The AIDS Pandemic

What does HIV/AIDS cost? The answer to this question depends a lot on whom you ask.

2010-10-26T08:34:00.000-07:00

Ask the UN and you’ll get the staggering sum of $10 billion. A year . The annual per capita cost of treating infected Africans, where much of the UN money goes, is around $1,100. One of the major problems facing HIV/AIDS advocates is their inability to lower this number. An estimated $600 is spent on anti-retroviral drugs, while the remaining $500 is spent on other AIDS associated conditions. Even $10 billion wouldn’t cover treatment for the more than 20 million Africans with HIV/AIDS. A considerable portion of the proposed UN budget is directed not towards treatment but towards prevention. A major problem is that no one can seem to agree on the actual cost. Although the UN has held firm to their estimate, other groups have presented vastly different figures. The World Health Organization has presented four different scenarios which vary wildly in both the projected outcome and cost. To merely maintain the current status quo, WHO estimates more than $400 billion will need to be spent over the next 20 years. To significantly reduce annual new HIV infections, WHO’s figure is more than $700 billion. Unfortunately such different figures can sometimes complicate funding by making it hard for donors to decide how much to give.

Ask someone who is living with HIV/AIDS and you’ll get a number that’s a lot smaller. The average AIDS patient in America takes a combination of drugs that add up to around $14,000 a year . Much of this cost in the US is defrayed by private insurance, government insurance or sometimes through AIDS drug assistance programs (ADAPs) . These programs are meant to provide access to drugs for low income individuals. Currently 89% of people enrolled in ADAPs make less than 300% of the federal poverty level. However recently the economic conditions have forced many states to scale back their support of these programs. States have either closed enrollment entirely, or narrowed eligibility-forcing people to drop out. Currently the nationwide waiting list is at an all time high of 3,586 people .

Ask the companies that manufacture these lifesaving drugs and you’ll be back to huge figures. One of the newest drugs to enter the market, Fuzeon , is produced by the giant Swiss company, Roche. Roche maintains that Fuzeon’s price (nearly $20,000 a year, or three times the next most expensive drug) is due to the $600 million cost of development. The average drug begins to turn a profit in 16 years, but analysts estimate that Fuzeon’s pricing, and anticipated demand, could mean profits for Roche in as little as three years.

Ask an economist and you’ll get a couple different figures. By 1995 more than $75 billion had been spent on AIDS. Since then, spending has increased most years, with an average of $10 billion more being spent every year. But money spent directly on AIDS does not even begin to cover the true cost. In addition, economists have tried to measure the costs related to lost productivity, wages, and premature death, due to the disease. Figures vary, but some think that indirect costs account for nearly 80 percent of the total cost of AIDS. Worst case scenario guesses estimate that AIDS robs the world of 1.4% of gross domestic product, or the equivalent of wiping out the economy of Australia .

A government study in Uganda found that some companies are hiring and training two employees for a single job in the hope that one will stay healthy. The UN estimates that since 1981 AIDS has reduced Africa’s overall labor force by 25%. Sick days and absenteeism due to AIDS related illness have further reduced productivity in the countries hit hardest by AIDS.

Ultimately the cost of HIV/AIDS is extraordinarily difficult to measure. The disease affects so many people worldwide that it would be impossible to assess the impact that it has had on everyone. However it is obvious that unless something drastic changes, the costs will continue to grow until they become unbearable.

A Picture of Life with HIV in Africa

2010-10-19T12:04:00.000-07:00

Africa. The seed of the world. One of the most beautiful and most scintillating places on earth. From the deserts of the Sahara and the rainforests of the Congo to the bright and bustling metropolis of Cape Town, life is rich everywhere. Yet amidst all this beauty and splendor, a deadly scourge threatens the people of this continent. AIDS.

Sub-Saharan Africa is more heavily affected by HIV/AIDS than is any other region in the world. Somewhere around 22.4 million people in the region are currently living with HIV. This makes up a whopping two-thirds of the global number of HIV-infected individuals. Whereas in other areas of the world the disease affects only certain groups, here, HIV/AIDS affects everyone. This affliction picks apart whole extended families one by one. Schools are gradually emptied over time as students are orphaned. Healthcare and economic development have all taken a hard hit because of the impact of HIV/AIDS on the African peoples. Organizations simply don’t have the funds to support or expand prevention, treatment and care efforts and for this reason, it is likely that the death count will continue to rise. Life expectancy has been drastically reduced across the continent, falling to as low as 31 years in some of the worst afflicted areas. HIV/AIDS is present everywhere we look. It is an unavoidable aspect of everyday life.

The following dialogue includes excerpts from various interviews. I spoke with a group of college students who lived for six months in South Africa and Zambia, another student who lived 2 years in Nigeria, and a field biologist currently doing research in Cameroon. Their testimonies will enhance the picture of daily life in African countries afflicted with HIV/AIDS.

Take the country of Cameroon, for example. As of 2008, the population in Cameroon neared 19 million. Of that, about 600,000 are living with HIV/AIDS. More than half of that is made up of women 15 years and older. While prevalence here is much lower than other countries, HIV/AIDS remains a chief concern. When asked about general knowledge about the disease, most agreed that the “information is very available to middle and upper class citizens, but not necessarily to the lower class citizens and those that are at highest risk.” There is a large focus on prevention here, and the country is littered with billboards promoting abstinence, safer sex practices and condom use.

Public Service Announcement in Cameroon
“Sex can wait…my future comes first.”

South Africa is a key example of a country, of a government that has failed its people. Until very recently, the government took no part in the fight against AIDS. Thabo Mbeki, president from 1999 to 2008 refused to believe that HIV causes AIDS and that condoms can prevent infection. This leadership has fueled outlandish beliefs such as that condoms cause AIDS, or that white people are pushing condoms laced with AIDS to wipe out Africans. When asked about the role of the government in the fight against AIDS, one student said, “The president is not very influential considering he stated that he took a shower after having had sex with someone infected with AIDS, and therefore he would not contract the disease.” Here, she is referring to the current president, Jacob Zuma, who publicly stated that showering after sex with an HIV-positive woman would reduce his risk of being infected. A fellow student added, “NGOs are much more active. They have done a much better job fighting AIDS through their provision of important information and items such as condoms and antiretrovirals.”

Incumbent President of South Africa, Jacob Zuma

The picture of life here has changed drastically since AIDS exploded on the scene. While treatment and prevention are improving in some areas, the governments of more conservative countries, such as South Africa, need to step up and face this issue with full force so that HIV/AIDS is no longer a shadow looming over the lives of everyone.

Facts and figures were obtained from AVERT International HIV and AIDS charity, the Global Health Council, USAID, and Elizabeth Pisani’s The Wisdom of Whores.

I would like to recognize Albert Noah-Messomo, an African native of the Beti people in the rainforest of Cameroon. His traditional African-style music was featured during this Podcast. I would like to thank Kurt Kristensen, Sara Levintow, Nikki Pagano, and Rebecca McQuade for their contributions to this Podcast.

Compulsory HIV Testing

2010-10-14T08:59:00.000-07:00

No one can argue that HIV testing is a bad thing. Knowing one’s status allows a person to access treatment earlier, change risky behaviors, or rest assured that he/she is indeed HIV negative. With that said, why not make HIV testing mandatory for everyone? Hello, I am Katie Morris and this is The AIDS Pandemic, a podcast hosted by Dr. Dave Wessner, associate professor of biology, and his students at Davidson College.

Compulsory HIV testing—which requires that the entire population, or at least certain high-risk groups, is tested for HIV—has gotten a bad reputation in recent years from human rights activists who argue for a person’s right to choose to know whether or not they have HIV. However, studies have shown that usually, once a person knows he/she is HIV positive he/she will change his/her risky behaviors to avoid transmitting it to anyone else. Would compulsory testing not at least hinder the spread of HIV among populations? I fully support the freedom of choice, however I also support the right to live and if compulsory testing can reduce the number of people dying from AIDS it should at least be considered by policy makers around the globe.

One of the largest barriers to HIV research and prevention programs in the developing world is a lack of knowledge of the specific epidemics in each country. By requiring people to be tested for HIV, the public health community would gain valuable information on how many people are infected and what groups are most at risk, significantly aiding prevention programs. Bill Clinton, the former President of the United States and founder of the Clinton foundation, which funds a great number of HIV/AIDS programs around the world, is an advocate for mandatory testing in developing countries with high HIV prevalence rates. In a statement made to Reuters, he said, "[W]e can save people's lives, and we can reduce the stigma. There is no way we are going to reduce the spread of this epidemic without more testing because 90% of the people who are HIV-positive don't know it." Everyone who is sexually active, injecting drugs, receiving blood transfusions, or breastfeeding is at risk for contracting HIV, regardless of their age, skin color, education, financial status, or sexuality. Therefore in order to increase more individuals’ knowledge of their statuses so that they do not unknowingly spread HIV, testing needs to go beyond voluntary clinics.

In the aforementioned quote, President Clinton made a statement about reducing the stigma around HIV by implementing mandatory testing. This statement is contrary to what many human rights groups argue. Their concern is primarily with confidentiality breaches, especially in the developing world where the poor infrastructure cannot guarantee secure record keeping and adequate training for counselors. While a valid concern, so much of stigma surrounding HIV in the developing world involves testing itself. People are reluctant to be tested because they associate HIV testing with people who are promiscuous, homosexual, or drug users. By requiring everyone to be tested, the stigma associated with those walking into an HIV testing clinic is eliminated. Also, in places like sub-Saharan Africa where many countries have HIV prevalence rates above 5%, mandatory testing has the possibility to normalize being HIV positive. Of course this requires time and the decision by people to be open about their status but there is potential to show that everyone and anyone can contract HIV and that good things—like treatment, support groups, and advocacy opportunities—can result from knowing your status earlier.

Unfortunately, once you get into the implications of such a policy, things do not remain so straightforward. In the developed world, many argue that compulsory testing is simply a waste of money. That same Reuters report found that in order for population-wide mandatory testing to be cost-effective, the prevalence rate should be above 5%. In the United States where HIV prevalence is believed to be less than 0.004%, mandatory HIV testing may not be the most financially wise decision even though the U.S. is one of the few countries that can actually afford to successfully implement a compulsory HIV testing program. It should be noted that there are certain high-risk groups in specific regions of the U.S. with prevalence rates above 5% that could benefit from mandatory testing. However, requiring testing of one group and not another can be considered discrimination and stigmatize or alienate certain people.

In the developing world where, again, many countries, particularly in sub-Saharan Africa, have HIV prevalence rates above 5% and could seemingly benefit from population-wide HIV testing, new issues arise. First and foremost, these countries lack the resources to be able to test everyone. HIV tests are expensive and require sanitary facilities, laboratories, and trained professionals to draw blood. With this blood test, it can take up to three months to obtain results, creating a large loss due to follow-up. Furthermore, what happens next? HIV testing is only beneficial if it is accompanied by proper education and counseling. These are additional costs and require more trained professionals that are difficult to find in the developing world. If a person tests positive, where do they go from there? Will policies be enacted that require the person to disclose their status to their friends, family, or sexual partners? How will this be enforced? What if ART is not available or affordable to the person who tests positive? Their positive test results have just come as a death sentence, which can lead to a fatalistic attitude and discourage behavior change. If a person tests negative, there is a danger of developing a complacent attitude—since he/she does not have the virus, he/she may feel no responsibility to the HIV epidemic.

Although the benefits to compulsory HIV testing are clear, the realities of implementing a population wide mandatory testing campaign around the world make it not the best option at this point in time. In the developed world where prevalence rates are low, the cost of HIV tests outweigh the benefits of finding the few positive people. This might not always be the case in the future with treatment regimens improving and the early-detection of HIV reducing the long-term opt-out costs of ART. In the developing world, infrastructure, financial, and human resource barriers raise concerns to human rights groups and make the implementation of such a program a nightmare. Also, there remains the question of what to do from a policy standpoint for the people who do test positive. Compromises can be made to reap some of the benefits of compulsory testing without requiring all of the necessary resources. First, there are certain groups that should be required to have HIV tests—pregnant mothers to prevent transmission of HIV to their babies, health professionals to reduce the risk to patients, and sex workers in areas like the Netherlands where their profession is regulated. Second, opt-out HIV testing policies (administering an HIV test to everyone except those who specifically ask not to be tested) are a great way to encourage more HIV testing without requiring it. This is more effective in the developed world where people go for annual health check-ups but there are creative ways to bring opt-out to the developing world through mobile clinics strategically placed in markets, farms, churches, or schools. Compulsory HIV testing is a messy topic but that doesn’t mean the discussion should end there. We should continue to find ways to have as many people as possible aware of their HIV status in hopes of slowing the spread of the HIV epidemic.

Katie Morris, & David R. Wessner (2010). Compulsory HIV Testing The AIDS Pandemic

AIDS 2010 - Day 6

2010-07-24T13:16:00.000-07:00

The XVIII International AIDS Conference has come to a close. During the final day, summaries of the meeting were presented and the organizers of the next meeting were introduced.

In 2012, the XIX International AIDS Conference will be held in Washington, DC. The meeting is being held in the US for the first time sonic 1990 because the US recently lifted it's ban on the entry of HIV positive people.

I'll write more about this meeting in the next couple weeks. Right now, though, it's time to pack.

AIDS 2010 - Day 5

2010-07-23T10:12:00.000-07:00

At this meeting, the official sessions - plenary talks, poster presentations, panel discussions - are only half of the story. For the week of he International AIDS Conference, the city of Vienna has been awash with other events, all related to the conference. It's hard to make time for everything, but I've tried my best!

One day this week, I visited a counseling center for female sex workers in Vienna. The visit was one of several local engagement tours organized by the conference to give participants a closer look at programs related to HIV/AIDS in Vienna. On my tour, I visited Sophie (http://www.sophie.or.at). The director talked to us about the legality of sex work in Austria and the issues faced by sex workers in Vienna.

On another day, I visited a exhibition kf works by Keith Haring, the influential artist who died of AIDS in 1990. The exhibit, at the Kunsthalle Wien, focused on his works from 1978 to 1982. The show was great. I was especially intrigued by the detailed notebooks he kept while painting.

Finally, we attended the AIDS Gala Concert by the Royal Philharmonic Orchestra. They performed works by Mozart, Tchaikovsky, and Beethoven. Quite simply, it was amazing.

Many other events, from film series to dance performances, have been ongoing throughout the week.

AIDS 2010 - Day 3 & 4

2010-07-21T03:17:00.000-07:00

The big news at the conference on Tuesday was the announcement of an effective vaginal microbicide. Dr. Abdool Karim and colleagues from South Africa made the announcement to a very enthusiastic crowd. For the first time in the 30 year battle against AIDS, there now is some hope that women may some day be able to control their risk of infection.

In thus study, the researchers provided women in both an urban and a rural area with capsules of a gel containing 1% tenofovir. Other women received capsules containing a placebo. This antiretroviral drug is a nucleoside analog that has been well studies and shown to effectively reduce viral replication. Women were told to apply the gel intra-vaginally no more than 12 hours before having sex, and again no more than 12 hours after having sex. Participants were tested regularly.

After 30 months, women who used 1% tenofovir showed 38% reduction in HIV infections, a significant difference.

The researchers noted this was only a proof of concept study. Additional studies, examining doses, timing, and other factors need to be tested. But these first tests are exciting.

AIDS 2010 - Day 2

2010-07-19T13:13:00.000-07:00

Today was the first full day of activities at the XVIII International AIDS Conference. And what a day it was. Again, I'm amazed by the energy and excitement associated with this meeting. And at this year's conference, unlike previous AIDS conferences that I have attended, there seems to be a legitimate sense of optimism.

As we have heard from several speakers, remarkable progress has been made over the past few years. More drugs have been developed and these drugs are available to more people. Thanks to programs like PEPFAR, The Global Fund, and the Clinton Foundation, more people in developing countries are receiving antiretroviral treatment. The progress has been amazing.

But, as former president Clinton noted, this is only the end of the beginning.treatment alone is not the answer. Dr. Sharon Lewin, in a wonderful opening session talk, expertly explained why we cannot rely on treatment alone. First, studies have shown that even the best treatment regimens do not fully restore life expectancy. This, she noted, is not acceptable. Second, sh explained that treatment is not a cure. Viral reservoirs remain in the body during treatment. Virus may remain latent in resting T cells or in various tissues, such as the brain.

So what does this mean? We must continue our prevention efforts. A solution
requires increased treatment, increased testing, and increased prevention efforts.

Tomorrow - a visit to the Global Village at the conference center and a visit to a Vienna site for sex worker education.

Rights here, right now - AIDS 2010

2010-07-18T21:38:00.000-07:00

Today marked the opening of the XVIII International AIDS Conference in Vienna, Austria. What strikes me most about this biennial conference is the energy and excitement. People from all over the world gather with a single goal - the end of the AIDS pandemic. Everyone here, from scientists to politicians to educators to activists are passionate about their work and united in their desire.

After being here for only a day, a few themes seem to be emerging. First, this conference feels very much like a conference about and for Eastern Europe. As we heard from several speakers already, Eastern European and Central Asian countries are seeing the fastest growing HIV epidemic. Another theme that has emerged is the need for harm reduction policies. Finally, we have heard about the need for policy based on evidence, not ideology.

I'm looking forward to day 2.

Born HIV Free campaign to end mother-to-child-transmission

2010-07-07T13:15:00.000-07:00

“By 2015, let us end the transmission of HIV from mother to child. This is not a dream: we can do it.”

Carla Bruni-Sarkozy,
The Global Fund Ambassador

With that simple statement from Ms. Bruni-Sarkozy as its guiding principle, the Global Fund to Fight AIDS, Tuberculosis, and Malaria has launched Born HIV Free. The goal of this new initiative is straightforward – stop the mother-to-child transmission of HIV. As Ms. Bruni-Sarkozy notes, this goal is achievable. We have at our disposal the means of protecting our children from infection.

When an HIV+ woman becomes pregnant and gives birth, the virus can be transmitted to the infant during gestation, during delivery, or through subsequent breast-feeding. These types of transmission collectively are referred to as mother-to-child transmission. The terms vertical transmission and perinatal transmission also may be used.

