virulence. For example, in some individuals, TB is silent, detected only by a skin test or X-ray, whereas in others it has a rapidly fatal course despite antibiotics.