HIV/AIDS Stigma in Rural America

One of the largest obstacles to proper care of patients early in the AIDS epidemic was and may still be stigma associated with the disease. A common question throughout any major crisis and especially the AIDS epidemic is how the reaction in urbanized America differs from the more rural parts of the United States. To gain some insight into these issues, I have asked my parents to share their first experiences with AIDS patients and their thoughts on these issues. My father, Dr. James Raver, is a respiratory and intensive care specialist in the private sector of health care and my mother, Dr. Sue Raver, is a pediatrician in public health. Both of them live and work in rural western Maryland. I'm Charles Raver. To listen to the interview, please listen to the podcast at: http://www.bio.davidson.edu/people/dawessner/361HIV/podcast/AIDS_Pandemic_23.m4a

Side effects of HAART

Welcome to this installment of the AIDS Pandemic, a podcast hosted by Dave Wessner of the Department of Biology at Davidson College. I am Justin Fried.

A study recently published in the Journal of Infectious Diseases credited AIDS treatment for saving 3,000,000 years of life in the United States (Walensky et al 2006). While effective treatment of common AIDS-related opportunistic infections has indeed benefited AIDS patients, the study cites treatments that decrease the virulence of the HIV virus as having the greatest impact on mortality rates of AIDS patients (Walensky et al. 2006). In the United States and countries that can afford it, the standard treatment for HIV is highly active antiretroviral treatment, HAART for short. HAART is composed of a combination of three or four drugs that fit into as many as three categories: reverse transcriptase inhibitors, protease inhibitors, and fusion inhibitors. Each of these categories of drugs attempts to interrupt the viral life cycle at a different point. Reverse transcriptase inhibitors block the activity of reverse transcriptase, an enzyme the virus uses to build new DNA from its RNA. Protease inhibitors inhibit the activity of viral enzymes used by HIV to cleave new proteins for final assembly into new HIV virons. Fusion inhibitors, the newest addition to the HAART treatment, block entry of HIV into the cell membrane, preventing infection of uninfected cells. The medications of HAART complement each other and are taken together to give an additive effect.

While the HAART treatment has had a profound impact on the AIDS epidemic in America, it should be understood that the HAART treatment is not a cure for HIV and carries its own drawbacks. Until recently, the only HAART treatments available were complicated regimens that required patients to take a series of pills at varying times of the day. Atripla, a new once a day HAART treatment, has greatly simplified the HIV treatment regimen but it is not for everyone. Aside from its expense, it is likely that the HIV virus in some people will eventually evolve to become resistant to one or more drugs in Atripla, and those patients will have to revert to more complicated treatment regimens.

While side effects of HAART treatment vary considerably between individuals and the particular medicines making up their therapy, the most common side effects include diarrhea, nausea, and vomiting ("Side effects"). Lipodystrophy is another common side effect of HAART treatment in which fat is redistributed to other parts of the body (Ammassari 2001). Often in this condition, face and limbs become thin while one's breasts, stomach and/or neck enlarge. Hyperglycemia and onset of diabetes have also occurred in a significant number of HAART patients. Liver toxicity including liver failure, pancreatitis and neuropathy are other unpleasant and potentially life threatening side effects experienced by some patients. These side effects can amount to such a physical and psychological burden that patients skip doses or stop taking their medications all together which increases the likelihood of drug resistance developing. In fact, about 25 % of patients stop therapy within the first year on HAART because of side effects (d'Arminio Monforte 2000). Reconstitution of the immune system, a major goal of HAART treatment, may even carry risks in some patients. A debilitating inflammatory syndrome has recently been linked to HAART treatment (Stoll and Reinhold 2004).

This podcast installation was not meant to scare anyone away from seeking HAART therapy; indeed as I stated earlier, it is very effective in combating infection and allows many HIV positive patients to live longer healthier lives. My goal was to simply alert people to the fact that there are frequently side effects and complications associated with HAART treatment. Prevention is still the best treatment for HIV that carries no side effects.

Until next time this is Justin Fried....

References:
Ammassari, A., Murri, R., Pezzotti, P., Trotta, M., Ravasio, L., De Longis, P., Caputo, S. Narciso, P., Pauluzzi, S., Carosi, G., Nappa, S., Piano, P., Izzo, C., Lichtner, M., Rezza, G., Monforte, A., Ippolito, G., Moroni, M., Wu, A., and A. Antinori. 2001. Journal of Acquired Immune Deficiency Syndromes, 28(5): 445-449.

d'Arminio Monforte, A., Lepri, A., Rezza, G. 2000. Insights into the reasons for discontinuation of the first highly active antiretroviral therapy (HAART) regimen in a cohort of antiretroviral naïve patients. AIDS, 14:499-507.

"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.

Stoll, Mathias, and Reinhold Schmidt. 2004. Adverse events of desirable gain in immunocompetence: the Immune Restoration Inflammatory Syndromes. Autoimmunity Reviews, 3: 243-249.

"Side Effects of HIV or Medication." The Body: The Complete HIV/AIDS Resourse. Retrieved October 12, 2006 from http://www.thebody.com/treat/side_effects.html.

Walensky, R., Paltiel, A., Losina, E., Mercincavage, L., Schackman, B., Sax, P., Weinstein, M., and K. Freedberg. 2006. The survival benefits of AIDS Treatment in the United States. Journal of Infectious Diseases, 194: 11-19.

Selective Pressures on CCR5-Δ32 in the European Population

I'm Pete Levandoski

Recent research into the HIV pandemic has focused on the presence of individuals who do not become infected by HIV when exposed to the virus. So-called co receptors, which are essential for viral docking and infection, are thought to play a role in this immunity. One such co receptor is the protein CCR5, a chemokine receptor on the surface of T4 cells (Galvani et al.). Individuals who lack functional CCR5 protein do not become infected when exposed to HIV-1. A gene mutation, CCR5-Δ32, which causes a deletion of the allele for making CCR5, is present in about 10% of the European population (Galvani et al.). Homozygous individuals are completely immune to HIV-1 and heterozygotes while still susceptible to viral transmission, show slower progression of infection (Galvani et al.). A study done by Doctors Alison P. Galvani and. Montgomery Slatkin published in the December 9th, 2003 Proceedings of the National Academy of The Sciences in the United States, suggests that the higher rate of CCR5-Δ32 in European populations is the direct result of selection pressure caused by Small Pox epidemics.
Previous studies have tried to correlate the augmented prevalence of CCR5-Δ32 in Europe with the intense selection pressure caused by Bubonic Plague. Galvani et al. propose that a correlation between CCR5-Δ32 and Small Pox is a more likely scenario (Galvani et al.). To back this up, a population genetics model was set up using derivations of Hardy-Weinberg equations. These models assume that the CCR5-Δ32 is at least 700 years old and measure selection pressure caused by both diseases on CCR5-Δ32 since 1300 (Galvani et al.). Derivations of the Hardy-Weinberg equation, which factor in the frequency of outbreaks, percentage of mortality and age of the victims, were used to calculate the selection pressure of each disease on CCR5-Δ32. These models were used to determine whether or not each disease exerted enough selection pressure to cause 10% prevalence of CCR5-Δ32 in the European population over a 700 year period (Galvani et al.). This model shows conclusively that the Bubonic Plague did not exert enough selection pressure over 700 years to cause 10% prevalence of CCR5-Δ32 in the population while Small Pox did (Galvani et al.)..
Small Pox exerted higher selection pressure than Plague for a variety of reasons. Small Pox appeared in the population as early as 1,300 years before the first outbreak of Plague. Small Pox outbreak cycles were more frequent than Plague, correlating to a greater mortality (Galvani et al.). Finally, children, who had the greatest reproductive potential, were most susceptible to death by Small Pox while Bubonic Plague tended to eliminate people indiscriminately (Galvani et al.). All of these factors were included in the mathematical model, which showed that Small Pox was enough of a selecting force in Europe to cause the prevalence of CCR5-Δ32 to increase from 0-10% over 700 years.
There were two other pieces of evidence used by the authors to support their claim. The first came from noting that CCR5-Δ32 was present in a higher percentage of the population (14%) in Scandinavia, where Small Pox epidemics were most severe (Galvani et al.). When examined at the molecular level, the mechanism for infection by Small Pox virus involves the use of chemokine receptors, like CCR5, while Y. pestis infection in Plague is independent of these receptors (Galvani et al.).
The implications of this study on the future the HIV-1 pandemic are alarming. At least 700 years of fairly high selective pressure on a population by Small Pox conferred only 10% immunity (Galvani et al.). Since jumping species, HIV has already evolved into two subtypes, three groups and nine clades. In addition, co-infection with different clades is producing recombinant viruses, which are resistant to drug treatments and have stronger binding affinities for immune cells (Avert). HIV is evolving faster than the human race, which from a Darwinian perspective, does not bode well for our species. An interesting application of this data would be to run the same sort of population models in Africa. The selection pressure there on CCR5-Δ32 and other genes, which confer immunity to HIV, theoretically will be high. A measurement of the evolution of HIV immunity would be a helpful tool in determining the prospects for this embattled continent.