We now know that relatively simple and relatively cheat antiviral regimens can dramatically reduce the rate of mother-to-child transmission. In a 1999 study, Dr. Mary Lou Lindegren and colleagues noted that rates of perinatal transmission dropped significantly in concert with zidovudine (AZT) treatment for the mothers. With the development of better drug regimens, these drops in transmission rates have continued. According to the CDC, an estimated 1,650 HIV-infected infants were born in the US in 1991. In 2004, that number had dropped to less than 200.

This success, however, has not been mirrored in developing countries. The causes of this disparity are several-fold. The most important factors affecting the continued problem of mother-to-child transmission of HIV in developing countries include access to treatment and access to testing. In recent years, antiretroviral drugs have become more available throughout the developing world, thanks, in large part, to the influx of money from sources such as the United States PEPFAR program and the United Nation’s Global Fund. Additionally, other groups, most notably the Clinton Foundation, have fought hard to make these drugs more affordable. But we need to do more. Too many HIV+ women still do not have access to the necessary treatments.

In addition to making drugs more available, we also must work diligently to increase the levels of testing. Treatment to prevent perinatal transmission requires that women know their HIV status.

To find out more about the Born HIV Free campaign, please visit their website at http://www.bornhivfree.org. Let’s join Ms. Bruni-Sarkozy in ending the transmission of HIV from mother to child.

National HIV Testing Day

2010-06-25T19:45:00.000-07:00

Welcome to this installment of The AIDS Pandemic. June 27, 2010 is National HIV Testing Day. For many people, this news probably is met with ambivalence. We have a day for everything, it seems. So here it is - another day with another name. We shouldn't, though, link National HIV Testing Day with the made-by-Hallmark days. This day should be different.

On National HIV Testing Day, we all should remind ourselves of the vital role testing plays in our continuing efforts to rid the world of HIV/AIDS. According to the CDC, 1.1 million Americans are infected with HIV. Approximately 1 in 5, however, do not know they are infected. This needs to change. When one knows his or her HIV status, he or she is less likely to transmit the virus. Knowing one's status can lead to earlier treatment, and earlier treatment results in better outcomes. For women, knowing one's status can help decrease the rate of mother to child transmission.

National HIV Testing Day is more than just a day marked on the calendar. This day is a reminder to all of us that testing, along with education and prevention, are necessary and interlocked components of our ongoing efforts against this pandemic.

So how can one get tested? Use this helpful testing locator, provided by aids.gov. And tell your friends.

Find HIV/AIDS
Prevention & Service
Providers

Enter your location, such as: "Washington, DC", or "20002".

For more information on this widget, please visit AIDS.gov.

Please contact contact@aids.gov with any comments or concerns.

Taking Lessons from the CCR5Δ32 Mutation for Patient Treatment

2009-11-20T10:31:00.000-08:00

I’m Lindsay Sween, and welcome to this installment of the AIDS Pandemic blog and podcast.

Human immunodeficiency virus type 1 (HIV-1) invades a CD4+ (T4) cell through the attachment of the viral protein gp120 to its primary cellular receptor, CD4, and to a transmembrane chemokine coreceptor, usually CCR5 or CXCR4. Agrawal et al. (2007) explain that the removal of 32 base pairs from the CCR5 gene results in the CCR5Δ32 mutation, which produces a shortened, nonfunctional protein that cannot act as a coreceptor due to the fact that it is no longer expressed on the cell membrane. Thus, individuals homozygous for the CCR5 mutation (also known as CCR5 -/- individuals) are extremely resistant to contracting HIV-1, while heterozygous people (aka CCR5+/- people) express fewer CCR5 proteins on the surface of their lymphocytes than wild type individuals, which slows the transition of HIV infection to AIDS. The CCR5Δ32 mutation confers HIV-1 resistance by two mechanisms: the mutated protein cannot be expressed on the lymphocyte surface, and it actively downregulates CXCR4 coreceptor production by causing the formation of heterodimers between CCR5 and CXCR4 proteins that then get trapped in the endoplasmic reticulum.

As explained by Nazari and Joshi (2008), individuals with the CCR5Δ32 mutation appear perfectly healthy in all other areas of their immune systems, which seems to indicate that the CCR5 chemokine receptor is not absolutely essential for immune function. Thus, with no selective pressure against the CCR5Δ32 mutation, Agrawal et al. (2007) report that Caucasians carry the mutation relatively frequently, with about 1% of individuals being homozygous for the mutated allele and approximately 10% of the population being heterozygous. Individuals of purely African or Asian descent, however, almost entirely lack the CCR5Δ32 mutation.

Figure 1. The CCR5Δ32 mutation results in a nonfunctional protein that cannot serve as a cell surface coreceptor for M-tropic (aka CCR5-tropic or R5) HIV viral isolates and, thus, confers some resistance to HIV-1 infection. The immune cells are still fully receptive to T-tropic (aka CXCR4-tropic or X4) viral isolates, which could bind to their coreceptor, CXCR4 (aka fusin), and transmit HIV-1 infection.
From: Samson, Michel. “Human immunodeficiency virus (HIV).” Access Science Online.
McGraw-Hill.
.

There is now a new antiretroviral drug called maraviroc, which was approved by the U.S. Food and Drug Administration U.S. Food and Drug Administration in August 2007 and mimics the natural CCR5Δ32 mutation by acting as an antagonist for the CCR5 receptor and preventing the viral envelope protein gp120 from binding to it. Lieberman-Blum et al. (2008) report the results of two Phase IIb/III clinical trials, MOTIVATE 1 and 2, in which the effects of treatment with 300 mg of maraviroc once or twice daily were compared to placebo treatment in patients who were already being treated with HAART and still had primarily R5 HIV-1 infection. Maraviroc was found to decrease viral load by a greater percentage than placebo. Of the patients receiving maraviroc once or twice daily, 43.2% and 45.5%, respectively, had virus particle counts of less than 50 copies per milliliter, as opposed to 16.7% of patients in the placebo group. After the 48 weeks of the studies, patients demonstrated average viral load reductions of -1.68 log10 copies/mL for the once daily group and -1.84 log10 copies/mL for the twice daily group compared to -0.78 log10 copies/mL for the control group.

Figure 2. Most patients given maraviroc once or twice daily had lower HIV-1 viral loads and higher CD4 cell counts at the end of 48 weeks and had a long time period until treatment failure than did patients taking placebo.
From: Gulick, R.M., Lalezari, J., Goodrich, J., Clumeck, N., DeJesus, E., Horban, A., Nadler, J.,
Clotet, B., Karlsson, A., Wohlfeiler, M., Montana, J.B., McHale, M., Sullivan, J., Ridgway, C., Felstead, S., Dunne, M.W., van der Ryst, E., Mayer, H. 2008. Maraviroc for Previously Treated Patients with R5 HIV-1 Infection. The New England Journal of Medicine 359: 1429-1441.

As would be predicted by the absence of adverse health problems in individuals lacking functional CCR5 receptors due to the CCR5Δ32 mutation, maraviroc produced few severe side effects for the immune system by blocking the CCR5 surface protein. According to Lieberman-Blum et al. (2008), 21 of 426 (4.9%) individuals taking maraviroc and 11 of 209 (5.3%) individuals taking placebo had poor health outcomes that lead them to stop taking their medication and quit the trials. Most patients (92.3%) reported at least one side effect, which included upper respiratory illness, cough, fever, and abdominal pain. The primary concern with the use of antiretroviral drugs that block the CCR5 receptor is that the HIV virus will evolve into X4 or R5X4 variants that will then evade the drug’s action. For the individuals who were not benefitted by maraviroc, 54.4% of the once-daily patients and 55.2% of the twice-daily patients demonstrated virus that had changed from the R5 strains to either X4 or R5X4 strains. When the researchers performed phylogenetic analyses of the viral envelope proteins in these strains, however, they found that the new X4 or R5X4 strains had developed from preexisting viral particles of these strains that had been missed in the screening process before the beginning of the drug trials and had not resulted from R5 mutation during the course of drug treatment. Thus, these clinical trials suggest that maraviroc could be a good possibility for “salvage therapy” for those HIV+ individuals who have experienced treatment failures in the current categories of HIV/AIDS medications. More studies are still needed, however, to determine the long-term effects of antagonizing the CCR5 receptor.

The CCR5Δ32 genetic mutation and the recent research investigating it and its therapeutic implications are very relevant topics given the fact that the HIV/AIDS pandemic is one of the greatest public health concerns in the world, especially in developing nations. As cited in Lieberman-Blum et al. (2008), the Joint United Nations Programme on HIV/AIDS and the World Heath Organization report that as of 2007 33.2 million people worldwide were HIV+, and 2.5 million of those cases were new infections. In addition, the virus’s high mutation rate makes viral resistance to current antiretroviral medications a growing problem for disease treatment. The research into the CCR5Δ32 mutation aided scientists in developing the new class of antiretroviral drugs known as CCR5 antagonists. Furthermore, most new infections of HIV-1 are caused by R5 (also known as CCR5-tropic or macrophage-tropic) viral isolates. Thus, gene therapy involving the complete downregulation of CCR5 by the CCR5Δ32 mutation inserted into cells via viral vectors could one day prevent transmission of HIV by removing the coreceptor in the semen-receiving individual. Through the CCR5Δ32 mutation, evolution and natural selection may have unwittingly supplied we humans with a very powerful weapon in the fight against the HIV/AIDS pandemic.

For more information, please see:

Agrawal, L., Jin, Q., Altenburg, J., Meyer, L., Tubiana, R., Theodorou, I., Alkhatib, G. 2007. CCR5Δ32 Protein Expression and Stability Are Critical for Resistance to Human Immunodeficiency Virus Type 1 In Vivo. Journal of Virology 81: 8041-8049.

Lieberman-Blum, S.S., Fung, H.B., Bandres, J.C. 2008. Maraviroc: A CCR5-Receptor Antagonist for the Treatment of HIV-1 Infection. Clinical Therapeutics 30: 1228-1250.

Nazari, R., Joshi, S. 2008. CCR5 as Target for HIV-1 Gene Therapy. Current Gene Therapy 8: 264-272.

The Search for an HIV vaccine

2009-11-11T13:20:00.000-08:00

I'm Paige Bates and this is The AIDS Pandemic

The RV144 study was a phase III HIV vaccine trial conducted by the US Army and Thai government over seven years on 16,402 volunteers—all HIV negative men and women between the ages of 18 and 30 in parts of Thailand. For ethical reasons, all participants were taught HIV prevention behaviors, given condoms, and promised lifelong antiretroviral treatment if they contracted HIV. Half of the volunteers were given a prime-boost vaccine regimen and half received placebo vaccinations. The prime-boost approach utilizes Sanofi Pasteur’s ALVAC-HIV vaccine as a prime and AIDSVAX (originally made by Genentech) as a boost. ALVAC-HIV is comprised of a canarypox virus with three HIV genes grafted onto it. AIDSVAX contains a recombinant gp120 protein found on the surface of HIV. These vaccinations were combined because one was designed to create antibodies and the other to alert white blood cells. These vaccinations were focused on the two strains of HIV commonly found in Thailand, but it is unclear whether this regimen would have any benefit elsewhere in the world. The participants were regularly tested for HIV for three years following the completion of the vaccine regimen. In September, the companies and agencies which implemented and funded the trial announced in a press release and interviews that new HIV infections were observed in 74 of the 8,198 people who received the placebo, but in only 51 of the 8,187 given the vaccine. They claimed that this was a statistically significant 31.2% reduction in infection. However, the vaccine did not reduce levels of HIV activity in those who became infected and did not appear to produce any neutralizing antibodies.

Source: Wall Street Journal, September 25, 2009

In the 1980s, top officials embarrassed themselves by predicting an HIV vaccine in five years. Reminiscent of these overly optimistic declarations, the backers of the RV144 trial claimed that “we now have evidence that a safe and effective HIV vaccine is possible.” In the first wave of press subsequent to the initial press release and interviews, many reputable news sources, such as the San Francisco Chronicle, New York Times, NPR radio and BBC news, suggested that these results were highly encouraging, and some even went so far as to suggest that this regimen might be the forerunner or basis for a usable vaccine in the near future. The LA Times suggested that these findings would “energize and redirect” the HIV vaccine field. Many articles quoted Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Disease which largely funded the $100 million dollar study, as saying “I don’t want to use a word like breakthrough, but I don’t think that there’s any doubt that this is a very important result.” The Wall Street Journal suggested that this finding could be the second “big game changer in AIDS research since the mid 1990’s” with the advent of drug cocktails. Many articles later qualified with the cautionary statement that much more research is necessary before the vaccine could be available to the public. Phrases urging the public to be “cautious” but “hopeful” and describing the results as “modest” yet “encouraging” rang throughout the media and press releases.

However, only days later, the LA Times wrote “By Thursday afternoon, the initial wave of euphoria had given way to the recognition that many vexing questions will have to be answered before researchers can produce a vaccine that will reliably shield people from HIV.” Experts predicted that it would require two to three years of research to unravel how and why the vaccine regimen worked, and then an additional five to ten years to produce a vaccine that was ready to test in people. The fact that this still overly optimistic statement was a step back from the “initial euphoria” shows the extent of the preliminary sensationalism. The media reported that the researchers would now compare the blood of those who were vaccinated and resisted infection, and those who did not in order to determine whether the regimen stimulated antibodies or other protective molecules against HIV infection. In an article entitled “If AIDS went the way of smallpox,” a New York Times reporter recognized many problems with the initial reports including that many headlines in the first 24 hours after the press release read “One Third Protected,” while in reality the margin of success was “razor thin.” In addition, even the experts overseeing the trial could not explain why blending two failed vaccines suddenly resulted in “working” vaccine. Finally, this article recognized the financial difficulties surrounding a regimen that requires six shots over the span of months resulting in minimal protection. While this might be practical in rich countries, AIDS generally burdens the poorest nations in this world. Only one article mentioned that some researchers were suggesting that the apparent reduction in infections might be a statistical fluke due to the small number of HIV infections observed. Throughout all articles, there were minimal reminders to keep vigilance about prevention, testing, and the necessity to utilize current retroviral care.

Source: Wall Street Journal, October 12, 2009

In 2004, there was so much skepticism about this trial that 22 top AIDS researchers published an editorial in Science magazine suggesting it was a waste of money. Five years later, the organizations which conducted the trial announced in a press release that there has been significant protection, before making the scientific data available to peer review. When the full details of the study were released on October 20th at a meeting in Paris, the statistic frailty of the study was revealed. The vaccine was not shown to protect people at the highest risk of HIV infection. As The Washington Post noted on October 21st, when the results are analyzed using alternate methods, the protection is no longer statistically significant. For example, when only the people who received all six injections are counted, the trend towards protection is no longer significant. This raises many questions. What are the societal implications of the press surrounding this vaccine? If this vaccine doesn’t have much, if any, effect, what is the societal consequence of the data being overstated? The possibility of a public backlash against vaccination efforts wouldn’t be too hard to imagine. In fact, Gregg Gonsalves, an AIDS activist, remarked that, “When this was rolled out a couple of weeks ago, it was terribly hyped by the investigators. Some people think that you have to dangle the slimmest morsels of hope in front of the general public in order to keep them interested in an AIDS vaccine. But I think that damages the credibility of the effort.” The extent to which these results might represent a breakthrough can only be determined after the mechanism behind the possible conferred immunity is discovered. As Gonsalves points out, the over-exaggeration of the success in the media will likely hurt the results of the study if they prove to be less remarkable than originally stated. Furthermore, this study raises a general question about scientific results: is it appropriate to have news press releases before data is available for full review by scientific peers?

While this trial may not have been the scientific breakthrough that it was praised as, at the very least, this tremendous study is an example of international and interagency collaboration in conducting a large-scale vaccine trial, including the Thai and US governments, private companies such as Sanofi Pasteur, and non-profit organizations such as Global Solutions for Infectious Diseases (GSID). In this regard, it provides incredible hope for HIV vaccine efforts in the future.

For more information, please see these articles.
US Military Research Program in Thailand

BBC news coverage of RV144

The Wall Street Journal: Data Call ito Question HIV Study Results

Intersecting Epidemics: HIV/AIDS and Tuberculosis

2009-10-17T12:46:00.000-07:00

Hi, I’m Justin Eusebio.

While tuberculosis is one of the world’s oldest surviving plagues and HIV-1 infection is one of medicine’s newest challenges, there is an undeniable relationship between HIV/AIDS and tuberculosis. Independently, Mycobacteria tuberculosis and HIV are formidable pathogens but in concert, the prospects for controlling either epidemic are jeopardized. TB-HIV coinfection and interaction complicate all aspects of each disease: pathogenesis, epidemiology, clinical presentation, diagnosis, treatment, prevention, and even social and economic issues.

Not only are individuals more likely to undergo tuberculosis infection if living with HIV, depending on their geographic location, people living with HIV infection are 6-50 times more likely to develop active TB than people living without HIV. Thus, with one-third of the world’s population at least latently infected with Mycobacteria tuberculosis, the current pace of new HIV-1 infections threatens public health on a wide scale.

Tuberculosis infection is believed to have the greatest potential among other common opportunistic infections to increase viral load and to accelerate HIV-1 disease progression. This is in part due to the chronic nature of active TB disease, the marked increase in tumor necrosis factor-alpha (TNF-α) expression for macrophage activation, and intensified antigen presentation causing the recruitment of CD4 T lymphocytes to the site of TB infection.

Manoff and others demonstrated that active tuberculosis is associated with increased viral load in HIV-1 infected patients. Also, TB-HIV coinfected persons have a significantly higher HIV RNA load than persons without opportunistic infections and similar CD4 cell counts.

Figure 1. Schematic hypothetical individual’s of risk of TB infection compared to CD4 cell count.
From: Havlir, Diane V., Haileyesus Getahun, and Ian Sanne. “Opportunities and Challenges for HIV Care in Overlapping HIV and TB Epidemics.” Journal of the American Medical Association 300.4 (2008): 423-430.

