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Thursday, November 01, 2001


Twenty Years of HIV/AIDS

Twenty years ago, on June 5, 1981, a report appeared in the medical literature of five cases of pneumocystis carinii pneumonia (PCP), a rare and unusual disease, seen only in people with problems with their immune system. All five cases were reported in previously healthy young homosexual men in Los Angeles, who were in fact the first patients diagnosed with the disease now known as acquired immunodeficiency syndrome, or AIDS.

In the 20 years since the appearance of these first cases, AIDS has exploded into a full-grown epidemic of global proportions, with an unprecedented impact on every aspect of society. Although HIV infection rates differ greatly from nation to nation, there is not a single country upon which the disease has not had some effect. The modes of HIV transmission guarantee that no country can remain free of it. Indeed, AIDS is only one of a number of contemporary public-health issues with a truly global presence. This is the first in a series of articles that will address a number of these issues (bioterrorism, mad-cow disease), as well as their social and financial impact on every level of society.

AIDS is caused by the recently discovered human immunodeficiency virus (HIV). While there were numerous theories regarding its cause early on in the epidemic, epidemiological and biological data now strongly support the premise that HIV is responsible for AIDS. In some quarters, doubt persists, but improvements triggered by medications targeting HIV have strengthened the association between HIV and AIDS. The predominant modes of transmission of HIV are sexual intercourse and exposure to infected blood. Since the first AIDS cases were reported in 1981, HIV has caused approximately 22 million deaths worldwide.

In the United States, approximately 400,000 persons have died, and approximately one million have been infected. At the outset of the epidemic, the affected population consisted overwhelmingly of homosexual men, leading some to assume incorrectly that the disease would be contained within the gay community. New cases of HIV today, however, result predominantly from injection of drugs and heterosexual contact. Of these newly infected people, half are estimated to be younger than 25 years old and are infected sexually. In Greece, the World Health Organization (WHO) estimates 8,000 adults and children to be living with HIV/AIDS as of 1999. The estimated number of adults and children who have died of AIDS in Greece since the beginning of the epidemic is 1,600. Of the cases diagnosed in Greece from 1997 to 1999, 24% were homosexual men, 13% heterosexuals, 2% intravenous drug-users, and 59% with an undetermined transmission mode. HIV prevalence has remained low in intravenous drug-users (in Athens and elsewhere). HIV prevalence in prostitutes who were not intravenous drug-users in Athens was actually zero percent in 1991. The reason for this is unclear, but might be because prostitution is legal, with the resultant routine screening and care of sex workers with sexually transmitted diseases.

Today, AIDS has taken on global proportions, with the greatest burden falling on sub-Saharan Africa. In contrast to the number of cases in the United States and other developing nations, the worldwide numbers are staggering. Over thirty-six million people are infected with HIV, while an additional 21.8 million have died, and 13.2 million children have become AIDS orphans, having lost their mother or both parents to the disease. More than 14,000 new infections occur daily, 5.3 million in 2000 alone, including 600,000 in children younger than 15. Approximately 70% of cases occur in sub-Saharan Africa, where approximately 25% of adults are infected.

In the 1990s, the so-called “cocktail” became available. This combination of drugs, known in the medical community as highly active antiretroviral (HIV is a retrovirus) therapy (HAART), has made significant inroads into the epidemic in the United States and other developing nations. HAART therapy has led to substantial decreases in the incidence of AIDS and in the annual number of AIDS deaths.

Therapy costs more than $10,000 a year, however, and is almost completely unavailable in developing countries. Thus, the United States and the world’s other wealthy nations need to provide assistance to make these therapies affordable. Treatment of HIV in Africa is estimated to cost $1.1-3.3 billion dollars per year. This investment, especially in providing medication to pregnant women, may decrease new infections by reducing the potential to transmit the virus. In the US, the rate of HIV transmission from mother to infant can be as low as one to two percent for women taking HAART.

In many developing countries, the social stigma associated with HIV infection has contributed to difficulties in controlling the epidemic. Persons who might benefit from knowing their HIV status often reject counseling and testing because they fear the consequences of disclosure. Other disincentives are the lack of resources for care and treatment and the sense that little is gained from learning that one is infected with HIV. Programs for prevention in developing countries are also compromised by poor infrastructure and social and political instability.

The future of the HIV epidemic is unknown and to some degree depends on the actions and reactions of the world community. A vaccine will not be available in the near future. Stabilization and reversal of the epidemic will depend in large part on programs targeting education and prevention.

WHO and the United Nations have shown a new commitment to responding to the HIV/AIDS crisis with an appeal to the world to act on this global emergency. The central focus of any program should be prevention. While we try to develop a vaccine for HIV and find the best care for everyone infected with the disease, it is of utmost importance to prevent new infections. Prevention programs should target women and young people. In order to succeed in reaching these populations, frank discussion about causes and prevention – including use of condoms – of HIV and other sexually transmitted diseases is necessary. In addition, drug treatment programs should include the provision of clean needles. Implementing these interventions continues to be problematic because of personal, social, and political barriers of varying types in all countries and by all governments.

Efforts to improve the care of people already infected with HIV are also needed, including the delivery of medications to developing countries. The UN and G8 nations have called for developing a global health and AIDS fund. Governments, private entities, foundations, and individuals have committed almost $1.5 billion to this fund. Pharmaceutical companies are beginning to work with WHO and developing nations to speed access and reduce the cost of HIV medications.

It is encouraging that the pharmaceutical industry recently dropped its efforts to block South Africa, where one in four adults is infected with HIV, from importing cheaper drugs. A growing number of companies are beginning to offer drugs at prices close to production cost. Brazil has had significant success in controlling the HIV epidemic by allowing generic-drug companies to make HIV drugs for local sale. Nevertheless, it is noteworthy that the United States has objected to Brazil’s practice as a violation of patent rights.

Theoklis Zaoutis is attending physician in special immunology (pediatric HIV) at the Children’s Hospital of Philadelphia and an investigator for the Pediatric AIDS Clinical Trials Group (PACTG). He is also a fellow in pediatric infectious diseases at the Children’s Hospital of Philadelphia and an instructor in the department of pediatrics at the University of Pennsylvania School of Medicine.
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