Sources
Avert. “Introduction to HIV types, groups and subtypes”. . Avert International Aids Charity: 13 July 2006. (21 October 2006).
Galvani, A.P. et al.. “Evaluating plague and smallpox as historical selectivepressures for the CCR5-Δ32 HIV-resistance allele”. Proceedings of the National Academy of The Sciences in the United States. Vol. 100, no. 25. 9 December 2003. pp. 15276-15279.

Mother to Child Transmission of HIV

When the AIDS epidemic commenced in the early 1980s, the high risk groups were identified as the 4 H’s: homosexuals, hemophiliacs, Haitians, and heroine users. Today, the face of the AIDS epidemic has transformed and women have the highest rates of infection. As more women become infected, the potential for vertical transmission from mother to child increases. Of the nearly seven million children newly infected with HIV in 2003, it is estimated that over ninety percent acquired the disease from mother-to-child-transmission. Similarly, it is estimated that over 90% of the HIV-infected children in sub-Saharan Africa acquired the infection vertically. While a combination of intervention methods can reduce the risk of vertical transmission to less than 2%, mother-to-child HIV transmission still persists worldwide, especially in developing countries which account for 95% of the vertically transmitted HIV cases.

Vertical HIV transmission is the cause of most cases of HIV in children below age 15, so it is important to understand how HIV passes from mother to child. Without intervention or treatment, the possibility of HIV transmission from mother to child is 15-30% in developed countries and 30-45% in developing countries. While 50-80% of infants are vertically infected during delivery, HIV transmission can also occur during pregnancy and after birth. During pregnancy, the fetus can become infected by contacting maternal blood through a placental hemorrhage or by swallowing infected amniotic fluid. Maternal factors which increase the chance of mother-to-fetus transmission include: maternal seroconversion during pregnancy, high viral load, malnutrition, other sexually transmitted diseases, and lack of or poor compliance with antiretroviral drug therapy.

During birth, factors that increase the risk of mother-to-child HIV transmission include: vaginal delivery, rupture of vaginal tissue, contact with maternal blood and vaginal secretions, and chorioamnitis. Pregnant women with chorioamnitis have a potentially increased white blood cell count that acts as a target for the HIV virus. Higher maternal viral load is positively correlated with vertical HIV transmission. Posnatally, the most significant risk factor is breastfeeding. The HIV virus has been isolated from breast milk, demonstrating the risk of long-term breastfeeding in infants. Transmission of HIV through breastfeeding occurs in 16-29% of cases. Specific risk factors during breastfeeding include: cracked nipples, mastitis (breast inflammation), breastfeeding for extended time periods, postnatal maternal seroconversion, high viral load, and low CD4 cell count. Mixed feeding of breast milk and other food sources has been shown to increase the risk of HIV transmission. Scientists hypothesize that an infant’s immune response is triggered by the introduction of new foods, attracting white blood cells to the gastrointestinal tract and increasing targets for the HIV viruses to spread infection.

The most successful methods of intervention to prevent mother-to-child HIV transmission include: antiretroviral medication for mother and child, caesarian section, and refraining from breastfeeding. While the recommended type and regimen of antiretroviral drugs for mothers varies, mothers on antiretroviral drugs have less than a 2% chance of transmitting HIV to their babies. The Pediatric AIDS Group Protocol 076 (PACTG 076) was an important study that demonstrated the effectiveness of using zidovudine in reducing vertical HIV transmission. This study showed that zidovudine given during pregnancy and labor and given to the baby during the first six weeks of life decreased the risk of vertical transmission by 66%. Another drug called nevirapine, a nonnucleoside reverse transcriptase inhibitor, is also effective in reducing vertical HIV transmission when given during pregnancy and after birth to the child. Aside from drug therapy, pregnant HIV positive women are also advised to have a cesarean section at 38 weeks to further reduce the risk of vertical transmission. Cesarean delivery reduces exposure of the infant to maternal fluids and tissues which is high during vaginal delivery. Finally, HIV positive women are encouraged to refrain from breastfeeding to reduce the risk of spreading HIV to their babies postnatally.

While the methods of preventing vertical HIV transmission are fairly effective, implementing these interventions in sub-Saharan Africa and other developing areas of the world is difficult due to cultural and economic barriers. While encouraging HIV-positive mothers to refrain from breastfeeding is a logical preventive measure against vertical HIV transmission, most women in poverty-stricken areas cannot afford to pay for formula or do not have access to clean drinking water to prepare the formula. Also, women who stop breastfeeding to protect their children from HIV risk the stigma of being labeled as HIV positive. These obstacles, combined with the lower level of access to antiretroviral drugs in developing countries, create obvious barriers to decreasing vertical HIV transmission worldwide.

I'm Meredith Prasse. Thanks for listening.

HIV/AIDS and the South African Disability Grant Program

I’m Erika Larson.

I want to get sick so the doctor will give me a grant, and my children will have healthy food. Even if I die, my children will be better taken care of.

These words were spoken by Zolile, one of over 4.8 million HIV-infected South Africans. Her story illustrates the perverse incentives of the South African disability grant program that offers $130 per month to those with a CD4 count of 200 or below. Because grants expire after six months, patients have stopped taking medicine to remain sick in order to receive the grant and feed their families. Selwyn Jehoma, Deputy Director-General of South Africa’s Social Security Department is investigating yet another possible problem the program has created. “There’s another area that we’ve investigated: we’re asking ourselves ‘Are people leaving children with family members for the provisions for a foster care grant. And why are they doing this? Given there is a lack of income and they can’t support their own children, and obviously one would like to look at support systems.” In a country where unemployment soars to nearly 40%, HIV patients are confronted with a desperate choice: a choice between personal health and the well-being of their family.