Researchers from Case Western Reserve University demonstrated that not only do TB-HIV co-infected patients have significantly higher viral loads than those without TB, the timing of infection by M. tuberculosis affects HIV-1 disease progression. In fact, these researchers showed that TB had its strongest impact on HIV-1 viral load when patients are least immunodeficient. Furthermore, from the same study, more than 25% of TB-HIV coinfected patients developed TB when their CD4 cell counts were at least 500 cells/µl. Thus TB infection is unique because it can occur at any CD4 cell count level.
Perhaps the most problematic tuberculosis-induced effect contributing to HIV-1 disease progression is its apparent impact on HIV-1 evolution. While reverse transcriptase, a polymerase without proofreading capabilities, provides an effective mechanism for genetic diversity, M. tuberculosis infection increases HIV-1 heterogeneity through compartmentalization.

In a cohort of patients matched by their CD4 cell counts, dually infected TB-HIV patients were found to have greater systemic, or more general, HIV-1 heterogeneity and more frequent occurrences of distinct HIV-1 quasispecies than HIV-1 patients without TB infection. A population of diverse quasispecies increases the viral capacity to evolve and adapt to the host immunological response. Furthermore, upon examination of the lung sites of M. tuberculosis infection of TB-HIV coinfected patients, Collins and others found greater genetic HIV-1 heterogeneity and distinct quasispecies in the pleural space compared to blood samples. While phylogenetically distinct HIV-1 subpopulations have been shown to develop in other organs or tracts in humans (i.e. kidneys, brain, urogenital tract and blood), compartmentalization of HIV-1 occurs most significantly and is more defined in the lungs of co-infected TB-HIV patients. Therefore, the lungs, induced by active tuberculosis disease, function as a reservoir for genetically diverse HIV-1.

In addition to accelerating the disease progression of one another, their collision has highlighted underlying public health and human rights failures. Africa, although only home to 10% of the world’s population, is the major site of intersection between the two epidemics with an astounding 75% of the world’s TB-HIV coinfections.

Figure 2. The disproportionate incidence of HIV and HIV-TB coinfection in Africa in 2000. Each person indicates 5% of the global population. The African population is shaded red while blue represents the rest of the world.
From: Corbett, Elizabeth L, Barbara Marston, Gavin J. Churchyard, and Keven M. De Cock. “Tuberculosis in Sub-Saharan Africa: Opportunities, Challenges, and Change in the Era of Antiretroviral Treatment.” Lancet 367 (2006): 926-937.

Thus, novel TB diagnostic tests are needed in HIV-endemic regions because HIV infection reduces the sensitivity of current diagnostic methods such as direct smear sputum microscopy. In terms of treatment, high pill burden and toxicity often discourage adherence among many coinfected patients. Furthermore, rifampicin, a common antibiotic component of tuberculosis chemotherapy disrupts antiretroviral treatment by accelerating the metabolism of both protease inhibitors and nonnucleoside reverse transcriptase inhibitors (NNRTs). Finally, if antiretroviral treatment of coinfected patients is started too soon after treatment for TB, a rapid recovery of CD4 T cell levels may induce an overwhelming inflammatory response against previously hidden opportunistic infections resulting immune reconstitution inflammatory syndrome (IRIS).

The connection between the biology of the two diseases is clear and complications are numerous. Thus, experts in HIV and experts in TB should respond accordingly and move towards greater collaboration and shared research.

Until next, this is Justin Eusebio.

For more information:

Bartlett, John G. “Tuberculosis and HIV Infection: Partners in Human Tragedy.” Journal of Infectious Diseases 196 (2007): S124-5.

Collins, Kalonji R., Miguel E. Quioñones-Mateu, Mianda Wu, Henry Luzze, John L. Johnson, Christina Hirsch, Zahra Toossi, and Eric J. Arts. “Human Immunodeficiency Virus Type 1 (HIV-1) Quasispecies at the Sites of Mycobacterium tuberculosis Infection Contribute to Systemic HIV-1 Heterogeneity.” Journal of Virology 76.4 (2002): 1697-1706.

Collins, Kalonji R., Miguel E. Quioñones-Mateu, Zhara Toossi, and Eric J. Arts. “Impact of Tuberculosis on HIV-1 Replication, Diversity and Disease Progression.” AIDS Review 4 (2002): 165-176.

Kalonji Collins et. al, “Greater diversity of HIV-1 quasispecies in HIV-infected individuals with active tuberculosis.” Journal of Acquired Immune Deficiency Syndrome 24, 408-417.

Friedland, Gerald, Gavin J. Churchyard, and Edward Nardell. “Tuberculosis and HIV Coinfection: Current State of Knowledge and Research Priorities.” Journal of Infectious Diseases 196 (2007): S1-3.

Manoff, SB, H Farzadegan, A Muñoz, JA Astemborski, D Vlahov, RT Rizzo, L Solomon, and NM Graham. “The Effect of Latent Mycobacterium tuberculosis infection on Human Immunodeficiency Virus (HIV) Disease Progression and HIV RNA Load Among Injecting Drug Users.” The Journal of Infectious Diseases 174.2 (1996): 299-308.

Nunn, Paul, Alasdair Reid, Kevin De Cock. “Tuberculosis and HIV Infection: The Global Setting.” The Journal of Infectious Diseases 196 (2007): S5-14.

Vignuzzi, Marco, Jeffrey K. Stone, Jamie J. Arnold, Craig E. Cameron, and Raul Andino. “Quasispecies Diversity Determines Pathogenesis through Cooperative Interactions within a Viral Population.” Nature 439.7074 (2006): 344-348.

Preventing Mother to Child Transmission of HIV in Mwandi, Zambia- A Success

2009-10-02T10:57:00.000-07:00

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

This past summer, I traveled to Mwandi, Zambia through a Davidson biology and pre-medical program. Mwandi is a predominantly Lozi village of about 7,000 people and the catchment area totals about 25,000 people. We spent 5 weeks in Africa, 3 of which were spent working in the Mwandi Mission Hospital, the Mwandi AIDS clinic, the Orphans and Vulnerable Children’s center, and the Mother and Child Health Center. We all went with a research topic to study that was based on some aspect of Mwandian life. I looked at Mwandi’s Prevention of Mother to Child Transmission of HIV, otherwise known as the PMTCT program, and its effectiveness over the past three years. Here, I will talk about my findings.

About out of every five pregnant women in Zambia is infected with HIV and without any prevention or treatment interventions, more than 300,000 babies would contract HIV from their mothers each year. Starting in 1999, many Zambian mission and government hospitals started PMTCT programs. The Mwandi PMTCT program was launched in 2005 by an American Pediatrician in conjunction with the Mwandi missionary who was going to serve as the leader of the program. The procedure for PMTCT at the Mwandi Mission Hospital is as follows: 1) discuss the PMTCT program and HIV/AIDS information during group antenatal care visits, 2) offer private pre-test counseling, 3) test the mother for HIV and CD4 counts and give her the results, and 4) offer post-test counseling and discuss further treatment and a re-test in three months. According to the hospital staff in Mwandi, HIV testing of any pregnant mother is required by law in Zambia.

If a woman tests positive, she is evaluated at the Pastoral Care Center for AIDS treatment. If she is considered a WHO stage IV or has multiple symptoms for WHO stage III, HAART treatment is usually started unless the woman chooses to undergo short-course treatment instead. Many of the HIV positive mothers choose to undergo HAART treatment because of its documented increased ability to treat HIV/AIDS symptoms and to lower the viral load by decreasing viral replication. The Mwandi hospital staff is good about giving options to the positive mothers and explaining each option and its risks and benefits. Due to the staff’s willingness to counsel and inform the HIV positive pregnant mothers of treatment options, a majority of these women decide to take part in a course of HIV/AIDS treatment in order to help themselves and to prevent the transmission of HIV to their babies.

Although record-keeping is sparse and sometimes hard to find and evaluate, some records for the PMTCT program proved helpful in evaluating the program’s success over the years. From March of 2005 to September of 2007 (before HIV testing was mandatory), 1,205 women attended an antenatal care appointment to sign up for the PMTCT program and of these 1,205 women, only 35 women or about 3% refused the HIV test. Of the 1,170 women who agreed to be tested, 24.4% tested positive for HIV. This statistic is quite high, but reflects the belief that about 1/3 to ¼ of Mwandi’s population is infected with HIV. Because the PMTCT program was in place, the HIV positive women were able to learn their status, get treatment, and prevent (for the most part) the transmission of HIV to their babies during pregnancy, delivery, and breastfeeding.

Mwandi’s PMTCT program has changed drug regimens in order to stay current with the most effective treatments. Originally, the program was based on a single dose of nevirapine given to the mother during delivery and to the baby right after birth. In April of 2006, the PMTCT program switched to a dual therapy involving both nevirapine and AZT for both mothers and babies. Starting in November of 2007, Mwandi updated its treatment regimen to the most current and effective triple therapy drug treatment. This drug therapy involves a mixture of AZT, 3TC, and NVP for the mother and baby. This new therapy has proven to be very effective and the PMTCT program workers approximate that transmission from mother-to-child rates have decreased to less than 10% and possibly even as low as 6% or 7%.

Possibly the most enticing aspect of the PMTCT program for pregnant women is the free formula feeding program provided to HIV-negative babies of HIV-positive mothers. Breastfeeding is the most common type of mother-to-child HIV transmission, so by providing free formula for those babies who test negative (after 6 weeks of age), the worry of transmission by breastfeeding can be alleviated. Currently there are over 100 babies receiving infant formula and most, but not all, are HIV-negative babies of HIV-positive mothers who participated in the PMTCT program. The program has never resulted in a case of child dysentery, a common negative outcome of formula feeding programs, which is often a result of incorrectly boiled water used to make the formula. This clean record is a result of the care and attention put forth into teaching the mothers how to correctly make the formula and clean the bottles.

Compared to many other Sub-Saharan African PMTCT programs, Mwandi’s program is doing a very good job of keeping the program advancing, as far as the number of women being treated and the updates to newer forms of drug therapies. The program could however still make larger strides in incorporating more women from far out in the catchment area and by possibly providing more rural village outreaches for the sole purpose of PMTCT.

The Case for Thai MSM and MSW

2009-03-27T10:21:00.000-07:00

The prevalence of HIV/AIDS in certain high risk groups is on the rise today as government funding for prevention campaigns nears an all-time low in Thailand, a country once touted the ‘poster-child’ for HIV/AIDS prevention efforts. Hello, I am Devynn Birx-Raybuck and this is The AIDS Pandemic, a podcast hosted by Dr. Dave Wessner, associate professor of biology, and his students at Davidson College.

Though Thailand’s initial response to the AIDS epidemic was weak in its early years, in 1991, the new Prime Minister made HIV prevention and treatment a national priority. However, the country’s grip on the disease seems to be slipping recently, as evidenced by decreased funding in important sectors, increases in infection rates among MSM (men who have sex with men) and injection drug users, inconsistent condom use by sex workers, and increasing risky sexual behavior, especially by young people.

Thailand is notorious for its sex industry. Brothels, go-go bars, massage parlors, and other venues cater to native Thais as well as Western tourists, who travel to the country on “sex tours.” Unfortunately, commercial sex is not only omnipresent; it is often backed and funded by corrupt government officials. Thankfully, with initiatives such as the 100% Condom Program and Mechai Viravaidya’s (a.k.a. Mr. Condom) tireless public outreach, HIV prevalence among female brothel-based sex workers decreased significantly after the early 1990’s, when as many as four out of five of prostitutes were infected. The 100% Condom Program began in 1991, along with a substantial public education campaign. The goal of the Program was to encourage and enforce constant condom use by female sex workers in commercial sex establishments. However, male sex workers have been neglected during such efforts to protect their female counterparts and clients.

A famous street in Pattaya where many commercial sex extablishments are located (left). Kathoeys (tansgender males) outside a go-go bar (right).

By the turn of the century, these enormous gaps in focus and funding were revealed. In a comprehensive review of the situation written in 2000, authors McCamish, Storer, and Carl, made a case for the inclusion of MSM in the country’s prevention efforts. Indeed, male sex workers (MSW) and MSM are at high risk for HIV infection, according to several studies which identified infection rates as high as 30% in these groups. Education and prevention programs aimed at MSW have been infrequent, limited to tourist areas, and generally unsuccessful in the past. The authors advocated for bar-based interventions and peer-support groups, which they believed would impact both the freelance and employed MSW.

Finally, in February 2006, “Sex Alert,” a safe-sex information campaign directed at MSM, was founded, with the hope of reaching this community that has been largely neglected by other efforts. According to the regional director, Dr. Somchai, the organization uses several media to advertise and educate, including the Internet and text messages. They also provide counseling, free condoms, and information regarding other health issues. This new outreach effort, along with others, will hopefully curb the rising rates of infection among MSM. However, programs such as these cannot act in isolation. They require the support of the Thai government, people, and most importantly, those affected most by the epidemic. Perhaps, despite recent concerns over rising HIV/AIDS infection rates and risky sexual behaviors, Thailand will prevail once again in the fight against the AIDS pandemic.

Free clininc in Bangkok that a sex worker might visit for counseling or treatment. This particular building is a collaborative center run by the Thai Red Cross and Armed Forces Research Institute of Medical Sciences.

On behalf of Dr. Wessner and his students, I thank you for listening.

For more information, please visit:
AVERT.org
USAID
Thailand’s rising AIDS threat
UNAIDS Evaluation of 100% Condom Programme
Mr. Condom
Brothel-based sex workers

The Dissidents' Views of HIV Tests

2009-03-04T13:16:00.000-08:00

Momentum for the alternate HIV/AIDS explanation started in 1987 when Dr. Peter Duesberg, a professor of Molecular and Cell Biology at the University of California at Berkeley and initial demonstrator that the influenza virus has a segmented genome, published a paper claiming that HIV cannot be the cause of AIDS. Four years later, a number of scientists formed “The Group for the Scientific Reappraisal of the HIV/AIDS Hypothesis” which later established itself as an official non-profit organization. Within another four years, 32 scientists with advanced medical degrees published a statement in Science asking for the reconsideration of the current HIV/AIDS theory. Since this publishing, over 2,100 people have signed this statement. Should institutions acknowledge any concerns from this small, not-too-silent minority or are their claims completely unsubstantiated? I’m Colby Uptegraft from Dr. Dave Wessner’s Biology of HIV/AIDS class at Davidson College, and while AIDS dissidents have many claims, I will present their arguments regarding HIV testing.

HIV critics rest a substantial amount of their theory on the problems with HIV tests. Currently, there are three main types of tests—antibody tests, antigen tests, and PCR tests. Dissidents primarily scrutinize the antibody tests.

HIV antibody tests begin with an enzyme-linked immunosorbent assay (ELISA). A second test confirms a positive ELISA. These secondary tests include Western blot assays, indirect immunoflorescence assays, line immunoassays, or a second ELISA. When used in combination, these tests are 99.9% accurate in detecting HIV antibodies.

According to Rebecca Culshaw, author of Science Sold Out: Does HIV Really Cause AIDS?, the flaws in antibody tests originate in the proteins initially used to define reactivity on ELISA and Western blots. Before HIV had been isolated, scientists stimulated cell cultures from AIDS patients with mitogens to produce more proteins. Researchers found 30 of these proteins to have densities characteristic of retroviruses and selected the 10 that most commonly reacted in blood from AIDS and pre-AIDS patients to be from HIV alone. Do you see the circular logic? Researchers assumed HIV caused AIDS and automatically attributed the 10 most common reactive proteins to HIV. Positive test results may have a high correlation to developing AIDS, but according to Culshaw, they do not mean HIV is the cause. HIV supporters ascribe her claims to outdated data.

Robert Geraldo, a medical doctor working at the Cornell University hospital, added suspicion to these tests when he discovered that everyone reacts positive on the ELISA test for HIV. Lab technicians typically use a 1:400 dilution of HIV-suspected serum samples for these tests. Many antibody tests for other viruses such as hepatitis A and B, rubella, and syphilis use undiluted samples, and the ones that use dilutions such as the Epstein-Barr virus, use dilutions an order of magnitude less. When Geraldo tested 100 undiluted samples, including his own blood, they all produced positive ELISA results. When diluted 1:400, all specimens produced negative results. He claims his results indicate that we all have antibodies to HIV or at least ones that will cross-react with ELISA tests. AIDSTruth.org presents the counter argument. One cannot compare antibody tests for other viruses to the HIV test. All antibodies are unique and require different dilutions to eliminate false-positives resulting from non-specific binding.

The second HIV test detects antigens, substances that trigger generation of antibodies in organisms. The most common HIV antigen that provokes an immune response is the protein p24. According to Culshaw again, the dissidents assert that many AIDS patients do not have detectable levels of p24 and that many people without HIV infection produce positive p24 results. However, the HIV hypothesis acknowledges the disappearance of p24 in the bloodstream as AIDS progresses, and states lab technicians can use the p24 antigen test in conjunction with other antigen or antibody tests to increase its accuracy.

The third and final family of HIV tests uses PCR to amplify minute levels of RNA or DNA to quantities sufficient for detection. However, Kary Mullis, the inventor of PCR technology, proclaims, “Quantitative PCR is an oxymoron” and believes PCR is not applicable to HIV detection. PCR is too efficient in that it will amplify any DNA in a sample, whether it represents contamination or belongs to HIV. Therefore, scientists cannot use PCR to ascertain HIV infection status or viral load, the number of DNA or RNA copies per milliliter of blood. Even with these dissenting claims, the FDA approved these tests for monitoring the health of people with HIV and high statistical correlations exists between these tests and the onset and severity of AIDS.

While believing in Bigfoot or that the Holocaust never happened provides entertainment to some, the conspiracies cannot sustain actual scientific inquiry. The theory that HIV does not cause AIDS is not any different. AIDS dissidents cling to small individual details and pull them out of context with the vast majority of HIV evidence and research. In the case of HIV tests, critics ignore the use of multiple tests to predict HIV status and the combined accuracy of these tests in predicting the onset of AIDS and the causative nature of HIV. They instead focus upon the individual use of each test and make the illogical assertion that the unknowns in each are additive and cannot be used to support each other.

If you believe the United States never landed on the moon, then consider the arguments of the AIDS dissidents. If you like reality, then stick with the traditional explanation.

HIV/AIDS Orphans in Sub-Saharan Africa

2009-02-19T08:11:00.000-08:00

More than twenty-five million people have died from AIDS since it was first recognized in 1981, making it one of the most destructive epidemics in history. It is undeniable however, that sub-Saharan Africa is the hardest hit and most affected area in the world. Of the global 2.9 million AIDS related deaths in 2007, 72% occurred in this area. AIDS has devastated the social and economic framework of societies in sub-Saharan Africa by mostly infecting people in the age group of 15-49, while 63% of the 40 million people living with HIV/AIDS today live in Sub-Saharan Africa. What is also startling is that, of the 2.9 million people who died from AIDS in 2007 one in seven was children. HIV/AIDS also has many indirect effects. Children of HIV positive parents compose the largest group of secondary sufferers. Africa is home to 95% of the world’s 13 million children orphaned as a result of AIDS. It is estimated that by 2010 a third of African children will be orphaned.

Caring for these orphans has become a severe humanitarian disaster. With the rapidly increasing numbers it is difficult to care and provide for all of these children. However, the potential for these children to form a large group of dysfunctional adults, which could further destabilize societies already weakened by AIDS, has increased the urgency of finding an effective solution to the crisis. The response to the problem has been unsustainable given the number of children that need aide. In Zimbabwe, fewer than 4,000 orphans out of an estimated 800,000 are accommodated in the country’s 45 registered institutions.

As an entire generation is being devastated by HIV/AIDS, major secondary effects are occurring on the children watching it all unfold. These impacts arise in a number of overlapping ways, including, economic consequences, changes in position of caregiver, education, nutrition, long term psychological effects, and even the likelihood of infection. What overarches all of these is how children psychologically process and respond to the stresses HIV/AIDS adds to their lives. It is important to focus on the psychological impact on a child who is forced to drop out of school, who must care for themselves and younger siblings, and face losing a parent or family member. These psychological effects are what lead children to destructive or with drawn behaviors that could make them more likely to become infected. If an attempt is made to better understand what these children are experiencing, it may be possible to reach them on a level that would help encourage them to protect themselves from the dangers of HIV/AIDS.

A child’s age effects not only how they respond to and understand AIDS as a disease but in what ways they are most affected. Pre-school aged children show the primary effects on growth and health in relation to losing a caregiver. School-aged children show more effects related to loss of education and therefore the development of a vulnerability to internalization and anti-social behaviors. It appears in several studies that children over the age of ten years are most vulnerable to becoming orphaned, but are a group neither specifically targeted by many current programs nor institutions that house affected children. In these cases family, community, or school based intervention is essential.

The loss of a parent or loved one generally speaking is associated with psychological conditions including anxiety, rumination, depression, social isolation, survivor’s guilt and low self esteem. Mel Freeman, former director of Mental Health and Substance abuse in the South African Department of Health, states that children after losing a parent will have difficulties with modeling, boundary setting and development of value systems necessary for moral development; as well as the support, caring and discipline needed for emotional stability. If children have problems figuring out how to set boundaries and develop moral standards then it is likely they will also be at a higher risk for HIV infection. This secondary impact of HIV/AIDS is a catastrophic one because it will cause a whole new generation to be at an even higher risk and only further the HIV/AIDS epidemic. Orphaned children have an increased incidence of internalized psychological problems, and 34% of AIDS related orphans have contemplated suicide within the year after their parent or parents’ death.

In response to preventing the majority of psychological disorders and their related effects, the main goal is to postpone the death of a parent. When extending the life of the parents, you increase his or her chance to complete school and possess the proper mechanism to establish a sound value system. Nearly one half of children who lose a parent to HIV/AIDS drop out of school. This is a secondary impact that can be reduced by attempting to supply more infected people with ARV treatment that is both successful and easily attainable. It will both extend their life span and improve the quality of life for their children.

US Travel Ban on HIV-infected Individuals

2009-02-10T08:40:00.000-08:00

Welcome to this installment of The AIDS pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Middleton Chang.

Since 1987, the United States Department of Health and Human Services has imposed a travel ban on HIV-infected individuals, under the premise that HIV falls into their list of “dangerous and contagious” diseases which present a public health risk. The law specifically prohibited foreigners from immigrating or obtaining a travel visa to the United States. Activists had long decried the ban for several reasons, until this past summer. On July 30, 2008, President Bush signed into law a five-year, $48 billion bill to fight AIDS, malaria and tuberculosis around the world as well as lift the ban on HIV positive travelers. Yet the ban has still not actually been lifted. HIV/AIDS activists, at first praising the current administration are becoming impatient for an actual removal of the ban.

HIV/AIDS activists originally declared the ban to be unnecessary and unfair. The ban was not codified into law however until 1993 during the Clinton Administration, much to the chagrin of activists. This legislation made HIV the only specific medical condition mentioned as grounds for inadmissibility to the United States. Activists argue that the ban was just another in a long string on US inconsistencies on HIV/AIDS policy. Helene Gayle, president of CARE, stated that the ban was not consistent with the international leadership role the United States has taken with PEPFAR (President’s Emergency Plan for AIDS relief). Experts at the International AIDS conference this past fall were full of praise for the new legislation lifting the travel ban. However, little has been done to actually lift the ban. In order to do so, the Department of Health and Human Services must write a new rule, submit it for public comment, and finalize it. The Bush Administration has moved with the speed of a rolling stone gathering moss on this issue. Last week 58 house Democrats submitted a letter to President Bush urging “swift action” on the issue.
Due to the ban, no major AIDS conference has been held on US soil since 1993 as no activists or researchers infected with the virus may enter the country without embarking on a complicated waiver process. In 1991, 40,000 Haitian political refugees fled to the United States. Of these refugees, 158 were detained in Guantanamo Bay, Cuba due to the ban. For nearly twenty months, Guantanamo Bay hosted these 158 political refugees, due to either being HIV-positive, or a relative of one of the positive refugees. A court order was needed to force the Clinton Administration to close down the razor-wire encircled refugee camp setup in 1991 by the Bush Administration.

Despite the fact President Bush has signed the bill mandating removal of the ban into law, HIV remains on the list of “dangerous and contagious” diseases that may prevent entry into the United States. Recently, the Department of Homeland Security released a revised and “streamlined” process for obtaining a waiver, making it easier to obtain the necessary paperwork. However, the Department of Heath and Human Services has still not removed HIV from the list of medical conditions which are grounds for exclusion from entering the United States.

A study conducted in 2006 showed that of 1113 HIV positive survey respondents. 349 (31%) had traveled to the United States. Of those 349 that had traveled to the US, only 14.3% traveled with the mandatory waiver to obtain a travel visa. Many simply did not disclose their status. This study not only shows the inefficacy of the travel ban, but shows the harm presented to HIV positive individuals who desire to visit the United States. The study showed that patients on anti-retroviral therapy (212 patients) were more likely to go off their medication, increasing their chances of developing drug-resistant HIV strains or developing AIDS. The study concluded that people do so “with insufficient planning and advice.”

Only about a dozen countries around the world maintain a travel ban on people living with HIV. These countries are: Iraq, China, Saudi Arabia, Libya, Sudan, Qatar, Brunei, Oman, Moldova, Russia, Armenia, and South Korea. Should the United States still include itself amongst these countries in discriminating against people living with HIV?

Thanks for listening, until next time I’m Middleton Chang.

For more information:
Mahto M, Ponnusamy K, Schuhwerk M, Richens J, Lambert N, Wilkins E, Churchill DR, Miller RF, Behrens RH. “Knowledge, attitudes and health outcomes in HIV-infected travellers to the USA”. HIV Medicine 2006; 7: 201–204.

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"
-An excerpt from The New Colossus, which hangs within the Statue’s Pedestal.

Ryan White CARE Act

2009-01-09T13:19:00.000-08:00

I'm Utsha Khatri.

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, was the first piece of comprehensive AIDS legislation created to provide funding for people living with AIDS (PWAs) to access care and treatment. Ryan White was a young, Caucasian hemophiliac who contracted HIV through a blood transfusion. He was diagnosed with AIDS at age thirteen and died six years later. Prior to the media’s coverage of the Ryan White story, it was widely held that HIV/AIDS only affected marginalized sectors of society namely homosexuals, intravenous drug users, and racial minorities. However, because of the widespread media attention given to the Ryan White story, the American people soon realized that this was not the case and that it could potentially infect anyone. When Ryan White’s story was put on the media agenda in 1985, it changed the meaning of HIV/AIDS for the media, the public and policymakers.

Political scientist Mark Donavan explains that this shift in public consciousness allowed policy-makers to formulate an AIDS policy that would deliver benefits to what were considered “deserving” target populations. When people with AIDS were considered to be social deviants and dependents, policy-makers could not defend the use of tax dollars to provide care and treatment to these populations. However, when Americans realized that the HIV/AIDS epidemic started affecting “innocent victims” (whose infection was not caused by their behavior), policy-makers were able to create programs to provide benefits to a “deserving” population. For this reason, Ryan White CARE Act bills passed both houses with overwhelming bipartisan support in 1990.

Donavan emphasizes that during the drafting of the legislation, lawmakers attempted to, “downplay the receipt of benefits of gays while emphasizing the benefits granted to positively constructed populations, most notably children,” During floor debates lawmakers told moving stories of people with AIDS to win over support for the bill. Of the 19 stories told on the Senate floor, only one story was that of a homosexual. Lawmakers needed to justify the act by ensuring each other and the public that the recipients of the benefits did in fact deserve it. Donavan describes the final version of the bill emphasized women and children as the “victims” of the epidemic and deemphasized the extent to which benefits would be delivered to negatively constructed groups. The bill did nonetheless provide benefits to populations with negative social constructions as well; however, to the public, the policy was directed towards helping populations with positive social constructions.

The Ryan White CARE Act was first passed in 1990 as Congress’ attempt to financially assist many urban public hospitals that had not been compensated for care they provided to AIDS patients. It was reauthorized in 1996, 2000 and most recently in 2006. The reauthorization in 2006 changed the acceptable use of Ryan White funds. The amendments emphasized providing funding to urban areas with the highest prevalence of AIDS, encouraged outreach and testing and required that 75% of funding be spent on “core medical services.” Core medical services include services such medications, outpatient and ambulatory medical services, mental health services, substance abuse services, hospice care, early intervention services and home health care. Ryan White funds are also used for support services, including transportation, respite care, outreach and language services.

The Ryan White program presents the third largest source of federal funding for HIV/AIDS care, after Medicaid and Medicare. Currently, it provides about $2.2 billion a year to fund over 2,500 organizations and provides some level of care to about 500,000 people living with HIV/AIDS. Unlike Medicaid and Medicare, it is not a health insurance program. It is a series of flexible grants given to cities, states, and other public and private nonprofit organizations to develop and operate systems that deliver health and support services to uninsured or underinsured individuals affected by HIV/AIDS. Though the CARE Act was originally designed to fill the gaps in financing care, it has now grown into a major source of funding essential to the operation of HIV/AIDS programs across the country. The reauthorization in 2006 extended the program for an additional three years. After September 30, 2009 further legislative action will be needed to provide continued federal funding.

It is important to recognize that the program by itself is not capable of improving access to HIV/AIDS care and treatment for the majority of the infected population. The CARE Act is a discretionary grant program that receives annual appropriations from Congress. Services are provided only as long as the finite funds last. Therefore, it is not able to meet the rising demands in services due to the growing number of people living with HIV/AIDS. Furthermore, CARE Act programs vary from region to region due to the flexibility given to organizations in formulating programs and services. The programs therefore do not provide a single, unified policy solution to a national problem. Rebecca Haag, Executive Director of the AIDS Action Council, while expressing appreciation for the 2006 reauthorization, stressed the need of more funding. As Haag described, “…this bill alone is not sufficient to ensure that life saving drugs and medical treatment is available to all who are infected. Appropriations have fallen far short over the last several years while the epidemic is growing with 40,000 new infections every year.”

Time to Prepare for “PrEP”

2008-12-17T07:05:00.000-08:00

It all began with a 1994 study that showed antiretrovirals given to HIV-positive pregnant women before and during childbirth – as well as to the child upon delivery – reduced the risk of mother-to-child HIV transmission by 50%. Next were the post-exposure prophylaxis guidelines issued by the Center for Disease Control and Prevention in 1998, recommending an antiretroviral regimen for healthcare workers after unintended HIV exposure. Then, 2006 brought exciting data gleaned from a study of monkeys who remained uninfected after repeated exposure to a HIV-like virus as a result of taking the antiretroviral drugs tenofovir and emtrictabine. These studies raised the question: Can drugs prevent HIV? After recent unimpressive results in vaccine and microbicide tests, scientists’ leading hope for stopping HIV infection before it starts seeks to answer that question with pre-exposure prophylaxis, or PrEP.

By the middle of next year, close to 15,000 individuals will be enrolled in PrEP trials. That’s more people than all HIV vaccine and microbicide trials combined. In the PrEP approach, an oral antiretroviral agent (specifically, Viread or Truvada) is taken daily to prevent HIV infection. In theory, this method inhibits HIV replication and permanent infection from the moment the virus enters the body. If proven safe and effective, PrEP could significantly reduce the risk of HIV infection for high-risk individuals all over the world. It would be particularly advantageous for individuals in serodiscordant relationships as well as those unable to negotiate other proven protective measures such as condom use. Perhaps most importantly, PrEP would represent the first female-initiated intervention method.

Currently, three studies conducted by the CDC are underway to test the safety and effectiveness of PrEP. In Thailand, injection drug users are using once-daily Viread. In Botswana, young heterosexual men and women are taking once daily Truvada, and in the US, once-daily Viread is being tested among men who have sex with men.

PrEP is quickly becoming a reality. Over the course of 7 years, the CDC will spend an estimated $53 million researching PrEP. Most importantly, the CDC has recently urged public health leaders to begin planning for PrEP implementation. The time has come to discuss the optimal use and delivery of PrEP if found effective. PrEP raises particularly challenging questions that need attention now. How will we ensure that individuals use PrEP in concert with other proven preventative strategies? Some people may refuse to use condoms if they learn that their partner is taking PrEP and, theoretically, protected from HIV transmission. No single strategy will likely be 100% effective against HIV infection, and reducing transmission will require integration of all biomedical and behavioral methods. How will healthcare providers ensure that PrEP is used before exposure, and not after infection, to prevent drug-resistant HIV? Who exactly would be prescribed PrEP? Would people be required to prove that they are at "high risk," and if so, will that lead to their being stigmatized? What will happen if an individual disregards instructions for daily use and takes the pill before a night on the town? Will this ineffective so-called “disco dosing” become rampant? Already, rumors are emerging of new drug cocktails of Truvada, Viread, Viagra and Ecstasy that are being sold in gay dance clubs.

Clearly, this new strategy will not be a panacea for the difficult issues involved in the HIV pandemic, including stigma, the sexuality of young people, drug use, homophobia and the sex industry. PrEP may one day be an important response to AIDS, but that response will never be equitable nor ultimately successful unless we begin planning for it now.

I’m Charlotte Steelman. Thanks for listening.

New Leadership in South Africa brings hope for AIDS Reform

2008-12-09T10:57:00.000-08:00

72% of the 5.5 million South Africans who are HIV-positive are in need of antiretroviral (ARV) drug treatment. In leading the movement against ARV drugs, recently removed South African President Thabo Mbeki denied millions of his people HIV treatment. He believes that the AIDS pandemic was created by Western pharmaceutical companies to take advantage of Africans and maximize their profits. Mbeki also sides with dissident scientists in denying that the HIV virus causes AIDS and in 2003 he was quoted as saying, “Personally, I don’t know anybody who has died of AIDS” and when asked if he knew anyone infected with HIV he responded, “I really, honestly don’t”. Mbeki’s views opposing antiretroviral drugs were echoed by his Health Minister, Manto Tshabalala-Msimang, more commonly known as “Dr. Garlic”, who promotes garlic, olive oil, beetroot, and African potatoes as a cure for AIDS.

Because the South African government has been reluctant to supply its people with antiretroviral drugs, HIV/AIDS activist groups, such at the Treatment Action Campaign (TAC), have been instrumental in the push to allow the distribution of these drugs. It was not until 2004 that the South African government, pressured by HIV/AIDS activist groups, finally began to provide ARVs for its people. It also took a Constitutional Court battle and much lobbying from the TAC to compel the Health Department to allow the administration of AZT and nevirapine to HIV-positive pregnant women to prevent mother-to-child transmission of the virus.

However, the recent resignation of Mbeki as President of South Africa and the September 25th appointment of the ruling African National Congress (ANC) deputy head Kgaleme Motlanthe as interim president, give HIV/AIDS activists hope for change. His first day in office, Motlanthe demoted “Dr. Garlic” to a less important Cabinet position and appointed Barbara Hogan, a senior ANC member of Parliament, as Minister of Health and Dr. Molefi Sefularo as Deputy Minister of Health. The TAC applauded Motlanthe’s change in administration and issued a statement in support of the new appointees. The TAC credits Hogan as being “one of the few Members of Parliament to speak out against AIDS denialism and to offer support to the TAC” and cites Dr. Sefularo as supporting “ARV rollout and the implementation of the Prevention of Mother to Child Transmission” at Health of North West Province.

Hogan has already promised to “champion the issue” of the government increasing spending on providing ARVs to HIV-positive individuals. In an interview just hours before being sworn into office, Hogan was quoted as saying, “I would thoroughly endorse the roll-out of anti-retrovirals and any way that we can accelerate that, the better”.

Looking ahead to the next president’s administration, in the most recent edition of the ANC newsletter Jacob Zuma, current ANC President the expected future South African President, is quoted as wanting “more action with regards to the reduction of HIV infections…widespread HIV prevention, treatment and support programmes”. Yet, Zuma’s infamous statement during his 2006 rape trial that he showered after intercourse with a HIV-positive woman to minimize the risk of becoming infected lingers in the back of my mind. I question that how such change can be implemented when South African government officials still need to be educated about how HIV is transmitted and how to reduce their risk of infection.