Decisions like those of Zolile suggest not only inadvertent problems with the welfare program, but consequences of South Africa’s poverty. Destitution increases vulnerability to HIV. Migrant laborers, sex workers, disempowered women, and low education have augmented the spread of the epidemic. In turn, HIV compounds impoverishment. Affected households earn only 50-60% of the income earned by non-affected families. Low incomes, further drained by medical bills and funerals, do not adequately finance nutritional food, thereby increasing the chances for opportunistic infections. South Africa’s dilemma demonstrates that the vicious cycle between poverty and HIV has yet to be broken.

Though solving the problem seems unfathomable, there are alternatives to the disability grant program. When asked about other options, Dr. Peter Hess, Professor of Economic Development at Davidson College, drew from the success of Mexico’s educational conditional cash transfer program. For South Africa, a program would mobilize community health workers to test patients’ CD4 counts before and after medication, measuring their regime adherence and rewarding them for continuing drug therapy. Conditional cash transfers not only lighten the heavy bureaucracy, but also provide a space for positive incentives and community involvement, both essential components to sustainable development.

These South African songs are reminders not only of a profound culture, but also resilient religious and civil societies. Like Brazil, South Africa can draw on both churches and NGOs to create a comprehensive approach, fusing both top-down epidemiology and bottom-up development.

Though President Mbeki’s denial of HIV as the cause of AIDS has created an unredeemable lag in tackling the HIV issue, South Africa can find hope in policies that address HIV, poverty, and malnutrition. By engaging the expansive, young population through education and open dialogue, South Africa can harness one of its most important assets, its people.

Though it may be easy to criticize South Africa, we should ultimately examine our own choices. Have we, as an international community, failed to recognize the link between HIV and poverty? The moral imperative to address AIDS lies beyond science—it can be found in stories like that of Zolile, narratives that are reminders of what it means to be a part of global community.

Perspectives on Condom use in Zambia and the U.S.

I’m Steve Halliday.

During the month of July, 2006 I had the opportunity, along with several other Davidson students, to travel to Mwandi, Zambia with the Davidson Biology department. As a part of this trip I had to research and write a paper on the effectiveness of education in preventing HIV/AIDS. Through my experience in the local classrooms, and interviews with hospital workers and community members I realized that the level of HIV awareness and the general knowledge of the disease was very high, but for some reason seemed to have relatively little effect in preventing HIV transmission.

While there are obviously many factors that contribute to this problem, such as abject poverty and lack of access to healthcare, I found that one factor that may play a very large role are the adverse attitudes towards condom use in the community.

The town of Mwandi, which is largely centered around a mission compound, is very Christian. Most everyone in town attends religious services at least once a week, and the mission hospital is the only Western medical institution in the area. While the mission is affiliated with a protestant church, it is still a quite conservative Christian faith, and officially the church does not advocate condom use, except between monogamous married couples. As a result of this the hospital is not supposed to distribute condoms to patients, and it presents a major conflict of interest in the counseling they can offer.

The actual opinions on condom use vary substantially from person to person, based on personal views as well as what they’ve seen in their line of work. For example, the head clinical officer openly advocates condom use, and distributes them as often as he can receive shipments from the ministry of health. But at the same time, he does not believe that condoms should be talked about or distributed to children because he believes it will increase promiscuity.

Condom use is taught in school, but with the caveat that they are not very effective, and the only real way to protect yourself is through abstinence and monogamy. This creates an attitude where condom use is not thought of seriously, and when a child becomes sexually active they are less likely to use a condom.

These attitudes toward condom use are detrimental to public health, and severely decrease the effectiveness of HIV prevention. These attitudes aren’t limited to Mwandi, to Zambia, or even to Africa, but are common throughout the world. The main scapegoat for spreading this sentiment is the Catholic church, which is opposed to condom use on the grounds that premarital and extramarital sex are sins, and the now less common belief
that married couples should only have sex for the purpose of procreating. The Catholic church is certainly not the only organization at fault though, as even the current administration of the United States supports abstinence only education.

This idea of abstinence only education is destructive to sexual education, and contributes to the spread of STDs and unwanted pregnancies, and needs to be abolished worldwide. Condom use should be taught in all schools as a viable means of protection from HIV and STDs should a person decide to have sex, because it has been shown time and time again that simply telling people not to have sex doesn’t work. With the lack of a cure for HIV in the foreseeable future prevention is clearly the most important action that must
be taken, and education centered around safe sex needs to play a central role in prevention policy, along with social welfare programs and the empowerment of women.

Evidence that HIV-2 can infect CD4-negative cells

Human Immunodeficiency Virus Type 2, also known as HIV-2, is prevalent in West Africa and has spread recently to the western coastal region of India and to Europe. Compared to HIV-1 HIV-2’s mortality rate is thought to be a third lower and appears to be closer to the Simian Immunodeficiency Virus or SIV. As of 1999 it is known that all three types of immunodeficiency virus interact in some fashion with the CD4 cell surface and a co-receptor triggered by contact with the viral protein gp120. It is known that HIV-1 uses CCR5 and CXCR4 as its major co-receptors, but SIV and HIV-2 can use other co-receptors besides CCR5 and CXCR4 for infection in CD4+ cells.
Clapham, McKnight, and Weiss in 1992 showed that one strain of HIV-2 was able to successfully fuse cell to cell and have an efficient infection in CD4- human cells, while other strains were still dependent on CD4 or sCD4 (soluble CD4) for fusion. Reeves et al. in June of 1999 wanted to see if primary HIV-2 strains could infect CD4- cells that expressed either CCR5 or CXCR4 receptors.
They began by characterizing the co-receptors used by HIV-1, HIV-2, and SIV strains in CD4+ cells and found that compared to HIV-1, HIV-2 did use a variety of co-receptors for infection in almost all the viral strains but predominately CCR5 and CXCR4. They then tested for CD4-independent infection for the different HIV-2 strains using CD4- cells. The researchers concluded that certain strains could produce an effective infection in the cells using only CCR5 or CXCR4 receptors. To verify this, Reeves et al. used specific ligands of CCR5, CXCR4, and CD4 and confirmed that infection could occur independent of CD4 with CCR5 or CXCR4.
Overall, they found that there were 7 HIV-2 strains that used CCR5 and/or CXCR4 to infect CD4+ cells, but in CD4- cells 2 strains used only CXCR4, 2 strains used only CCR5, and 3 used neither CCR5 nor CXCR4 efficiently.
In comparing HIV-1, HIV-2, and SIV, they showed that HIV-2 and SIV are less reliant on CD4 for infection and that certain strains using CCR5 to infect CD4- cells levels were very similar to SIV strains in CD4 independent infection.
It is unknown why, but astrocytes although not expressing CD4, in vivo can be infected with HIV-1. Reeves et al. then determined whether astrocytes, CD4- cells, were susceptible to infection. Results showed that infection occurred via the CXCR4 receptor and that the concentration of the receptor might play a role in the efficiency of infection.
Thus the ability of HIV-2 to infect a cell independent of CD4 depends on the cell type and the concentration of co-receptors on the cell surface. The researchers note that there could be other receptors or factors that have yet to be identified. Co-receptors could have different conformational changes in different cells or could exist as oligomers, which would influence their activity and identification.
It is theorized that the original SIV and HIV strains used only one receptor and then evolved to the two co-receptor mechanism. This explains the difference between the different types of immunodeficiency viruses and variation of the strains within the sub-types. It is unknown why HIV needs 2 co-receptors to infect a cell, but it does seem selective pressures to gain immune resistance have evolved to make it harder for the body to inhibit viral infection. The fact that there are differences between types and strains make HIV mechanism difficult to understand and makes HIV treatment even more difficult to design.