World AIDS Day – The Power of One

2008-12-01T08:33:00.000-08:00

Today is the 20th annual World AIDS Day, a day set aside to remember those who have died of HIV/AIDS and those who are living with HIV/AIDS. It’s also a day to remind ourselves that we all are affected by this disease. Today, many of us are wearing red ribbon pins. Many of us have placed red ribbon photos on social networking sites. Many of us will be attending HIV/AIDS breakfasts or seminars. Many of us are blogging about HIV/AIDS.

Do any of these events really matter? Roughly 35 million people worldwide are infected. 14,000 people become newly infected every day. Will wearing a red ribbon or attending a breakfast change that? Sometimes, the pessimist in me says no. But then I look around at the various activities going on and think differently. Never underestimate the power of small actions. Never underestimate the power of one.

At Davidson College, groups of students are making a difference. For several years now, the members of Warner Hall, a women’s eating house at Davidson, have hosted the Red and Black Ball, a charity event for HIV/AIDS. This year, the proceeds will benefit Metrolina AIDS Project in Charlotte and Thyatira
Hospital in Mwandi. The members of Warner Hall also help Metrolina AIDS Project in other ways. Recently, I joined them on a Saturday morning to make condom packets – small bags containing condoms and information about getting tested for HIV – to be distributed at local bars and clubs.

Students at Davidson College make condom packets for Metrolina AIDS Project

This effort, though, is not solely an extracurricular activity. In a mutually beneficial partnership, the students in my Biology course on HIV/AIDS cooperate with Warner Hall on some of these projects. Together, we have sponsored screenings of movies like 3 Needles, volunteered at a local HIV/AIDS benefit triathlon, collected toys for the annual Metrolina AIDS Project holiday party, and organized speakers and symposia. Academic and extracurricular activities are wonderfully joined.

Volunteers getting ready for their assignments at a triathlon to benefit Metrolina AIDS Project

None of these events, individually or even in total, will end the AIDS Pandemic. But each and every one of these events does make a difference. Maybe one person will receive a condom packet and, as a result, not become infected. Maybe the money sent to Mwandi will help provide care for a child in need. Maybe one person who listens to a seminar will enter a career of public service. Maybe all of us will be a little more aware.

Today, I’m wearing my red ribbon. Today, I’m blogging about HIV/AIDS. Today, I’m attending an HIV/AIDS breakfast. Today, in some small way, some almost imperceptible way, I’m making a difference. We all can make a difference. Never underestimate the power of one.

The role of concurrent relationships in the spread of HIV in Africa

2008-11-21T13:12:00.000-08:00

I'm Courtney Sanders.

According to the 2008 UNAIDS Report on the Global AIDS Epidemic, countries in Sub-Saharan Africa continue to bear a disproportionate share of the global HIV/AIDS burden. In all, an estimated 67% of people living with HIV reside in Sub-Saharan Africa. In 2007, three-quarters of all deaths resulting from AIDS occurred in Sub-Saharan Africa. Though the first HIV cases in the United States were noted in 1981, HIV was not seen in African countries until the late 80s. From its first appearance, the infection rate has soared with unequivocal momentum. Currently, the infection rate in Sub-Saharan Africa falls in the range of 15-28%. Just to give you a point of comparison in understanding the magnitude of this statistic, the HIV infection rate in the United States has never exceeded 1%.

Nevertheless, public health officials will never be able to tackle the problem in Africa using methodologies which have proven successful in the United States. Rather, they must craft a solution tailored specifically to causes of the epidemic in Africa. With the statistics which I mentioned above, I think that we can all agree that there is more to the problem than simply poverty. There are a number of theories which have been proposed in trying to explain the astronomical infection rate, the majority of which pertain to African sex practices.

One theory, which initially seemed quite logical hypothesized that African people had a unique “sexual system” which was characterized by high rates of casual and premarital sex. Though this theory initially seemed intuitive given the polygamous traditions and the cultural pressure to bear many children, it gave rise to much controversy. Contrary to many stereotypes regarding African sexual behavior, studies have shown that Africans are no more promiscuous than men and women in the Western world. Children in Africa, Europe and the United States usually become sexually active around the same age—late teens. In addition, African males usually report fewer lifetime sexual partners than do heterosexual men in the west. Because African heterosexual men and women are no more promiscuous than men and women in the west, this theory raises doubt.
Another theory supposes that Africans’ weakened immune systems as a result of malnutrition and infection (common among the poor) cause them to be more vulnerable to HIV infection. This theory received attention in the wake of a study in 2006 which discovered that malaria enhances the transmission of HIV. The major weakness in the theory is that it does not explain why many poorer countries have lower rates of infection. For example, the supposition fails to explain why some of Africa’s most impoverished, worn-torn and parasite-infested countries like Ethiopia and Somalia have lower rates of infection than the richer, more peaceful countries like Botswana and Zambia.

The most widely accepted theory for explaining Sub-Saharan Africa’s disproportionate share of the global AIDS burden is the model of “concurrent partnerships.” Literature defines concurrency as having “multiple relationships which overlap in time.” According to many informed sources, having many ongoing relationships at one time is fairly common among African men and women, regardless of their marriage status. Unlike the “serial” or “sequential” nature of sexual relationships common to polygamous men and women in the United States, African men and women may have sex with the same man or woman in addition to their marriage partner for a lifetime. The serial nature of the sexual practices in the United States may actually help to protect men and women from contracting the virus since the likelihood of infection when having sex with an HIV positive person is only about 1 in 100 acts.

The theory of concurrency has been defended by numerous studies and was even touted in the most recent edition of the UNAIDS Report on the Global AIDS Epidemic. A few studies, the first of which debuted in 1992, attempt to use mathematical modeling to investigate the effect of concurrency on the prevalence of HIV infection. The majority of these studies have concluded that, when the number of sexual partners is held constant, concurrent relations are associated with higher rates of HIV infection than serial relationships. According to one author, these concurrent relationships are incredibly dangerous since they “link people in a giant web of sexual relationships that create ideal conditions for the rapid spread of HIV” (from The Invisible Cure by Helen Epstein).

Recognizing how exactly the sexual practices of Africans contribute the incredible rate of HIV/AIDS infection in Sub-Saharan African is a vital part of implementing a successful plan to combat the pandemic.

The reality of HIV/AIDS: It hasn't gone away

2008-11-11T06:43:00.000-08:00

In a recent episode of the television show South Park, one of the main characters is infected with HIV. In an attempt to find a cure, he must continually deal with the public opinion that AIDS is no longer a threatening condition. He is told that his disease is “a disease of the 80s and 90s” and even that he is “retro” for being infected with HIV. But has this retrovirus truly become retro to Americans? If we take South Park as a social barometer, then it seems that the disease has been marginalized in the public eye. Public interest on the Internet regarding AIDS is declining as well. A recent government blog about Google search hits for the terms “HIV” or “AIDS” shows a declining trend over the past four years. Each year, fewer people searched for the terms “HIV” or “AIDS” on December 1st (World AIDS day) than the previous year. Why has the US public marginalized this disease, which twenty years ago was the terror of the nation?

Searches for “AIDS” and “HIV” have decreased for four years running now. Have Americans stopped caring about this disease? Photo courtesy of Google, Inc.

A simple reason may be that the media sensationalism of the disease has settled down. As people become accustomed to news, it ceases to be news, no matter how horrible the reality of the situation may be. The early media coverage of the AIDS epidemic focused on the fact that the disease seemed to infect only gay men. Some even believed that AIDS was the punishment for the lifestyles of gay men, and AIDS became known as the “gay cancer” by many after its initial discovery. In this way, AIDS aided U.S. society in demonizing the gay population in the early 1980s. AIDS was deemed a gay problem, and the rest of society could forget about it. Ryan White’s struggle against the disease helped dispel some of these myths, but many fallacies have persisted regardless, even to the present day. Many choose to ignore the AIDS epidemic, as they believe that they will not come in contact with the disease if they are not homosexual.

AIDS may also be ignored because its prevalence in the U.S. is perceived to be decreasing. In South Park, the public seems surprised when the main character is newly infected with AIDS. In many regions of the U.S., taboo prevents open discussion about AIDS, and if people aren’t hearing about a problem, they tend to imagine that it is going away. In reality, 56,000 new cases of AIDS are diagnosed in the U.S. every year. This figure only represents the number of cases detected; the true occurrence is likely higher. Why does the public believe, then, that AIDS is on the decline?

The apparent decrease of infection rate is caused by the fact that infected individuals generally live longer and healthier lives than they would have in the 80s, when the average lifespan following diagnosis was approximately three months. This fact is largely due to the success of many drugs in delaying the onset of AIDS after exposure to HIV. AIDS advocates are victims of their own success, then, as the myth has arisen that AIDS will no longer kill infected individuals. This belief is wrong; AIDS is a lethal disease. Drugs do a great deal these days to slow its progress, but HIV has the uncanny ability to develop resistance to these drugs and overwhelm the body’s immune system, which invariably leads to death.

One additional aspect of fading public interest in AIDS, sadly enough, may be the lack of infection of a public figure. The movie star Rock Hudson was a famous AIDS victim in his time, and his death helped shock the nation into action against HIV. Rock Hudson is relatively unknown by today’s youth, who grew up after the passing of the star. These days, when most people think of celebrities with AIDS, Magic Johnson is the first name that pops to mind. This former basketball superstar retired after being diagnosed with HIV and began working towards a cure for the deadly virus. Indeed, in the South Park episode, the character with AIDS must travel to find Magic Johnson who may have the cure for AIDS. Magic Johnson faded from public view when his basketball career ended. The fact that no Hollywood star or public figure of great significance has recently been diagnosed with AIDS means that the disease is no longer the vogue disease it once was.

Rock Hudson (left) and Magic Johnson (right) are two of the most famous AIDS patients. Neither are well-known by much of today’s younger generation. Photos courtesy of Wikipedia.

As is typical for the satirical style of South Park, the characters discover that the cure for AIDS is to inject large quantities of cash directly into the bloodstream. While there is no real cure for AIDS, the biting commentary of this cartoon is telling. Wealthy AIDS patients, like Magic Johnson, often live the longest and healthiest lives following their infection. Many AIDS patients do not have access to the resources that Magic Johnson enjoys, and are therefore much more susceptible to the disease. The average cost of a year’s supply of antiretroviral drugs is between $10,000 and $15,000, which means that those living near the poverty line with AIDS must devote an enormous portion of their income to their drug regimen. Some of the hardest hit regions of the world with regards to AIDS are also the poorest. Sub-Saharan Africa is among the worst regions, with up to 30% infection rates in the population. The disease is therefore easier to ignore for U.S. citizens, who are more likely to be wealthy enough to afford treatment.

South Park offers one final shot at society, stating, “Americans have forgotten that AIDS is a serious disease.” Decreasing public interest in the AIDS epidemic is apparent, which is unfortunate both for affected individuals and the general public alike. AIDS continues to rage as a fearsome epidemic, and the number of infected individuals continues to grow. Society needs to wake up again and face the reality that AIDS is still here, and is still a terrible disease.

HIV/AIDS in South Africa: Past, Present, and Future

2008-10-27T07:36:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Kara Earle.

Since the diagnosis of the first case of HIV in 1982, infection rates in South Africa have skyrocketed. It is currently estimated that one in five South Africans, or approximately 5.7 million people, are living with HIV. In addition, there are nearly 1,000 AIDS-related deaths occurring daily. Many AIDS experts around the world blame the South African government for their lack of appropriate response to this nationwide epidemic. Until 2003, South Africans using the public health system could only receive treatment for the opportunistic infections acquired as a result of being HIV positive, but not the antiretroviral drugs that fight the virus itself. As a result of slow government action, the HIV prevalence rate among pregnant women in South Africa increased from 0.8% in 1990 to 29.1% in 2006.

Since the end of Apartheid in 1993, South Africa has been governed by a popularly elected President. Beginning in April 1994, the African National Congress, or ANC, has consistently won a majority of votes to become the governing party, with the President of the ANC serving as President of South Africa. Thabo Mbeki was elected following Nelson Mandela in June 1999, and was forced to resign by the ANC September 24th, 2008, a mere 6 months before the end of his second term in office. With the election of Jacob Zuma as ANC President in December 2007, it is likely that when new national elections are held in April of 2009, the ANC will again be the victorious party and Zuma the new South African president. Until then, the South African Parliament has chosen Kgalema Motlanthe to lead the country.

Kgalema Motlanthe

As Deputy President under Nelson Mandela, Mbeki initially acknowledged widely-held views about the spread of HIV/AIDS in South Africa. However, shortly after his election to the presidency, Mbeki increasingly cited poverty, not HIV, as the primary cause of AIDS. He began to side with dissident scientists and did not believe antiretroviral drugs could help in the treatment of AIDS; rather, he believed the commonly used drugs were toxic. His beliefs were shared by the South African Minister of Health, Dr. Manto Tshabalala-Msimang, who advocated good general nutrition and a combination of lemon juice, garlic, and alcohol as treatment for HIV/AIDS. In 2001, the South African government, independent of President Mbeki, declared that AIDS is in fact caused by HIV and shortly thereafter the High Court ordered the government to make antiretroviral drugs available publicly. Even so, it is estimated that only 28% of South Africans who need treatment for HIV/AIDS are actually receiving the drugs.

President Mbeki was forced to resign due to allegations that he had interfered in a corruption case against ANC President Jacob Zuma. Since taking office September 25, 2008, President Motlanthe has replaced Health Minister Tshabalala-Msimang with Barbara Hogan, an advocate for the treatment of HIV/AIDS. In combination with increased awareness and involvement by the government in recent years, this change is seen as a step in the right direction for the HIV epidemic in South Africa. However, the expected next President, Jacob Zuma, arrives with a considerable amount of controversy. In addition to the recent corruption case brought against him, Zuma was tried in 2006 for raping an HIV positive family friend. He was acquitted of the charges by explaining that the victim was wearing a short skirt and sitting provocatively. He also told the court that he reduced the risk of HIV infection by showering afterwards. Despite these previous comments, he seems to address the HIV/AIDS epidemic in a reasonable manner.

It is impossible to know what changes the next six months will bring in South Africa as a result of the sudden change in government. In recent years, the country has shown a desire to take on the HIV epidemic through both prevention and treatment methods, regardless of the beliefs held by its President. It is widely believed that a country with as much wealth as South Africa should be able to provide antiretroviral drugs to all who need them, and not merely the 28% who are currently receiving them. In order to slow this epidemic, the incoming administration will need to devote significant time and funding to the development of prevention and treatment programs throughout South Africa.

I’m Kara Earle, thanks for listening.

Blog Action Day 2008: Poverty and HIV/AIDS

2008-10-15T11:22:00.000-07:00

Today is Blog Action Day 2008, a day in which bloggers throughout the world are blogging about a single issue - poverty. It is the hope of the organizers that this concerted effort will raise awareness about this important issue, lead to increased donations to groups combating poverty, and, ultimately, lead to some real changes. I am happy to be a part of this year’s effort.

While many of us this week are concerned about our shrinking 401(k) accounts, the situation is much more dire for millions of people throughout the world. According to the U.S. Census Bureau, 37.3 million Americans were living in poverty in 2007 and over 45 million Americans lacked health insurance. Nearly 1 in 4 African Americans are living in poverty.

According to Global Issues, over 3 billion people worldwide live on less than $2.50 a day. Every day, the deaths of 25,000 to 30,000 children can be attributed to poverty.

Inadequate financial resources also contribute to the spread of HIV/AIDS. In the US, HIV/AIDS increasingly is becoming a disease of lower socio-economic classes. Throughout the world, women who are not economically independent or empowered are more likely to engage in survival sex, or the exchange of sex for food, clothing, or shelter. One study in North Carolina found that roughly 28% of street youths engaged in some form of survival sex. In some parts of the world, children in impoverished families may be forced into a marriage with an older man. In this situation, the girls or young women are not in a position to abstain from sex or practice safer sex. In these situations, the children and young women clearly have an increased risk of becoming infected with HIV.

So what can we do? Each of us can contribute to groups who advocate for the poor. Each of us can contact our elected representatives and urge them to support the Millenium Development Goals, a United Nations program to eliminate poverty by 2015. Each of us can write about this issue and talk about this issue. Each of us can help a neighbor in need.

To find out how other bloggers are addressing poverty, please visit the Blog Action Day web site.

Until next time, I'm Dave Wessner.

AIDS-related dementia

2008-09-19T12:45:00.000-07:00

I’m Bevin English

Since the early stages of the AIDS pandemic, doctors have known about an important neurological complication of HIV infection. This condition, known as AIDS-related dementia, AIDS dementia complex (ADC), or HIV-associated dementia (HAD), is a complex and poorly understood disease, and has the potential to greatly impact many people’s lives, including HIV-positive individuals and their families and close friends. In the United States, HIV-1 is the most common cause of dementia in adults under the age of 40. Also, neurological impairment affects roughly 60% of HIV-positive patients throughout the world. The major causes of neurological impairment include opportunistic infections, such the parasite toxoplasmosis, and AIDS-related dementia.

The primary symptoms of AIDS-related dementia include cognitive impairment, such as the inability to concentrate and impaired short-term memory; motor dysfunction, including leg weakness, affected gait, and slow hand movements; and behavioral changes, such as depression, apathy, and social withdrawal. In rare cases, the dementia progresses so that the patient is in a nearly vegetative and mute state. Before the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, AIDS-related dementia affected up to 30% of HIV-positive individuals, but the current prevalence has dropped to approximately 10% in areas with high HAART availability. However, a less-severe form of the disease, called minor cognitive motor disorder (MCMD), has become more prevalent in regions where HAART is widely available, with estimates ranging up to a 30% prevalence rate. This high prevalence rate shows that HAART is not sufficient in reducing neurological impairment in HIV-positive individuals.

Despite years of research and progress, much remains unknown about HIV’s interaction with central nervous system (abbreviated CNS; this includes the brain and spinal cord), and this lack of knowledge has serious implications for treatment. HIV is found in the CNS of all AIDS-related dementia patients, but there is still controversy regarding how HIV enters the CNS. The brain is protected by the blood-brain barrier, which is a selectively permeable layer of tightly-linked endothelial cells that carefully regulate what enters and exits the CNS. While many things are excluded from the brain by the blood-brain barrier, some immune system cells are allowed to cross the barrier. The most widely accepted theory to explain HIV’s entry into the brain is the “Trojan horse hypothesis,” which states that infected monocytes (cells that later mature into macrophages) cross the barrier and carry HIV into the CNS. However, there are other possible explanations for the presence of HIV in the brain. For example, infected CD4+ T-cells may also carry the virus into the brain. It is also possible that the virus may be able to directly cross the blood brain barrier, especially if the barrier’s integrity is compromised, or that the cells that make up the barrier ingest the virus and expel it in the brain in a process called transcytosis. Because the virus may enter the CNS through many pathways, most of which are not fully understood, it will be difficult for scientists to come up with treatments to prevent the entry of HIV into the brain in the near future.

Once in the CNS, HIV’s most devastating effect is the sheer loss of neurons. For example, 20-40% of neurons are lost in the frontal cortex, a region of the brain that is involved in planning, coordinating, controlling, and executing behavior (or more specifically, impulse control, judgement, language production, working memory, motor function, and socialization). This large loss in neurons can be seen in the CT scans below (image courtesy of AIDS Images Library )

However, HIV cannot infect neurons because they do not express CD4, but instead HIV persists in the CNS by infecting other cells; thus, neurodegeneration is not a result of active infection of neurons. There are two major pathways for neuropathogenesis in AIDS-related dementia: direct and indirect. The direct pathway includes the effects of different viral proteins on neurons. For example, three HIV proteins, gp120, Tat, and Vpr, have been shown to cause neuronal cell death through many different pathways. Further, Tat has been shown to increase the permeability of the blood-brain barrier, thus increasing the amount of HIV that can enter the CNS. The indirect pathway of neuropathogenesis involves infected cells’ secretion of chemicals that harm neurons. For example, when activated by infected macrophages, astrocytes, which normally provide support for neurons, actually secrete neurotoxins. Thus, HIV causes neuronal cell death through many different mechanisms, making AIDS dementia extremely difficult to treat.

Despite these difficulties, many scientists have been investigating treatments to prevent or slow the progession of AIDS-dementia. Many antiretroviral treatments currently in use cannot penetrate the blood brain barrier, and the few that can enter the CNS do so very inefficiently. For example, protease inhibitors, an entire class of drugs, are actively pumped out of the CNS. The ineffectiveness of current antiretroviral treatments in penetrating the blood-brain barrier has led scientists to investigate other means of preventing neuronal cell death. Many different compounds that block different steps in the pathways that cause neuronal death have been tested in AIDS-related dementia patients, but so far none have shown any significant therapeutic benefits. However, progress is being made in understanding the processes involved in HIV’s interaction with the CNS, and these new discoveries may open the door for new treatments for AIDS-related dementia.

The Presence of HIV/AIDS in Prison Populations

2008-09-11T13:43:00.000-07:00

Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Ali Cundari.

U.S. prison populations are at a record high today, with barely enough room to house incarcerated individuals. Due to the close proximity and high-risk behaviors of inmates, as well as a lack of intervention from authorities, the transmission of HIV in prisons is a major problem today. A combination of both pre-existing and new infections plague prison populations, making them one of UNAIDS’ four major at-risk groups for HIV/AIDS.

In 2005, 1.8% of all state inmates and 1.0% of all federal prison inmates in the U.S. were believed to be HIV positive, leading to a total of 22,480 infected individuals behind bars. These percentages are disproportionate to the rest of the general population, making HIV/AIDS about four times as common among inmates than the population at large. Around 25% of all HIV infected people have spent time in a correctional facility, and these HIV infections are often accompanied and exacerbated by high rates of hepatitis and tuberculosis.

There are several means of transmission regarding the spread of HIV/AIDS in prisons, both primary and secondary. Injection drug use is one major cause of transmission, as sharing of dirty needles and syringes (estimated to be greater than 70%) is a common practice. Sharing items such as razors and toothbrushes contributes to the spread of other germs. Along with injection drug use there is tattooing and body piercing, a widespread activity among many inmates. Typically, it is performed through multiple skin-punctures and without sterile instruments, causing the inmates to resort to recycled, make-shift tools such as staples, paper clips, and plastic ink tubes from ballpoint pens. Finally, various sexual activities and rape directly contribute towards the problem. It is difficult to obtain accurate statistics regarding this area, due to fear and embarrassment, but consensual and non-consensual sex are both quite prevalent among prisoners. Boredom, identity issues, and the desire to assert dominance all contribute towards sexual activity. Types of sexual activities include consensual same-sex activity, sex between prisoners and staff, conjugal visits, and rape or other forms of sexual violence. Rape is a particularly complex problem, often brutal and gang related, and the violent nature of it makes recipients more prone to vaginal or anal tears, and thus increases the chances of HIV transmission.

Also contributing to the spread of HIV/AIDS, and co-infection with other STI’s, is the absence of condoms or clean needles. Additionally, a lack of information is a major problem, with many inmates being forced to live in a state of silence and fear, and a third major confounding factor is the lack of people getting tested. Currently, very few inmates get tested due to the large stigma surrounding it and fear of ridicule or violence if their test results confidentiality were to be violated. Additionally, the prison lifestyle and rapid turnover of inmates makes consistently adhering to ARV therapy difficult. Thus, the major hesitations to reform in U.S. prisons come from a lack of political will, security concerns, and false assumptions that such programs will encourage injection drug use and sexually risky behavior. Also, many opponents believe there is a lack of resources and technology to meet the overwhelming need in prisons.

In recognizing these problems, many ideas have been proposed for prevention and change. The main goal would be to develop a multi-pronged approach to enhance detection, prevention, and the reduction of sexual violence. Next, condoms, clean needles and syringes, and bleach kits must be distributed. Many advocates of reform also believe post-exposure prophylaxis (PEP) should be made available to victims of sexual encounters. Additionally, health education and support programs, and the strong encouragement to get tested would both serve to be useful. Finally, once diagnosed, HIV positive individuals must be able to receive consistent drug treatment.

Many model prisons show promising results in their quest to enact some of these changes, including the Hampden Country, MA, Correctional Center and Brown University’s Rhode Island Prison. Further lessons can be learned from countries like England who successfully prevented problems by targeting injection drug users early on in the epidemic, and Cuba, who was able to keep HIV under control through superb penitentiary health and clean conditions.

Overall, change is a daunting challenge due to the rapid turnover of inmates and the large sense of stigma and secrecy within prison walls. In order for change to be effective, it must occur on multiple levels. Officials can no longer turn a blind eye to this problem. Prisoners are ethically entitled to the same safety, health care, treatment, and support as the rest of society. Reforming the current state of correctional facilities would not only help these facilities run smoother, but according to the UNAIDS and WHO Framework, good prison health would equate to good public health. The vast majority of all incarcerated individuals will eventually return to society, bringing with them any known and unknown diseases they may have acquired in prison. If officials can bridge these barriers, they can indeed have a lasting impact on the spread of HIV/AIDS in the U.S. as a whole.

Thanks for listening. Until next time, this is Ali Cundari.

For more information:
• Jürgens, Ralf. “Interventions to Address HIV in Prisons – Prevention of Sexual Transmission.” World Health Organization. . 2007.
• Kanter, Elizabeth. “HIV Transmission and Prevention in Prisons.” HIV InSite Knowledge Base Chapter. . April, 2006.
• Lines, Rick, et al. “HIV/AIDS Prevention, Care, Treatment, and Support in Prison Settings.” WHO & UNAIDS Framework for an Effective National Response. . 2006.
• Maruschak, Laura. “HIV in Prisons, 2005.” Bureau of Justice Statistics Bulletin. . September, 2007.
• Polonsky, S., et al. “HIV Prevention in Prisons and Jails: Obstacles and Opportunities.” Public Health Rep. 109(5): 615–625. . September-October, 1994.
• “Prisons.” Joint United Nations Programme on HIV/AIDS. .

Impacts of HIV/AIDS on Economic Development

2008-08-29T11:40:00.000-07:00

In 2000, the United Nations created a list of 8 Millennium Development Goals to help promote economic growth and development among developing countries. One of these goals is to combat HIV/AIDS by stopping and reversing its spread and providing universal access to drugs for those infected. While this is definitely a worthwhile goal, why is it included among a list of targets to support growth? Well it turns out, that the impact of HIV/AIDS on the economy can be substantial.

The first immediate effect of HIV is a drop in household productivity as the working members of the household succumb to the disease. One study by UNAIDS estimated that household production could drop anywhere between 30%-60% due to an AIDS death in the family. Another study from the Ivory Coast examined what implications this could have on other aspects of the families’ lives. It was estimated that “families with a member sick from AIDS cut spending on their children's education in half and reduced food consumption by about 40 percent as they struggled to cover health expenditures that soared to four times their usual level.” Unfortunately this leads to a vicious cycle as these countries are often already experiencing higher malnutrition rates and lower education levels.

Individual companies will be affected by high levels of HIV as well. Not only will the actual amount of workers decline due to more AIDS deaths, but their quality of work will also decline due to ill-health and increased absenteeism. Companies will incur direct costs in order to hire and train new workers. Additionally, due to an inexperienced work force, productivity will decrease and the potential for accidents will increase. Finally, as AIDS deaths increase in number, employees will experience a loss of morale and labor cohesion.

These losses in household and company productivity have important implications for the national economy. One important indicator for development is domestic savings and investment. Households that are able to save money are better able to start their own business or finance their education in the future. Additionally, companies that invest in new plants or equipment can grow at a faster rate. However, with high levels of HIV, households are forced to spend more money on healthcare and companies have less to invest due to higher costs and lower productivity. As a result, the country experiences a much lower rate of growth.

Government expenditures will also be affected by HIV. Tax revenues will drop as companies and households are earning less money. At the same time, the government will be increasing health expenditures to help those affected by AIDS. With less revenues being generated and a higher percentage being spent on healthcare, government programs to promote infrastructure and growth will diminish in quantity and quality.

Economists have developed models that predict the growth domestic product (GDP) both with and without HIV/AIDS. Most of these models indicate a rather small drop, on the order of 0.5% to 1% per year. While this may seem small, when this drop is compounded over many years, the impacts can be substantial. One study estimated that due to HIV’s extensive impact on the economy, expenditures on HIV prevention would be 17 times more effective at promoting development than similar expenditures on capital investment. As a result, slowing the spread of HIV and treating those with AIDS will be an integral part of any development plan.

This is Ben Young, thanks for listening.

HIV/AIDS: The role of abstinence only programs

2008-08-22T08:19:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Amy Jendrek.

In fiscal year 2005, President Bush requested $270 million to fund abstinence-only education programs in the U.S. While Congress did not appropriate the full amount requested, they did allocate $167 million to support these programs. There are three principal programs that use federal funds to support abstinence-only education.

The first of these is SPRANS, Special Programs of Regional and National Significance, which has a sub-program devoted to Community-Based Abstinence Education. In 2001, its first year of funding, 33 SPRANS recipients received $20 million in grants. By 2004, the program had over 100 grantees and a budget of $75 million.

The second program is Section 510 of the 1996 Welfare Reform Act, which provided $250 million over five years for programs with “the exclusive purpose” of promoting abstinence. The law has since been extended in June 2004, providing $50 million per year.

The third program, the Adolescent Family Life Act (AFLA) was originally passed in 1981 to promote “prudent approaches” and self-discipline to adults. In 2004, it provided $13 million for abstinence-only education programs, and the same amount was again appropriated in 2005.

In 2004, California Representative Henry A. Waxman led an investigation of abstinence-only education programs funded by the federal government. The investigation, titled “The Content of Federally Funded Abstinence-Only Education Programs,” found that 80% of curricula used by two-thirds of SPRANS grantees contained false, misleading, or distorted information about reproductive health.

The report looked at 13 abstinence-only sexual education curricula, and found errors in scientific information presented by 11 of them. Many contained errors regarding HIV prevention and the effectiveness of condoms.

According to the CDC, “Latex condoms, when used consistently and correctly, are highly effective in preventing the transmission of HIV.” According to the Waxman report, multiple abstinence-only curricula use a 1993 study by Dr. Susan Weller which found that condoms reduce risk by 69%, using an analysis which both the FDA and the CDC found erroneous. One abstinence-only curriculum, “I’m in charge of the FACTS” claims that “The actual ability of condoms to prevent the transmission of HIV/AIDS, even if the product is intact, is not definitively known.”

These curricula fail to mention the multiple studies showing the effectiveness of condoms against transmission of HIV, as well as the rigorous standards the FDA holds for testing contraceptives.

Another area in which the Waxman report found many errors was in curricula’s analysis of HIV risk behaviors. Data on exposure risks is presented in a confusing and exaggerated manner. Data from CDC chart titled “HIV infection cases in adolescents and adults under age 25, by sex and exposure category,” is presented by FACTS as “Percent HIV Infection.” This means that, where the CDC chart showed that nearly 50% of male teens living with HIV reportedly acquired it through homosexual contact, the curriculum’s chart shows that 50% of homosexual male teens are HIV+. In a similar fashion, it implies that 41% of heterosexual female teens are also HIV+. After the Waxman Report, a caption was added to include the original title of the chart.

Many curricula use a one in ten infection ratio for HIV-risk activities, ignoring the fact that even with a high estimate, one in 300 people in the US are infected with HIV.

WAIT (Why Am I Tempted?) Training, a program used by 19 SPRANS grantees, places sweat, tears, and saliva in the “At Risk” category for HIV transmission. Since the Waxman report came out, WAIT Training has changed its curriculum to put sweat in the “No Risk” category, but maintains that there is risk of contracting HIV through tears and saliva, as the disease can be isolated from them, despite the CDC’s assertion that there is no risk of transmission from these fluids.

In some cases, even discussion of HIV and AIDS are not allowed under abstinence-only guidelines. The Franklin County, NC, school board had three chapters cut out of a ninth grade textbook because they did not adhere to state laws mandating abstinence-only programs. The chapters covered marriage and partnering, contraception, and HIV. In Orlando, Florida, a high school teacher was suspended when he chose to show a student-made video about HIV prevention. In Illinois and New York, AIDS-prevention presentations by an AIDS task force and the CDC were cut from programming because they were not “consistent with an abstinence-only message.”

Other errors are more simple. In what is probably a typo, but one that should have been caught, Tree of Life Preventative Health Maintenance, Inc., a grantee in Arkansas, tells teens on its website that “AIDS is the result of HPV.” One student handbook, from the FACTS curriculum, defines AIDS as “Acquired Immune Disease.”

Currently, only 12 states have not accepted federal abstinence-only money. That does not necessarily mean that all these states provide a comprehensive sex education, or that those states that have accepted money teach a strictly abstinence-only curriculum. However, 35% of school districts with a sex education policy require abstinence to be covered and either do not allow discussion of contraceptives or allow discussion only of their failure rates.

According to Planned Parenthood, “most reputable sexuality education organizations in the U.S., as well as some prominent health organizations, including the American Medical Association, has denounced abstinence-only sexuality programs.” In 1997, the National Institutes of Health concluded that “Abstinence-only programs cannot be justified in the face of effective programs and given the fact that we face an international emergency in the AIDS epidemic.”

I’m Amy Jendrek. Thanks for listening.

Opportunistic Infections in Developing Nations: A World Away

2008-08-15T12:42:00.000-07:00

In the United States and other developed nations, for many people, AIDS has become a manageable disease. With adequate care and lots of medication, HIV positive individuals can live with relatively few serious complications for a long time. In the US, 71% of HIV-infected individuals have at least started HAART therapy, decreasing deaths per infected individuals per year from 30/100 to 5/100 since the 1980’s. In developed nations, however, HIV positive individuals do not have the luxury of adequate care. In areas like Africa where the burden of disease is highest, HIV positive individuals must face an array of opportunistic infections as their CD4 counts dip lower and lower.

Because these opportunistic infections are generally localized to areas where HAART is not available, it is both hard for us to understand the difficulties in treatment and to determine which infections are endemic to what populations. For example, MAC (for Mycobacterium avium complex) is a common, life-threatening opportunistic infection in Asia causing a significant portion of AIDS-related mortalities. In Africa, however, MAC is rare. In addition, tuberculosis is a particularly life-threatening coinfection that is particularly common in many developing areas, especially Sub-Saharan Africa and Asia. Many opportunistic infections in these nations have developed resistance to the drugs typically used to treat them. Determining which disease populations have resistance to what medications can be exceptionally difficult given how isolated some of these areas are.

The HIV/IDS prevalence is highest in sub-Saharan Africa

The most reputable source for information like this is undoubtedly the World Health Organization. The WHO publishes information on the geography, morbidity, symptoms and treatment of various opportunistic infections for different nations and settings. While it is hard to determine where exactly the WHO gets their sources for information from developing nations, it is clear that they get their information from all parts of the globe. However, it is also hard to pick apart the complicated interactions of HIV and opportunistic infections in a multitude of settings, and even harder when there are additional complicating factors such as malnutrition, social unrest, and a lack of medical infrastructure for reporting treatment schemes. Many times, the WHO provides useful information about the scope of opportunistic infections in developing nations, but they often miss the deeper and more individual issues that a given region may have. If first-line drugs for opportunistic infections are not available in these developing areas (due to oppressively high costs or restrictive storage conditions), the WHO lacks vital information on how to cope.

The availability of antiretrovirals in lowest in sub-Saharan Africa

While it is not the fault of the WHO that there is a dearth of useable information for medical workers in low-resource environments, it is clear that there is a lack of necessary medical care in these nations that perpetuates a cycle of poverty and illness and that millions of HIV-positive individuals are dying as a result of a lack of ARVs. In a situation where prohibitively high costs of necessary drugs prevents individuals from being treated for HIV, we need to focus more on preventative efforts and HIV prophylaxis in the form of vaccines or microbicides. In this sense, the US and other developed nations are providing a massive amount of resources in trying to find a vaccine and developing useful microbicides to prevent HIV infection from happening in the first place. Because of the massive amount of people infected in areas that lack the resources to treat them, the disease needs to be treated when it is least expensive to do so. While it is hard to know what the future holds for those with HIV in developing nations, it is sure that we need to develop better ways of treating opportunistic infections and preventing the development of AIDS from HIV.