Jessica Lahre


Reeves, J. et al. (1999). Primary Human Immunodeficiency Virus Type 2 (HIV-2)
Isolates Infect CD4-Negative Cells via CCR5 and CXCR4: Comparison with
HIV-1 and Simian Immunodeficiency Virus and Relevance to Cell Tropism In
Vivo. Journal of Virology. 73 (9): 7795-7804.

HIV/AIDS in China

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. This is Cara Maguire.

With a population of 1.3 billion people, many of them poor and in heavily concentrated cities, China appears to be a country ripe for the easy spread of HIV/AIDS. In 2000, the estimated HIV-positive population exceeded 500,000, with a growth rate that could peak at 10 million people by 2010. However, today in 2006, the current estimate is 650,000 infected. In comparison, the United States has approximately 1 billion fewer people overall, but has 850,000 infected. How has the Chinese government managed to maintain such low numbers and prevent a healthcare disaster?
Traditionally, China has avoided widespread STD epidemics because of strict policies and conservative morals towards prostitution. For China, the twentieth century was basically drug- and prostitution-free. A theory explaining the recent surge in venereal disease is China’s increasing acceptance of a free market. With the economic reforms instituted in the 1980s came a growing wealthy population and the money to support the drug and sex trades. Although estimates in 2000 put intravenous drug users as 72% of the HIV positive population, more recent numbers suggest this group only makes up 42% of infections. It is difficult to assess the percentage of infections due to the sex trade; however, the two trades are often linked due to women offering sex for drugs.
For many years, the Chinese government was slow to recognize the threat of AIDS. Although drug abuse remained illegal, the penalties were relaxed. These penalties involved a variety of rehabilitation programs ranging from voluntary 10-day treatments to up to three years in a reeducation through labor center. In recent years, the Chinese government has taken several steps to address the growing epidemic more decisively. In 2004, guidelines were published for methadone maintenance treatment and needle exchange programs. Exchange programs provide intravenous drug users with clean needles, while methadone, an oral drug, is used to replace the intravenous drugs altogether. Although these programs are socially liberal (and not condoned in the United States), they were primarily confined to large urban centers.
On March 1st, 2006, the most recent governmental guidelines went into effect. By specifying the responsibilities of all levels of government, the guidelines force local governments to take action against the spread of HIV/AIDS. Governments must now provide free anti-HIV/AIDS drugs for rural and underprivileged patients and free testing and information. In addition, the guidelines protect the rights of patients by forbidding the release of any personal information. Finally, local governments must provide free tuition and fee exemption to AIDS orphans.
Overall, the measures taken by the government have done a good job in helping victims and limiting the spread of HIV in this large country.

WOMEN AND HIV/AIDS IN AFRICA

Globally, women now constitute 48% of the HIV positive population. 76% of these HIV positive women live in Sub-Saharan Africa, where women account for 59% of adults living with HIV. The rising rates of HIV infection in women and young girls is directly related to their inferior social, economic, and legal status in this region of the world. Women’s autonomy relating to sexual decisions is rarely respected. Men tend to dominate women’s sexuality in Africa’s dramatic context of poverty.
While women are account for half of the HIV burden, many responses to the epidemic have failed to address the social, economic, and cultural factors that put women at an increased risk for HIV infection. The ABC program, which emphasizes Abstinence, Be faithful, and Condom use, has been adopted by many African governments but is simply not feasible for women. They are not given the choice to abstain from sex, but are often raped or coerced into having sex as a means of survival. While they may remain faithful to their husbands, they are powerless to ensure that their husbands remain faithful to them. In addition, women are not given sufficient control over sexual situations to ensure that their partners, particularly their husbands, always wear a condom. Such programs fail to address the social factors limiting women and girl’s sexual autonomy and placing them at an increased risk for HIV.

Violence against women, whether in the context of rape or sexual abuse, is a significant factor in the propagation of HIV in women. Women who have been subjected to violence are three times as likely to be infected with HIV as women who have not. Girls in Africa are also pressured into marrying at a young age. Most of these girls are married to older men who are more likely to have had exposure to sexually transmitted diseases and are less likely to use a condom.

Education efforts need to be extended to women and heavy investments should be made in methods that would allow women to control HIV prevention. Female condoms are very effective in blocking the passage of microorganisms, including HIV. However, these condoms cost on average $0.70, making them ten times more expensive than male condoms. In addition, they are not widely available and most women don’t even know about their existence. Microbicides are a very promising new method of HIV prevention that are able to block or disable the virus as soon as it enters the body and before it spreads. Even the first generation microbicides are expected to reduce HIV transmission by 40 to 60%. A 60% effective microbicide is projected to prevent 2.5 million new HIV infections over a period of three years.

Antiretroviral treatment is now available to 1.3 million people, representing a significant increase in just a few years. Still, ARVs are only available to 17% of the people in Sub-Saharan Africa who need them. Data has not shown that there are significant gender discrepancies in access to treatment, but women do encounter more difficulties in adhering to the regimens. Because women are confronted with more intense stigma and marginalization than men when infected with HIV, many chose not to return to clinics for their test results. They are also afraid that their serostatus will be disclosed without their consent, which in many cases leads to women being kicked out of their homes and losing all economic support. One study in Zambia revealed that 66% of women did not disclose their status to their partner for fear of blame, violence, and abandonment. 76% did not adhere to their treatment regimen because they were trying to hide their pills.

To design more effective AIDS programs, it is essential that more women, especially those living with HIV, be included in international AIDS conferences and meetings where programs are designed. An effective program needs to focus on education, economic empowerment, improved access to health services, and better prevention options for married women. Laws need to be developed to protect women’s rights and allow them to have a reliable legal recourse when those rights are violated. Pressure needs to be brought against social and cultural norms that legitimize child marriage and domestic violence. Programs need to be implemented that recognize the specific challenges faced by HIV positive women and improve their access to reproductive health services. Access to testing and treatment should be facilitated and promises of confidentiality respected. Thankfully, there are feasible steps that can be taken to empower women and address the issues that make them vulnerable to HIV infection.