For more information on the global context of the AIDS pandemic, please visit:
Avert.org
WHO

Themes from the International AIDS Conference

2008-08-08T11:58:00.000-07:00

Today marks the end of the 17th International AIDS Conference. 25,000 delegates were in Mexico City this week to discuss the current state of the pandemic. While I was not able to attend this year’s conference, I have been following the proceedings online. What were some of the major themes? The infection rate in the US is higher than previously thought. We need to do a better job reaching out to men who have sex with men. We need to develop an effective microbicide. We need to serve our children more effectively. New media – blogs, podcasts, twitter, mobile phones – may help us get the message out.

Because of AIDS conference, there have been numerous reports about HIV/AIDS this week. Here are a few that I found interesting.

At InsideBayArea.com, Josh Richman tells us that Representative Barbara Lee (D – Oakland) has called for a domestic PEPFAR, stating that we need to spend billions here to fight HIV/AIDS.

At HuffingtonPost.com, Tamsin Smith urges us to develop intervention programs specifically designed to empower girls.

Also at HuffingtonPost.com, James Boyce makes a strong argument in favor of (RED). He argues that programs like this, termed Creative Capitalism by Bill Gates, work.

I hope you take the time to read this articles. And feel free to comment. I’d love to hear your thoughts.

Until next time, I’m Dave Wessner.

US to lift HIV travel ban

2008-07-28T12:37:00.000-07:00

“This week, Congress voted to expand a vital program that is saving lives across the developing world — the Emergency Plan for AIDS Relief, also known as PEPFAR. I thank members of Congress from both sides of the aisle for working with my Administration to pass this important bill, and I will be honored to sign it into law next week.”

With those words, President Bush on Saturday indicated his strong approval of the PEPFAR legislation passed last week by Congress. The bill provides an additional $48 billion over the next 5 years to fight HIV/AIDS, primarily in sub-Saharan Africa. According to Pres. Bush:

“When we first launched this program five-and-a-half years ago, the scourge of HIV/AIDS had cast a shadow over the continent of Africa. Only 50,000 people with AIDS in sub-Sahara Africa were receiving antiretroviral treatment. Today, PEPFAR is supporting treatment for nearly 1.7 million people in the region. PEPFAR has allowed nearly 200,000 African babies to be born HIV free. And this program is bringing hope to a continent in desperate need.”

But this legislation does more than provide much needed money. The bill also repeals the 20 year ban on travel into the US by HIV positive people. Enacted in 1987, the current policy prevents HIV positive foreigners from obtaining visas as tourists, immigrants, or students. The US is among only a small number of countries worldwide with such a ban. According to Senator Gordon Smith, a Republican from Oregon, “Our government still treats individuals with HIV/AIDS as modern-day lepers, categorically banning these individuals from entering into the US.”

More information about how this new legislation will affect travel to the US by people with HIV/AIDS can be found at the Immigration Equality web site.

Until next time, I’m Dave Wessner.

National HIV Testing Day

2008-06-27T13:10:00.000-07:00

Today, Friday, June 27th, is National HIV Testing Day. Many of us, I would guess, have become somewhat desensitized to these types of events. We are inundated by days or weeks or months dedicated to various causes. It would be easy to ignore National HIV Testing Day or view it as just another event on an already overcrowded calendar.

But I encourage all of you to pay attention to this special day. Why? Because HIV/AIDS is preventable. It is only preventable, though, if all of us know our HIV status. Today, the CDC estimates that roughly a quarter million people in the US are HIV+ and do not know it. We need to decrease this number. If we are going to beat HIV/AIDS, it’s important that people know their status.

Where can you get tested? If you don’t know of a local testing site, simply go to www.hivtest.org. Type in your zip code, and you will be provided with a list of nearby sites. Or, you can find a test site by texting your zip code.

If you have never been tested, or if you haven’t been tested in a while, get tested today. It’s the only way we can end this pandemic.

Until next time, I’m Dave Wessner.

Kwame Dawes reports on HIV/AIDS in Jamaica

2008-06-17T13:44:00.000-07:00

In a recent installment of The AIDS Pandemic, Tamar Odle described the stigmatization of homosexuals and people living with HIV/AIDS in Jamaica. As she reported, the discrimination against homosexuals stems from deep-rooted cultural beliefs and values. And this discrimination against homosexuals has increased the stigma associated with HIV/AIDS in this country.

Recently, Kwame Dawes, a poet and professor at the University of South Carolina, reported in The Washington Post on the current state of people living with HIV/AIDS in Jamaica. With funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the Jamaican government has been able to supply free or low-cost antiretroviral drugs to many Jamaicans living with HIV/AIDS. But public perception of HIV/AIDS remains a problem. And because of this public perception, adequate treatment remains an issue.

A young HIV+ Jamaican woman, Annesha Taylor, became the face of successful treatment. The government used her story in various ad campaigns to show people that it now was possible to live with HIV. But according to Dr. Dawes, when she became pregnant, “her role as the campaign’s public ambassador was over.” The story is poignant and telling. Despite our scientific understanding of the virus and the growing number of antiretroviral drugs at our disposal, stigma, misunderstanding, distrust, and fear remain the biggest obstacles to preventing new infections and treating those already infected.

I encourage you to read Dr. Dawes’ piece.

I also encourage you to read and listen to his moving poetry on HIV/AIDS in Jamaica at www.livehopelove.com.

His trips to Jamaica have been supported in part by the Pulitzer Center on Crisis Reporting.

Until next time, I’m Dave Wessner.

HIV/AIDS Outreach in African American Communities using Barbershops and Hair Salons

2008-06-13T07:16:00.000-07:00

Historically, barbershops and hair salons have served as hubs in the African American community where people go to discuss issues in the community, politics, family, and life issues. Within these establishments there is a sense of community, and it provides opportunities for African Americans to develop ideas and form a sense of identity. African Americans usually build relationships with their stylists where they are comfortable enough to gossip and share personal information. As a result, HIV/AIDS Outreach Programs have begun to use barbershops and hair salons to get through to the African American community. Such unconventional outreach locations are effective in providing prevention efforts that is culturally relevant, non-intrusive, and accommodating for sharing information and learning.

Barbershops are significant in facilitating important discussions and community within the African American population. One great example of this was in the 2002 Motion Picture, “Barbershop”, in which conversation and discussion by African American customers and employees within the shop was the basis of the film. The prominence of conversation/ discussion within barbershops was also highlighted in the book, “Barbershops, Bibles, and BET”, written by Victoria Harris-Lacewell. Lacewell states that, “They talked about White power structures, the relationship of African Americans to the state and to capitalism... critiqued black leaders, discussed political power in the black church, argued about reparations and cheered on African American Olympic athletes.”

Specifically, the purpose of Outreach programs through barbershops and hair salons is to target high risk groups like drug, alcohol users, homosexuals, heterosexuals, and men who have sex with men, to inform them about HIV/AIDS prevention. Some of the professionals that work towards these efforts include: public health experts, behavioral scientists, business owners, hairstylists and barbers. Some of the programs targeted towards HIV/AIDS prevention outreach are: The Down Low Barbershop Project and the Barber and Beautician STD/HIV Peer Education Program with Project StraighTalk. There are several other Outreach programs that use barbershops and hair salons as channels of outreach around the country in states like New York, Nevada, North Carolina, and Vermont.

The Down Low Barbershop Project is located in Seattle and Washington, DC is funded by the Center for Disease Control. The purpose of this project is to train barbers and stylists in Black communities to provide black men with HIV education, condoms, and referrals for free HIV counseling and testing. It is estimated that more than 1,000 people have participated in this program thus far. The Barber & Beautician STD/HIV Peer Education Program with Project StraighTalk began in 1989 with a poll that asked African American barbers and beauticians “what their clients talked about?” The results of the poll showed that 80% of the clients talked about sexual issues which urged Project Straightalk to begin their first training of stylist in HIV Outreach in 1990.

The training of barbers and beauticians in STD/HIV Peer Education is very critical to the success of these Outreach programs. It is important that the stylists are adequately equipped with facts, advice, and resources that are correct and beneficial to their clients. The training for these programs consists of: an overview of program, discussion of their role as educators, teaching of peer education skills and STD/HIV facts, a demonstration of correct prevention method use, instruction on providing client referrals, and role plays. At the end of training, the stylists are given a certificate, resources such as pamphlets and posters, and an “Ask Me About AIDS” Button.

The U.S. is not the only country that has decided to use barbershops and hair salons to target the black community. Similar efforts are taking place in Nigeria, Zimbabwe, and Canada, to name a few. In Canada, the peer led health promotion initiative called, Operation Hairspray, has begun. The goal of this program is to provide HIV/AIDS outreach for African American and Caribbean hairdressers and clients.

There are several implications related to the success, future, and long-term effect of Barbershop and Hair Salon HIV/AIDS Outreach Programs in the African American Community. These programs are culturally relevant to the African American community and provide outreach in non-intrusive informal setting. Likewise, they are specifically tailored to incorporate social norms and values; this is beneficial to targeted outreach for any group. Some critics argue that quality, content, and intensity varies in different outreach programs, as a result there efficiency is unclear. However, all of these programs provide much needed education, testing information, awareness, and support for African Americans which are all beneficial. Although the long-term effectiveness of these HIV/AIDS outreach programs is not apparent, the initiative that these programs have taken is positive and can ultimately help the African American community and aid in decreasing the number of HIV/AIDS cases.

Website Links Related to the Topic

http://www.newsobserver.com/664/story/543765.html
http://seattletimes.nwsource.com/html/photogalleries/northwestlife88/2.html
http://ottawa.ca/residents/health/living/sexual/hairspray_en.html

Social Components of HIV/AIDS Transmission in Mwandi, Zambia

2008-05-20T10:26:00.000-07:00

I'm Dominique Maietta.

Mwandi is a relatively rural village in the South-Western corner of Zambia. The town is home to the Mwandi Christian Hospital, which has a catchment area of approximately 25,000 individuals. During the summer of 2006, I traveled to Mwandi in order to study the psychological and social components associated with HIV/AIDS there. Here I will talk about some of my findings.

The incidence of HIV in the village is around 30-40% and the percentage of HIV positive people is larger within the Mission Hospital patient population according to interviews with medical officers on the hospital staff. The majority of the interviewees expressed their feelings that economic hardship is a major social component of the spread of HIV in Mwandi, just as it is in the rest of Sub-Saharan Africa. Despite the influx of education and knowledge regarding HIV and it’s spread, including mandatory classes in the schools and public service campaigns around the country, the low financial status of the Mwandi community is the root cause for many of the risky behaviors associated with HIV transmission, such as multiple partners and non-use of condoms. This need to engage in risky behaviors appeared to be a particular problem for women and girls who have no other way of making an income other than through sex. Sex for them is not about emotion, but instead about survival.

The problem of poverty affecting HIV rates in Mwandi has further been exacerbated by the construction of a new paved road linking this relatively rural village to other towns and countries. The relatively recent accessibility of Mwandi to the outside world has introduced truckers and migrant workers as passer-bys to the village, and thus created a uniquely new set of problems for HIV transmission in Mwandi. These migrant individuals provide both a source of income for the impoverished village, but also a ready supply of HIV positive individuals to transmit the disease to villagers. As one social worker explained to me, when people come, they come looking for women. Thus the presence of the road, and the truckers from neighboring countries provide a source of income for destitute women and girls with no other means of providing income for their families. Interestingly, the use of sex for money in Mwandi is not so much acceptable, but merely a behavior that occurs, and according to one nurse I spoke with, “this is one of the poorer parts of Zambia, and if a woman has to keep her family, especially if her husband is not around, she will do it somehow”.

Gender disparity issues, then, apart from womanizing on the part of men, is also seen as a major social component of HIV transmission in Mwandi. While men have the power and social standing to hold jobs and make money, women and children have no similar means of providing for their families. Furthermore, although some male orphaned heads of household are given governmental support such as fishing nets which can be used to make a living, young females in similar situations are given minimal support. Thus when husbands die or children are left orphans due to the death of their parents, (generally as a result of AIDS), there is little those children or women can do to raise money other than to fall back to prostitution.

The lack of finances for much of the Mwandi community was also linked by many of the people I spoke with to excessive alcohol consumption, which contributes to promiscuous sexual behavior among Mwandi townspeople. A majority of village leaders perceived that the paucity of jobs and alternative activities in Mwandi village led to the abuse of alcohol followed by unscrupulous sexual activity, (especially by men), which in turn exacerbated the already present problem of HIV transmission. The custom of casual sex and multiple partners was prevalent among men before the HIV pandemic, and is viewed in Mwandi as the “normal mode of boy existence”. This acceptance of male promiscuity also appears to be a key contributor to the continuance of HIV transmission in Mwandi. Lack of sexual control exerted by women, (especially wives), combined with a lax view of expected fidelity in men has resulted in a growth of HIV transmission as husbands will sleep with several partners, become infected, and then infect their wives.

Although it was generally recognized that women lacked the social dominance and power necessary to prevent their husbands from suffering the results of their risky behavior, there were conflicting views as to whose behavior was “responsible” for the spread of HIV. Many of the male interviewees implicated the social behaviors of young people and prostitutes in the spread of HIV. In Mwandi many traditional family cultural values are being challenged with the introduction of the “modern life. As a result, many perceive that young people and their rampant and unprotected sexual behavior is a major social problem contributing to the spread of HIV. This behavior is most often the result of children behaving in a manner mimicking their adult counterparts.

Thus, in Mwandi, extreme poverty combined with alcohol abuse, accessibility to outsiders, and a lack of role models attempting to change behavior are the main factors contributing to the spread of HIV. As the village and the rest of the world becomes more aware of these social factors, changes can be gradually made to stop those underlying social behaviors that support transmission of HIV. Already in Mwandi village leaders have begun to address the issues of poverty and gender disparity by supporting religious and governmental run support groups and clubs to promote sustainable income by women there. Furthermore, use of traditional drama has been incorporated in order to increase public knowledge about the connection between underlying social factors and the spread of HIV in order to stop the cycle of transmission. Although there is much work to be done, the residents of Mwandi are moving in the right direction to combat the social facets contributing to HIV transmission in Mwandi.

HIV/AIDS in China

2008-05-06T07:27:00.000-07:00

In 2006, official estimates put the number of HIV-positive individuals in China at about 650,000. This figure – reached by the World Health Organization – means that China, holding roughly 1/6th of the world’s population, contributes to only 1/60th of the cases of HIV/AIDS globally. However, it has also been estimated that if rising infection rates are not curbed, the HIV-positive population could breach 10 million by 2010. This has sparked a more liberal attitude from Party leadership toward sex education, which until a year ago, made possession of a condom adequate evidence for prostitution charges.

In developed nations, MSM can account for 70% of HIV infections, while in sub-Saharan Africa, which bears the brunt of HIV infections, heterosexual contact is a major route of transmission. But China’s battle with HIV/AIDS is unique. When HIV first surfaced in China in the 1980’s, it was associated largely with drug use and other practices deemed to be of Western origin. AIDS was known as aizibing, meaning the “loving capitalism disease,” and Party officials did not deem it a serious threat to the general population.

When four hemophiliacs were infected with the virus in the late ‘80s by imported Factor VIII, the government prohibited the use of imported blood products. This allowed for the development of a new for-profit blood collection industry based on the exploitation of poor peasants. Throughout the 1990’s blood collection units popped up throughout rural villages in China, paying peasants the equivalent of $5 for blood. Some would give several pints a day in order to feed their families. In order to keep the donors from becoming anemic, blood was returned to donors after removing the plasma, but the blood of multiple donors was commonly mixed before returning it, and no tests for HIV were conducted. While conservative estimates put the number infected through this route of transmission at under 100,000, others argue that more than a million were infected in Henan province alone. To this day, no government officials have been punished, despite the fact that even police and military units would set up collection stations to raise money.

After the backlash to the SARS outbreak in 2003, government officials in Beijing have opened up slightly, but many activists believe official cover-ups are responsible for preventing treatment to millions of sick villagers. Chinese Premier Wen Jiabao visited Henan Province on World AIDS Day this year to help spread awareness about the disease, but many sick villagers claim they were put on house arrest in order to prevent him from seeing the true state of the epidemic. In some of the worst areas, the so-called “AIDS villages,” activists believe up to 80% of the residents are infected. Gao Yaojie, a retired physician who has won several human rights awards for her work on uncovering the HIV epidemic in China said this of the Chinese Government:

The government's AIDS policy is superficial. It cannot really be implemented. There is a saying in the countryside. The village tells lies to the township government; the township tells lies to the county government; the county tells lies to the state council; the state council issues a document; the document is read by all levels of the government. After they finish reading it, they go into a restaurant, and the document is never put into practice.

Gao Yaojie’s books on the Aids Villages are banned in Henan Province.

In 2003, the government announced the Four Frees and One Care Policy, promising, among other things, free access to anti-HIV drugs for those who could not afford them. But many of those affected claim that these policies do not make it to the level of local implementation. Villagers protest that many hospitals do not offer HIV testing, or that they sell the drugs for their own profit, but their protests fall on deaf ears. Zhou Xihong, a lawyer who has worked with families in Henan trying to access the promised drugs, complains that the courts routinely dismiss their pleas. “They said AIDS patients can get free treatment, so the court doesn’t have to process their cases,” he said.

The Chinese government is now at a crossroads; their desire to control information must be reckoned with their growing integration into the global community. Reports of police violence and strong-armed tactics to quell protests of HIV activists at the local level suggest that international pressure will be the key to tackling the epidemic among China’s peasants head on. Policy changes enacted early this year provide hope that this needed change may be coming. To allow for better coverage of the upcoming Beijing Olympics, resident correspondents no longer need a government OK to go on reporting trips to provinces. But according to some recent reports, villagers who grant interviews to discuss the HIV epidemic still face intimidation and threats from local officials.

Read more about Gao Yaojie’s efforts in China.

Cancer in AIDS Patients

2008-04-23T08:09:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Mike Neri.

In this episode, I will talk about a topic that is gaining increasing interest from the AIDS community: cancer. This podcast goes over why cancer is becoming more of an issue for AIDS patients, why some cancers occur more often in HIV-positive people, the complications of treating people with AIDS for cancer, and what needs to be done in the fight against cancer and AIDS.