Lauren Finley

The Influence of Viral Factors on Long-term Nonprogressing HIV

The progression of HIV infection varies from one individual to another. Although “the median time from infection to development of AIDS is 8 to 10 years,” some individuals, known as long-term nonprogressors, fail to develop AIDS after infection with HIV (Hogan and Hammer, 2001). These individuals have been identified on various continents, and include persons with various types of exposure, such as commercial sex workers, hemophiliacs who have received HIV positive blood during transfusions, infants born to seropositive mothers, health care professionals accidentally infected by needlestick, intravenous drug users, and sexual partners of known HIV positive individuals (Zhu et al., 2002). Despite prolonged periods of HIV infection, long-term nonprogressors “remain asymptomatic and have normal CD4 cell counts and low or undetectable viral loads,” (Hogan and Hammer, 2001). The existence of long-term nonprogressors indicates the possibility of a natural immunity to HIV (Haynes et al., 1996). Though current research suggests a broad range of potential viral and host factors that may influence progression rates, further investigation is necessary to clarify the roles of each of these factors and elucidate how this knowledge can be applied to the therapeutic development of vaccines (Hogan and Hammer, 2001). This podcast will focus solely on the influence of viral factors.
Research has indicated that certain characteristics of the HIV-1 virus may affect transmission and progression rates. These factors include viral tropism, viral escape, viral attenuation, and viral subtype. Two variants of viral tropism have been identified for the HIV-1 virus, which are macrophage-tropic (M tropic) and T-cell-tropic (T-tropic). Early HIV infection usually results from M-tropic strains. As the virus mutates, its phenotype may change, resulting in a T-tropic strain, which is known to increase the rate of T-cell depletion. The progression from one tropism to the other has been associated with increased pathogenicity and progressive disease (Connor and Ho, 1994).
Another factor that has been linked to disease progression is viral escape from immune response. Viral escape may result from mutations that arise in the gag, pol, and env genes, allowing the virus to elude intense cell-mediated and humoral immune response (Hogan and Hammer, 2001). Additionally, attenuated HIV-1 viruses have been linked with slowed progression of AIDS infection. More specifically, a group of individuals infected with a strain of HIV-1 with a deletion in the nef gene have been identified. When discovered, all eight individuals infected with this strand of HIV-1 appeared to have nonprogressive infection. Upon tracking these individuals, however, the disease reflects slowed progression (Learmont et al., 1992). Further investigation into attenuated strains may present methods that can be used to delay progression of HIV-1 and prolong the lives of infected individuals.
Finally, individuals with different viral subtypes may experience slowed or enhanced disease progression. Epidemiologic studies seeking differences between subtypes are difficult and often inconclusive. However, there is evidence suggesting that HIV-2, a related human retrovirus, is less virulent and less infective, supporting the notion that HIV subtypes may have differential risks associated with transmission and pathogenicity (Marlink et al., 1994).
Although the role of viral factors has not led to conclusive evidence that slows the progression HIV infection to the development of AIDS, continued research of the virus and host may clarify key features of the disease that may aid in the development of vaccines or treatments that induce individuals to acquire the mutations that long-term nonprogressors have obtained naturally (Hammer and Hogan, 2001).

Thanks for listening. I'm Christie Brough.

References
Connor, R.I. and Ho, D.D. (1994). Human immunodeficiency virus type 1 variants with increased replicative capacity develop during the asymptomatic stage before disease progression. Journal of Virology 68:4400-4408.

Haynes, B.F., Pantaleo, G., and Fauci, A.S. (1996). Toward and understanding of the correlates of protective immunity to HIV infection. Science 271:324-328.

Hogan, C.M. and Hammer, S.M. (2001). Host determinants in HIV infection and disease (Part 1: Cellular and humoral immune responses). Annals of Internal Medicine 134:761-776.

Learmont, J., Tindall, B., Evans, L., Cunningham, A., Cunningham, P., Wells, J., et al. (1992). Long-term symptomless HIV-1 infection in recipients of blood products from a single donor. Lancet 340:863-867.

Marlink, R., Kanki, P., Thior, I., Travers, K., Eisen, G., Siby, T., et al. (1992). Reduced rate of disease development after HIV-2 infection as compared to HIV-1. Science 265:1587-1590.

Zhu, T., Corey, L., Hwangbo, Y., Lee, J.M., Learn, G.H., Mullins, J.I., and McElrath, M.J. (2003). Persistence of extraordinarily low levels of genetically homogeneous human immunodeficiency virus type 1 in exposed seronegative individuals. Journal of Virology 77:6108-6116.

HIV/AIDS in the Southeastern U.S.

The southern United States is a region both famous for fried chicken, sweet tea, and a slow pace of life, yet notorious for its religious conservatism and a history of slavery and segregation. The South has gained another reputation in the past few years, however, that is not so widely known: it is quickly becoming the center of the HIV/AIDS epidemic in the United States.
One reason why AIDS prevalence in the south has gone unnoticed for so long is that the average southerner doesn’t think the epidemic can affect them. Most associate HIV with large urban cities, like New York City, San Francisco, and Los Angeles, places that don’t have much in common with small southern towns. They also still see AIDS as a “gay disease” and are generally uneducated about HIV and what it means to be HIV+.
The southern region of the United States, as defined by the US Census Bureau, includes 16 states and the District of Columbia. The Deep South represents a group of six southern states (Alabama, Georgia, Louisiana, Mississippi, South Carolina, and North Carolina) that are disproportionately affected by the AIDS epidemic. From 2000-2003, CDC estimates show a 35% increase in new reported AIDS cases in the Deep South, but only a 5.2% increase nationally. The Deep South also has some of the highest AIDS death rates in the country.
Other health indicators, such as measures of diabetes prevalence, stroke rate, heart disease deaths, infant mortality and preterm births also show high mortality rates in the Deep South. Furthermore, the Deep South also has very high levels of STD infection. The Kaiser Family Foundation reported that in 2002, the five states with the highest rates of gonorrhea were all in the Deep South; these states also had high rates of chlamydia and syphilis. STD prevalence is of particular importance because the presence of an STD facilitates HIV transmission.
Since its discovery, HIV has disproportionately attacked socially marginalized groups, starting with the gay community and spreading to the poor and disenfranchised. Deep South states generally have higher poverty rates than other regions. Poverty contributes HIV/AIDS rates because individuals do not have access to health education or preventative services and cannot afford treatment. Poverty has also been associated with drug use, which can lead to HIV transmission through the sharing of needles.
The south also experiences a large number of rural HIV/AIDS cases. The 1995 US Census estimated that 43% of people living in the south live in rural areas. In rural areas it is often hard to find nearby healthcare, and many patients won’t or can’t get to services. This leads to late diagnosis and unintentional infection of others.
Nearly 80% of new AIDS cases in the South are among African Americans. The HIV/AIDS epidemic is concentrated in poor communities, where African Americans are disproportionately represented. This is particularly true in the Deep South, where populations are approximately 30% Black, compared to the 18.5% in other southern states. Overall, 25% of African Americans live in poverty and are 1.5 times more likely than Whites to lack health insurance. Medical and social service barriers for African Americans are not uncommon in the rural South, and access to HIV medication and care is no exception. Many African Americans feel distrust and anger towards the healthcare system due to historical oppression and enduring medical inequalities. This has led to conspiracy theories that are believed by even the most educated and has created barriers for HIV prevention.
HIV prevalence in the Deep South cannot be studied without a look at historical and cultural factors as well. Many people often blame the lack of medical professionals and poor access to healthcare for the South’s high HIV rates, yet the South is just as rural as the Midwest and does not have fewer health providers than other rural areas. The southern “culture of politeness” prevents discussion of topics that are deemed offensive, such as sex and homosexuality. Religious conservatism also contributes to the spread of HIV by affecting education. Many schools teach abstinence-only curriculums and don’t provide information about other forms of protection, putting youth at risk for infection. Religious conservatism is also associated with close-mindedness, which increases the perceived HIV stigma.
In the end it is important to consider all possible causes of AIDS prevalence in the Deep South states in order to provide more effective preventative and treatment services to everyone who is afflicted by HIV.



Sources:
Adams B. Polite to a Fault? HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=49&categoryid=1.
Adams B. The South Has Risen. HIV Plus.com May 2003; http://www.hivplusmag.com/column.asp?id=48&categoryid=1.
CDC. Fact Sheet: HIV/AIDS Among African Americans. Feb 2006. http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm.
Reif S, Geonnotti KL, Whetten K. HIV Infection and AIDS in the Deep South. Am J Public Health 2006; 96: 970-973.
Whetten, K, Nguyen, T. You’re the first one I’ve told: new faces of HIV in the South. New Brunswick: Rutgers University Press.

The Condom Controversy: religious fundamentalism and the fight against AIDS in Zambia

It was my first time to visit rural Zambia. As our crowded SUV entered the dusty city limits of the fishing village Mwandi, we were greeted by a large black and white sign, reading: “Welcome to Mwandi, we are concerned about AIDS.” Below were listed the ABCs, “Abstain, Be faithful, Condomise,” and in red letters, “D – or you will die.” It was quite a sobering welcome banner; but it was descriptive of the ideologies about how to fight AIDS which I discovered during my stay in Mwandi.
The incidence of AIDS in Zambia is staggering. According to the 2006 Global Report on the AIDS Epidemic, nearly twenty percent of the Zambian population has AIDS. It is a disease strongly associated with dire poverty, affecting more women than men across sub-Sahara Africa. Nearly half of the population in Zambia is less than fifteen years old, and there are an estimated 710,000 AIDS orphans, evidence of the crippling effects AIDS can have on a poor nation.
In Zambia, like most of sub-Sahara Africa, HIV is largely transmitted through unprotected heterosexual sex. Most non-sexually transmitted HIV results from mother-to-child transmission during child birth or breast-feeding.
Prevention of HIV is the single most effective weapon in the fight against AIDS. UNAIDS projects that treatment combined with prevention will avert 29 million new HIV infections worldwide by 2020, as opposed to only nine million with treatment alone. The UNAIDS protocol for HIV prevention calls for a combination of: abstinence, monogamy, reduction in the number of sexual partners, and correct and consistent condom use. The male condom is still a vital prevention strategy as it reduces the risk of HIV sexual transmission by eighty to ninety percent.
However, promotion of the condom as an AIDS prevention strategy has encountered resistance from some governments and religious groups. Traditionally, Christian fundamentalist groups focus on the abstinence and fidelity aspects of AIDS prevention but refuse to incorporate condoms. For example, in 2001 the Christian Council of Zambia was successful in removing condom advertisements from the radio, claiming they encouraged promiscuity. President Chilumba, who declared Zambia a Christian nation in 1991 and who said condoms were a sign of lax morals, supported the clergy in removing the condom ads as did the Minister of Education (AEGIS). Also, the Catholic Church widely rejects the use of contraception. In fact, at a 2005 meeting with African bishops, the Pope warned that “contraception was one of a host of trends contributing to a ‘breakdown in sexual morality’, and church teachings should not be ignored” (BBC news, 2005).
The condom controversy surfaces in areas where religious non-governmental organizations (NGOs) must create health policy due to lack of government involvement. Because most African countries do not have sufficient public health infrastructure, many nations rely on NGOs for health services, especially in rural areas. When religiously-funded organizations are charged with overseeing health policy, they may encounter a moral conflict. On one hand, they must comply with recommendations from the World Health Organization and UNAIDS to incorporate condoms in HIV prevention in order to save lives. On the other hand, they must appease the church by omitting condoms from HIV prevention strategies, which the statistics indicate will lead to more deaths from AIDS.
The condom controversy raises important questions as to the role of NGO involvement in health policy when NGOs are limited by their supporters of the religious right. Are they doing more harm than good in fighting the AIDS pandemic? Fortunately, condom distribution is now possible for some church-sponsored health clinics, which previously did not distribute condoms. For example, a July 2005 issue of Christian Century offers encouraging news about the condom controversy in Zambia. It claims that the Zambian Council of Churches “would promote the use of condoms only to prevent the further spread of disease.” The General Secretary and other bishops admitted, “If we don’t encourage this, we will be blamed for not saving lives” (Dart 2005).
Hopefully such tolerant attitudes will become prevalent among faith-based NGOs in the near future. If not, the consequences for the rural Zambian public could be devastating. Whereas there are many compounding factors in the solving the AIDS problem, adhering to the simple ABCs of AIDS prevention is certainly a good place to start.

Thanks for listening, I’m Wes Fiser

Bibliography
Dart, John. “The Council of Churches in Zambia is supporting the use of condoms in the fight against HIV/AIDS.” 26 July 2005. Christian Century 122(15):17.
“Pope Rejects Condoms for Africa.” 10 June 2005. BBC news. 21 October 2006. .
UNAIDS. Comprehensive HIV prevention. 2006 Report on the Global AIDS Epidemic. 2006. 14-50, 124-128.
“ZAMBIA-AIDS: Condom adverts deemed too explicit: ‘Condoms are one of the major ways of preventing the spread of AIDS.’” 12 January 2001.UN Integrated Regional Information Network. AEGIS. 22 October 2006. .

The Correlation Between Gender-Based Violence and HIV/AIDS

In sub-Saharan Africa, an average of three women are infected for every two men. Among young people aged 15-24, that ratio widens substantially to three women for every one man. This disproportionate impact of the AIDS epidemic on women reflects the conditions of social and economic inequality in which they live. Violence is one of the crucial social mechanisms by which women are forced into a subordinate position in which it is difficult, if not impossible, to protect themselves from HIV.
The correlation between gender-based violence and HIV/AIDS involves a combination of biological, social, and cultural conditions. Women are already at least twice as likely as men to contract HIV from unprotected sex, in part because semen carries more HIV than vaginal secretions. Violent sex and rape increase a woman's biological vulnerability to HIV by causing bleeding and tearing of the genital area, creating passageways for HIV to enter the bloodstream. Conversations about safer sex, HIV status, or HIV risk reduction are highly unlikely in rape situations, and condoms are not generally used. Many victims of sexual violence develop alcohol and/or drug dependency, depression, low self-esteem and post-traumatic stress disorder, which can in turn lead to multiple partners, unprotected sex or increased risk taking.
Violence between intimate partners is another consequence of gender inequality. Studies show that up to 50% of all women worldwide report being physically abused by an intimate partner. Physical violence between intimates contributes to HIV transmission by harming the ability of partners to communicate openly with each other. A woman is less likely to discuss HIV status or insist on the use of condoms when she is afraid of violent retaliation by her partner. The constant threat of violence makes women feel vulnerable and allows men to maintain control over the decision of when and how to have sex.
Gender-based violence also occurs as a result of HIV infection. Popular misconceptions about HIV, such as the belief that sex with a virgin can cure infection, lead to acts of rape and sexual violence. Being HIV-positive is a serious risk factor for violence against women. Many women who reveal their HIV status to partners, family members, and communities are in danger of being physically and emotionally abused. Sex workers also experience an increase in violence from clients who blame them for contracting HIV.
As the correlation between HIV and gender-based violence becomes increasingly apparent, urgent efforts are needed to combat the growing rates of infection among women. Laws and policies that protect against sexual violence and gender discrimination of all kinds must be enacted, publicized and enforced. Gender-based discrimination prevents women from making free and autonomous decisions, particularly with regards to sexuality and relationships. So long as women's human rights and dignity are not respected, sexual violence will continue to increase women's vulnerability to HIV and fuel the impact of the AIDS epidemic.

Product(RED): Raising funds for the Global Fund

What do Converse, Gap, Apple, and Motorola have in common? They all are partners in (RED), an initiative designed to raise money for the Global Fund to Fight AIDS, Tuberculosis, and Malaria. And today, October 13, 2006, marks the official launch of (RED) in the United States.

Founded by U2 lead singer Bono and Bobby Shriver, Chairman of DATA in early 2006, (RED) has enlisted several corporate sponsors, most notably the companies listed earlier. Each of these companies has designed one or more special (RED) products. A portion of the profits from the sales of these products will go to the Global Fund. More information about (RED) can be found at www.joinred.com.

So as of today, you can purchase a Product (RED) t-shirt at the Gap, Product (RED) Chuck Taylors from Converse, a Product (RED) iPOD nano from Apple, and a Product (RED) RAZR phone from Motorola. Not only will you have some pretty cool accessories, but you also will be contributing to the fight against HIV/AIDS and showing your support for this worthy cause.

Why should we do this? The (RED) Manifesto states it clearly and succinctly: “As first world consumers, we have tremendous power. What we collectively decide to buy, or not to buy, can change the course of life and history on this planet.” I hope you choose to buy (RED).

HIV/AIDS in Zambia: A Personal Account

By now, many of us have heard some of the numbers: over 70% of the people worldwide with HIV/AIDS live in sub-Saharan Africa; 5.4 million people in South Africa are infected with HIV; over one third of the population of Swaziland is HIV positive. AIDS clearly has ravaged the continent of Africa.

This summer, several students from Davidson College visited Zambia and experienced first-hand the effects of the pandemic on the people of this country. Jessica Hodge, a Davidson College student who went on this trip, shares her impressions of anti-retroviral drugs and HIV-related stigma in Zambia on the associated podcast. Please visit our podcast to hear more about her experiences.

p75: A protein essential for HIV integration

The development of drugs to combat HIV depends entirely on our detailed understanding of basic biological processes, such as HIV entry, replication, and assembly. Certainly, the anti-retroviral drugs currently available – nucleoside analogs, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and a fusion inhibitor – would not exist if it were not for the basic research completed by numerous scientists at public and private institutions throughout the world. And basic research reported this week in the journal Science may eventually be the basis for another anti-retroviral drug.

Researchers in the Molecular Medicine Program at the Mayo Clinic reported this week that a human protein, named p75 or LEDGF, is essential for HIV integration. After entering a cell, the viral genome is converted from RNA to DNA by an essential viral enzyme – reverse transcriptase. This viral DNA then is transported from the cytoplasm into the nucleus of the infected cell. Another essential viral enzyme, integrase, inserts, or integrates, the viral DNA into the chromosomal DNA of the infected cell. After this integration step, new copies of the viral genome and proteins can be produced. Until recently, the integration mechanism was not well understood.

Over the past years, researchers at the Mayo Clinic and other institutions demonstrated that a human protein, p75, plays an important role in integration. P75 binds both to integrase, the viral enzyme, and chromosomal DNA. It was therefore postulated that p75 could function as a tether, physically linking integrase to the target DNA.

To extend this finding, Dr. Eric Poeschla’s group asked a very straightforward question – what happens when p75 is removed from infected cells? As is often true in science, this simple question could not be addressed simply. To remove p75 from cells, the researchers used two somewhat complicated techniques. First, they depleted p75 via an RNAi strategy. In this approach, a small piece of artificially constructed RNA is placed in the cell. This interfering RNA targets the p75 messenger RNA for destruction by a normal cellular process. When the p75 messenger RNA is destroyed, no p75 protein can be produced. Second, the researchers employed a dominant-negative protein approach. Basically, they engineered a version of p75 that, when inserted into a normal cell, would disrupt the function of any native p75. In both cases, the researchers noted that in cells in which p75 was depleted, HIV integration was severely impaired.

Almost certainly, a p75-based anti-retroviral drug will not be available any time soon. In fact, this basic research may never lead to the development of a new anti-HIV therapy. But research like this does provide us with a better understanding of how HIV infects cells. And all advances in the treatment and prevention of HIV/AIDS depend on this basic research.

Thoughts about the XVIth International AIDS Conference

Lucy Marcil, a 2006 graduate of Davidson College, joined me at the recent International AIDS Conference. The following is a transcript of a conversation we had about the conference. Please subscribe to The AIDS Pandemic podcast to hear our conversation.

(DW) With me today is Lucy Marcil, who attended last week’s International AIDS Conference in Toronto with me. Welcome, Lucy.

(LM) Thanks. I’m happy to be here.

(DW) What were your general impressions of the conference?

(LM) At first it seemed like 24,000 people was a little bit overwhelming. But it also was really invigorating because there was so much energy and enthusiasm. There are so many ways to tackle to HI /AIDS pandemic. It really inspired me to become more of an advocate and activist. What did you think about it?

(DW) I guess I felt similarly. I was most impressed by the diversity of the participants. It truly is an international meeting. You are as likely to sit down next to someone from South Africa as you are to sit down next to someone from the United States. And also the diversity of ideas that are featured there. There are researchers and clinicians covering basic science. As you said, there also are advocates and activists who are there, too. There really is a great deal of diversity at the conference.

You attended one of the HIV/AIDS engagement tours organized through the conference. Can you tell us a little about that?

(LM) Sure. I spent a morning at the Toronto Department of Public Health. While we were there, we learned all about their sexual health programs. They have a wide breadth of programs and really creative programs. For example, instead of relying just on department officials to do community outreach, they give grants to different community-based organizations who better know the needs of those specific populations. They also, instead of closing bathhouses as San Francisco did in the beginning of the AIDS epidemic, used those to reach that risk population and better intervene in the epidemic

(DW) One of the issues that came up in a few sessions was harm reduction for injection drug users – methadone treatment programs, needle exchange programs – did that come up at all in the tour you went on?

(LM) Yes. They have needle exchange program at the Toronto downtown department. They also have vans that drive around the city and can arrange to meet drug users at any location that is convenient and do needle exchanges. So it seems like they have a really flexible program and are really working to help that population.

(DW) One of the things that really hit home for me during the conference was the number of different kinds of people at risk for HIV and the number of different kinds of treatment programs and prevention programs that you need. Certainly, injection drug users are going to require a different kind of prevention program than sex workers, for instance.

(LM) Definitely. I think that is really important and something they have realized. You have to let different groups come up with their own solutions.

(DW) For you, what was the highlight of the conference?

(LM) Probably getting to hear Paul Farmer speak a couple different times, because he is pretty much my idol! But, I also had a really interesting conversation with a guy from Sudan. That was really cool because he was from such a different part of the world and I got to learn about the HIV response in their country and also more about his country and their culture.

Did you have any similar highlights?

(DW) I guess I really enjoyed hearing Bill Clinton. He gave a talk one afternoon. That was probably the most exciting session that I attended. I think generally I was just most excited by the energy and the vitality that was present throughout the conference.

(LM) I definitely would agree with that.

(DW) So, are you planning on attending again in 2008 in Mexico City?

(LM) If I’m not still in Namibia, I will.

(DW) OK. Well, I hope we can see you there. Thanks for joining us today, Lucy.

(LM) Thanks for having me.

XVIth International AIDS Conference

Friday marked the end of the XVIth International AIDS Conference in Toronto. Along with Lucy Marcil, a 2006 graduate of Davidson College, I had the pleasure of attending the conference to present our work on developing an HIV/AIDS education web site. With 30,000 some delegates, this year’s conference was the biggest meeting ever devoted to AIDS.

From an opening ceremony that featured Alicia Keyes, the Blue Man Group, and the Bare Naked Ladies, to special sessions featuring Bill and Melinda Gates and former president Bill Clinton, the star power was high. But the real stars were not these high-profile celebrities. In my opinion, the real stars included Sasha Volgina, an HIV positive injection drug user from St. Petersburg Russia, who works for FrontAIDS, an HIV/AIDS advocacy group in Russia, Kerrel McKay, a 21 year old from Jamaica who became involved with HIV outreach when she was 15 years old, and the countless advocates, activists, researchers, and clinicians from throughout the world who attended the conference.

A major focus of this year’s conference was the empowerment of women and girls. As several speakers noted, women throughout the world too often are denied adequate educational opportunities, too often lack economic independence, too often are sexually abused, and too often cannot adequately protect themselves from HIV. All of these factors must change.

Microbicides may be part of the answer. In one session, Gita Ramjee eloquently described current research into the development of anti-HIV microbicides. These gels could be applied intra-vaginally by women, thereby allowing them to protect themselves from HIV. These microbicides, then, would empower women and stop, to some degree, a reliance on prevention methods controlled by their sexual partner. More information about microbicides can be found at the Alliance for Microbicide Development web site: www.microbicide.org.

MTV: Helping Young People Learn About HIV

With the catchy pop song, Video Killed the Radio Star by the Buggles, a new era dawned: the era of MTV. 25 years ago, on August 1st 1981, just weeks aftger the first scientific report about AIDS, the music video station was born. And, one could argue, music, television, fashion, and pop culture itself have never been the same.

To many, MTV is synonymous with Beavis and Butthead, Spring Break, and Pimp My Ride – not exactly the most enlightening fare television has to offer.

But MTV should be commended for contributing much more to the lives young people in the US and the world. For many of us, our first real insight into the life of a person with AIDS came via MTV. During the third season of The Real World, set in San Francisco in 1994, the viewers of MTV became familiar with Pedro Zamora. Pedro found out that he was HIV positive in 1989, while he was in high school. After graduating from high school, he became an HIV educator. On The Real World, he explained to his roommates, and many others in the television audience, how HIV could be transmitted. We also got to see the stigma associated with AIDS and the medical hardships associated with this syndrome. Pedro Zamora died on November 11, 1994, one day after the last episode of The Real World aired.

While the 1994 season of The Real World certainly represents the most direct way in which MTV has educated its audience about HIV/AIDS, the network continues to provide important information to its viewers. Its parent company, Viacom, along with CBS and the Henry J Kaiser Family Foundation have produced numerous public service announcements about HIV and have included HIV themes in many of their shows. More information about this ambitious initiative can be found at www.knowhivaids.org. And a first episode of new documentary – think HIV, produced by MTV and the Kaiser Foundation will debut on August 18, the last day of the upcoming International AIDS Conference. More information about this show can be found at www.think.mtv.com.

Atripla - a once a day triple drug cocktail for HIV

On March 19, 1987, the Food and Drug Administration announced that AZT had been approved for use as an antiretroviral drug, the first drug approved to combat HIV. This past week, the FDA made another, perhaps equally important, announcement regarding HIV medications. On July 12, 2006, the FDA announced that Atripla, a once a day antiretroviral drug cocktail, had received approval.

Since the approval of AZT as an antiretroviral drug in 1987, the FDA has approved a number of drugs to combat HIV. Today, approximately 20 drugs are available to combat this virus. These drugs include nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and a fusion inhibitor. And since the mid-1990s, it has been clear that combinations of these drugs are more effective at decreasing the viral load in people with HIV than are drugs taken individually. Rather than taking a single drug, monotherapy, people with HIV take multiple drugs. Currently, the recommended therapy involves three different drugs, usually two nucleoside reverse transcriptase inhibitors and a protease inhibitor.

This highly active anti-retroviral therapy, or HAART, is very effective, though not without its problems. One of the major problems associated with HAART has been the difficulty people with HIV have in adhering to the drug regimen. The standard regimen often requires that people take multiple pills at different times of the day. Failure to comply with this complex regimen can result in a rise in a person’s viral load and the development of drug resistant viral mutants.

Atripla may eliminate this problem. Atripla consists of a non-nucleoside reverse transcriptase inhibitor – efavirenz, manufactured by Bristol-Myers Squibb – and two nucleoside reverse transcriptase inhibitors – tenofovir and emtricitabine, manufactured by Gilead Sciences. The recommended dosage is a single pill, taken once a day. The wholesale price is roughly $1100 for a one month supply. More information about Atripla can be found on the AIDS Meds website at www.aidsmeds.com/drugs/Atripla.htm.

The cooperation of these two pharmaceutical companies should be applauded. This new drug combination represents a major advancement in the treatment of HIV. And if Atripla becomes available in developing countries, at a nominal cost, then we can really cheer.

AIDS and Pop Culture

Unfortunately, AIDS and pop culture have been tightly linked. We have lost talented artists like Keith Haring and Frank Moore, entertaining musicians like Liberace and Freddy Mercury, and many, many more to this disease. But the artistic community also has responded in a very positive way. Many actors, artists, and musicians have helped raise money to support HIV/AIDS research, treatment, and education. The Red Hot Organization has produced 15 CDs dedicated to raising money for AIDS research. Their first CD, Red Hot + Blue raised $3 million, and still is one of my favorite CDs. This CD, featuring U2, Iggy Pop, Annie Lennox, and others covering Cole Porter classics has just been re-released as a 2 disc DVD set.

More information about the Red Hot CDs is available on their web site - www.redhot.org. And more information about HIV/AIDS and popular culture is available at www.bio.davidson.edu/projects/aidspopculture.

Support HIV/AIDS research and education and listen to some great music. Buy some of these wonderful CDs.

One person CAN make a difference

One person CAN make a difference. Despite the staggering numbers - over 40 million people currently are living with HIV/AIDS, 15,000 people a day become newly infected, in some countries nearly one third of the population is HIV positive - there is hope. Paul Farmer and Partners in Health (PIH) have shown that small groups can dramatically improve the lives of people living with HIV/AIDS in resource limited settings. By addressing the underlying causes of disease, such as basic healthcare, education, and the empowerment of women, PIH has made a difference in Haiti, Peru, Russia, and other regions of the world. Of course, all of us can't form an international healthcare organization. But all of us can do something. Every individual can contribute in some way. Every individual can make a difference.

For more information about Partners in Health, visit their website at www.pih.org.

June 5, 2006: The 25th Anniversary of AIDS

In the summer of 1981, an unknown pop singer named Madonna began playing in New York City clubs, a new cable channel devoted to music videos, MTV, went on the air, and the first reports of the disease now known as AIDS were published in the scientific literature.

25 years ago today, on June 5, 1981, Dr. Michael Gottlieb and colleagues published a short report in Morbidity and Mortality Weekly Report describing a group of patients treated for Pneumocystis pneumonia. As the editors of MMWR noted, this disease in young, previously healthy individuals was unusual. To add to the mystery, it was noted that all of the patients were homosexual and exhibited signs of a severe immunodeficiency, leading to speculation that a new, sexually transmitted pathogen could be responsible for this syndrome. Within weeks, physicians in Los Angeles, San Francisco, New York, and Miami all reported clusters of young, gay men with similar immunodeficiencies and unusual opportunistic infections. These men all had AIDS.

Today, it is estimated that 25 million people worldwide have died of AIDS, over 40 million people are infected with HIV, and 5 million people a year, or nearly 15,000 people a day, become newly infected. Despite the work of thousands of dedicated researchers, physicians, and advocates, we still do not have a cure.

In subsequent parts of this series, the students of Davidson College and I will explore the biology of HIV/AIDS, the history of this pandemic, its social, economic, and political consequences, and review the latest scientific advances. Please join us as we explore HIV/AIDS, the most horrific plague of modern times.