Most people following the evolution treatment of AIDS patients focus on the development of more effective drugs against HIV as the main battle in the war against this disease. Certainly, finding medicines that can lessen HIV’s ability to destroy the immune system and function inside the body is critical to making progress in the treatment of this pandemic. However, many people don’t realize that prolonging the lives and improving the quality of life for people with AIDS is not the end of fight. In fact, newer drugs can often complicate treatment of other diseases later on down the road and contribute to more health issues as AIDS patients get older.

Cancer is one of the best examples of the problems that people with AIDS face even after their medication has allowed them to live a somewhat normal life. It is well known that as a person ages, his or her susceptibility to cancer increases. This is no exception in AIDS patients, and as more patients survive longer due to new medicines, cancer and cancer treatment of the immunosuppressed of the AIDS community will continue to become a bigger issue.

In the public eye, cancers are not normally associated with immunodeficiency or infectious particles, but rather with carcinogens, heredity, and genetic mutations. However, cancer statistics show that viruses are responsible for as many as 15% of cancers in humans, not to mention other infectious particles like bacteria that have been linked to some cancers. This fact may help to explain the increased occurrences of some cancers in the immunosuppressed of the AIDS community.

Certain types of cancers have been associated with AIDS since the first cases of the disease. In these early days of the pandemic, a very rare cancer called Kaposi’s sarcoma was often a tell-tale sign of AIDS, and thus became known as an AIDS-defining cancer. Some other AIDS-defining cancers were non-Hodgkin’s lymphoma and cervical cancer, both of which are associated with viruses (as is Kaposi’s sarcoma) and took advantage of a host’s decreased immune defenses. In contract, non-AIDS-defining cancers are those not associated with immunodeficiency and therefore were not indicators of HIV infection. However, research has shown that some cancers that were originally considered non-AIDS-defining, such as Hodgkin’s disease and lip cancer, are in fact associated with immunosuppression and thus could be moved from the non-AIDS-defining to the AIDS-defining cancer group. This association with decreased immune function may suggest either that these cancers are also associated with viruses or that an underperforming immune system makes a person susceptible to more types of cancer than just those caused by infectious particles.

Another study from 2005 looked at how the survival of people with AIDS from cancer has changed since the first cases of AIDS compared to the general population. While this only looked at survival for 24 months after cancer diagnosis, significant improvements were seen since the 1980s in the survival of AIDS patients with certain cancers. In particular, the time period since 1996 and the introduction of HAART (or highly active antiretroviral therapies) has seen marked increases in survival rates, suggesting that if HIV is treated with more effective drugs and the immune system is better protected, then more powerful anti-cancer drugs can be used, which translates to better survival.

A recent article from the Washington Post by Mark Wainberg does a good job of looking at some of the most recent and pressing issues surrounding cancer in people with AIDS. First of all there is the troubling fact that there have been increased cases of severe and untreatable cancers in AIDS patients above the levels in the general population. He attributes this trend to the fact that while antiretroviral drugs can help fight HIV, they cannot repair the immune system to pre-infection levels, and thus may leave a person with a decreased defense against cancer.

This fact and others are cause for concern in the AIDS community. For one, there is always the issue of treating two diseases at once – doctors have to be very careful about the side-effects of mixing powerful drugs in patients while weighing them against the effect of not giving the patient that drug at all. In addition, there is cause for concern about the rising number of cancer cases in people with HIV who have been infected for 5-15 years. Researchers are unsure about what this means for other groups, such as those infected for a longer time. There is always the worry that more and more different types of cancers will start to affect AIDS patients, which makes it harder to treat cancer since almost all types require different treatment regimens and finding drug combinations for AIDS and many different cancers could be a daunting task. These are just some of the many possible challenges that physicians and researchers face in fighting both AIDS and cancer in the coming years.

Wainberg’s article ends by emphasizing the importance of finding drugs that not only help fight HIV replication and spread, but also help repair damage already done to the immune system by the virus. In addition, there is a lot more research that needs to be done in this area to determine whether all the cancers that are occurring in higher numbers in AIDS patients are related to infectious particles or if there is some other way that HIV is causing an increased occurrence of cancer in its hosts. And physicians who deal with AIDS patients need to cooperate with those who treat cancer patients to find effective and safe drug therapies that can treat both diseases at the same time.

With a large portion of the HIV-positive population reaching the age of increased cancer susceptibility, this issue will become more significant in the AIDS community in the coming years. The sooner doctors and researchers start to take on this coming problem, the better the chances that we can find ways to prevent cancer from becoming a huge obstacle in AIDS treatment. While advances in antiretroviral therapy are great steps forward for the fight against AIDS, we need to keep making strides in treatment beyond just controlling the virus and look to anticipate and deal with issues in the treatment of HIV-positive people before they become critical.

That ends this installment of The AIDS Pandemic. I’m Mike Neri, and thanks for listening.

“Rethinking” AIDS: The Dissident Movement

2008-04-14T12:56:00.000-07:00

On October 25th, 2007, AIDS activist Ron Hudson posted an entry on his blog describing three apparently fraudulent e-mails he had received over the past month. Each of these messages appeared to come from a prominent member or group of the mainstream AIDS establishment (Dr. Robert Gallo, Dr. Luc Montagnier, and AIDSTruth.org), but each also supported the unconventional view that the HIV virus does not cause AIDS. This disputed notion is the primary tenet of a controversial group of activists who seek to overturn much of what is widely accepted about HIV and AIDS. Variously called the AIDS dissident movement, the AIDS reappraisal movement, and the AIDS denialist movement, this loosely affiliated community has various beliefs and goals but is united by the shared conviction that AIDS is not caused by HIV. In this podcast, I will examine the dissident movement’s tactics and its relation to the global AIDS pandemic.

The primary strategy employed by the AIDS dissidents is discrediting the existing scientific consensus while constructing their own dissident consensus in its place. Often this dual approach can be hypocritical. For example, dissidents vehemently reject studies or even whole groups of evidence that support the mainstream view on the basis of just one flaw or educated guess, and at the same time they selectively extrapolate from findings in other studies to arrive at conclusions consistent with their own beliefs. Additionally, they rebuff research papers published by mainstream scientists, arguing that their credibility is compromised by their funding sources or lack of expertise with HIV-AIDS, while simultaneously citing lists (like the one on Reappraising AIDS’ website) of dissident scientists, many of whom have a financial interest in “alternative” AIDS treatments or work in fields not even tangentially related to virology or epidemiology. These twin strategies used by dissidents to replace the mainstream AIDS consensus with a dissident version serve to mislead the public and obscure the truth.

A related tactic used by dissidents is “moving the goalpost”. When members of the mainstream AIDS movement offer new data in support of their view, dissidents regularly call for more or “better” evidence. Christine Maggiore, founder of the dissident website Alive & Well AIDS Alternatives, declares, “Since 1984, more than 100,000 papers have been published on HIV. None of these papers, singly or collectively, has been able to reasonably demonstrate or effectively prove that HIV can cause AIDS.”

A more subtle tactic employed by the AIDS dissidents is the exploitation of the widespread disenchantment with the scientific and medical establishment. The movement finds an eager audience among those frustrated with the high-priced treatments currently available for AIDS and the apparent lack of progress toward a vaccine or cure. This dissident strategy is especially effective among developing countries, racial and sexual minority groups, and others who have been historically exploited or oppressed by the predominantly wealthy, white, and Western establishment. Some dissident groups like VIRUSMYTH portray mainstream AIDS researchers as greedy capitalists profiteering from a fraudulent conspiracy that exploits the less fortunate. Such techniques engender skepticism and distrust toward the scientific mainstream among the public and continue to attract many individuals to the AIDS dissident movement.

So ultimately, given their occasionally disingenuous strategies, how should the AIDS dissident movement be viewed in the context of the global AIDS pandemic? I asked Ron Hudson, the activist I mentioned at the beginning of this installment, for his view on this controversial group, based on his previous interactions with them. He expressed his concern over their effect on efforts by mainstream AIDS activists to reduce and prevent the spread of HIV. He worries that the speculation and inadequately tested therapies offered by some dissidents may be construed as valid guidelines for AIDS treatment and prevention and therefore increase the risk of individuals for exposure to HIV. At the same time, however, Ron also supports the respectful exchange of ideas between individuals in the dissident movement and those belonging to the AIDS mainstream. I think that Ron makes an important distinction here regarding the dissidents, that between productive dissent and dogmatic denialism. Dissent can facilitate understanding and illuminate previously unexplored facets of HIV and AIDS, but denialism fosters animosity and suppresses established scientific facts regarding the disease. In order for the dissident movement to positively affect the AIDS pandemic, the scientific community should discourage detrimental denial and promote constructive dissent. This strategy, in my opinion, will prove to be the most effective in dealing with the AIDS dissident movement in the future.

Thanks for listening. I’m Bill Stokes.
References:

Myths and Misconceptions about HIV/AIDS

2008-04-07T14:14:00.000-07:00

Myths and misconceptions about HIV and AIDS have been around since the very beginning of the pandemic. The first myths stemmed largely from the lack of information on this relatively new disease. One of the first myths, one that claimed that AIDS was a gay disease only, was strongly encouraged by the media. This exacerbated problems with prevention as misinformation was widely circulated. Since then, new myths have emerged. These myths have emerged despite the fact that there is now more accurate information on HIV. These new myths also create problems with prevention as people unknowingly put themselves at risk to contract the virus.

Myths and Misconceptions about Prevention and Transmission
There are many contemporary myths and misconceptions about HIV prevention and transmission and they originate from many parts of the world. Some are about the demographics of the virus and claim that HIV/AIDS is a Black Person’s Disease only or that it only affects IV drug users. There is also the misconception in parts of Africa that there are young “virgin” prostitutes or special villages free from AIDS. There is also the speculation that HIV/AIDS is worse in Africa because Africans are hypersexual. Others come from theories on the origins of the virus. Some people think that HIV was engineered by the government for the purposes of exterminating Africans, African Americans and homosexuals. Others think that HIV was sent by God as punishment for sin. Other myths and misconceptions are about prevention and transmission. Among these are the misconceptions that only promiscuous people contract HIV, that women cannot transmit HIV to men, that people with HIV look sickly or have body odor, and that HIV does not cause AIDS. One very dangerous misconception about transmission is that two HIV positive people do not need to use condoms during intercourse. This misconception is dangerous because infection with multiple strains of the virus can occur. Paranoia has led to many myths. Some of those myths claim that HIV-Positive criminals are lurking, ready to stab victims, that AIDS can be contracted from a toilet seat, and that hugging an HIV-infected person will lead to infection. People also believe that HIV can be transmitted through kissing, or eating from the plate of an infected person.
A recent article documented a very popular myth among prostitutes in Malaysia. According to Sarawak AIDS Network, or SAN, “prostitutes and their customers shake up a can of coca cola and spray their genitals before sex”. The belief is that the bubbles in the soda will kill the virus. Dr. Andrew Kiyu, a SAN member, said that this myth likely emerged because people have seen doctors use detergent to cleanse the wounds of patients. Other myths have emerged based on current information about HIV/AIDS. As a result of scientists saying that HIV can be transmitted to women via bruises within the vagina, one popular myth states that if sexual intercourse can take place without bruises through which the virus can gain entry into the blood stream, infection will not occur. Some people believe that HIV cannot be contracted from getting tattoos and body piercings based on the fact that HIV is unlikely to be transmitted via kissing. Another myth, this time based on the knowledge of false-positives and false-negatives in testing, states that you can test negative once you’ve tested HIV-positive.

Myths and Misconceptions about a Cure
Other myths and misconceptions come from ideas about possible cures for HIV. People from diverse religious backgrounds believe that there are lucky charms, magic potions, or special rituals that can be used to prevent or cure the virus. There are also many proclaimed herbal and chemical cures; some include armenicum, colloidal silver, tetrasil, and virodene. Others think that taking ‘Immune Boosters’ or vitamins can cure AIDS. Some South Africans believe that a product called Ubhejane that is sold in pharmacies is a cure for AIDS. The creator of Ubhejane, Zeblon Gwala, says that it reduces viral load and increases CD4 counts in HIV positive people. Despite the fact that scientists have tested Ubhejane in the lab and found that it demonstrates minimal benefits, Ubhejane continues to sell.

Image Courtesy of Avert. “The fake AIDS cure Ubhejane on sale in a South African pharmacy.”

Other myths stem from celebrities and their HIV/AIDS status. Because some celebrities, like Magic Johnson and Andrew Stimpson, have been diagnosed with HIV and have not yet developed AIDS after a number of years, another popular myth is that there is a cure, but only rich people know about it because they can afford it.
One very popular myth that often leads to violence against women and young children is the myth of virgin cleansing. In parts of Africa it is widely believed that having sexual intercourse with a virgin will cure HIV. The belief is so widespread that leaders have launched campaigns to dispel it. In Zambia, billboards that depict small children and state that sex with them doesn’t cure AIDS have been placed in many areas.

Image Courtesy of Avert. “A road sign in Zambia confronting the "virgin AIDS cure myth."

In addition to this myth of virgin cleansing, is the myth of animal cleansing or specifically, that having sex with animals will cure HIV. People have also ingested and injected hydrogen peroxide because some alternative health practitioners have advocated it as a cure for HIV.

Problems with Prevention
These and other myths lead many people to expose themselves to HIV despite information that proves the contrary. This creates problems in the endeavor to curtail the spread of the virus. Though many of these myths are popular and affect those in the developing world, some of them do pose problems in the United States. Sex workers in different countries who, because of poverty, cannot switch their profession in the face of the AIDS pandemic may rely on some of these myths. Addicted drug users, who frequently encounter contaminated needles, may rely on some of these myths. The naïve adolescent who may be about to engage in sexual intercourse for the first time, may rely on some of these myths. There are present efforts in place to dispel these myths and most of the initiatives take the form of websites. However, more efforts are required before all of these myths and misconceptions are finally put to rest.

I’m Shanawa Richardson. Thanks for Listening.

The Stigmatization of Homosexuals and Individuals Living with HIV/AIDS in Jamaica, W.I.

2008-02-22T12:09:00.000-08:00

The HIV/AIDS epidemic hit the Caribbean in the early 1980s and was primarily transmitted by homosexual men. However, this trend was greatly reversed in the mid-1980s in which the main mode of transmission became heterosexual sexual contact. Despite the reversal of the mode of transmission from homosexual men to heterosexuals, there remains a large group of individuals in the Caribbean that still view HIV/AIDS as a “gay disease”. In the Caribbean, the most stigmatized groups that have HIV/AIDS are homosexuals (particularly men) and sex workers. As a result of this stigmatization, homosexuals and sex workers are denied health care and are victims of harassment and hate crimes in many Caribbean islands. Jamaica has the third largest population in the Caribbean of people living with HIV/AIDS. Of the Caribbean islands, Jamaica has dealt with major social issues caused by the stigmatization of homosexuals and people living with HIV/AIDS. A great deal of these issues is perpetuated by ignorance, politics, and one of Jamaica’s major genres of music, dancehall reggae.

Homophobia in the Caribbean stems from deep rooted cultural beliefs and values. Heterosexism in the Caribbean is centered on the ideals of masculine dominance; therefore, individuals that veer from such standards are ostracized and criminalized within these communities. HIV/AIDS is on an increase in Jamaica with an estimated 1.5 percent of people infected. However, the stigma of Jamaican homosexuals with HIV/AIDS which are enforced by law enforcement and the public has caused HIV positive homosexuals to be reluctant about seeking help for their illness. The link between HIV/AIDS and homosexuality in Jamaica has also resulted in HIV prevention programs and services to be negatively targeted within the community. People infected with HIV/AIDS in Jamaica also face difficulties receiving treatment in health facilities because health workers discriminate against them, provide poor care, talk to them in demeaning manners and even denying them treatment.

The stigma associated with HIV/AIDS and homosexuality in Jamaica is also perpetuated within political organizations. Jamaica has one of the most strict sodomy laws of any Caribbean island. Jamaica’s Offences against the Person Act, Article 76, states: “Whosoever shall be convicted of the abominable crime of buggery (anal intercourse) committed either with mankind or with any animal, shall be liable to be imprisoned and kept to hard labor for a term not exceeding ten years.” This law is definitely an impediment of human rights and serves as a justifying tool for police officers who harass, beat, and incarcerate homosexuals. There have been cases in which police officers have stopped HIV prevention and support groups from helping men who have sex with men. On a political scale, the Jamaica’s Prime Minister, PJ Patterson has been unresponsive to reports by the HIV/AIDS program’s repeal of discriminatory legislation. Additionally, the Jamaican Labor party encouraged the discrimination of homosexuals in 2001 by adopting the song called “Chi Chi Man” as their theme song. The song celebrates the killing and burning of gay men. On the eve of World AIDS Day 2006, Steve Harvey, a Jamaican gay leader and prominent AIDS activist was abducted from his Jamaica home and killed by four gunmen. Harvey was an open homosexual and the director of an AIDS Support outreach program in Jamaica that focused on helping sex-workers and homosexuals.

In Jamaican dancehall and reggae music there are repeated antigay lyrics that encourage violence, murder, and the segregation of homosexuals. Such lyrics refer to homosexuals as: “battyman” or “chi chi man”, which are derogatory words in the Jamaican Creole known as “patois”. The word “battyman” comes from the term “batty” which means buttocks and refers to homosexual men that have anal intercourse. Likewise, the word “chi chi man” is a derogatory slang for men who have intercourse with other men. In the song “Boom, bye, bye”, the reggae artist Buju Banton sings: “Boom, bai bai, iina battybwoy hed/ Ruud buai no promuot no naasi man/ Dem hafi dead/... Sen fi di matic ahn di Uzi instead/ Shuut dem, no come ef ei shuut dem”. In translation, the singer is saying: “Boom, bye, bye, in a faggot’s head/ Rude boys don’t promote nasty men/ They have to die/... Send for the automatic and the Uzi instead/ Shoot them, don’t come if we shoot them.” This song is one example of many anti-gay songs that are popular and well-liked in Jamaican and Caribbean culture.

So, what has been done to combat the homophobic and HIV/AIDS issues in Jamaica? The Jamaican Government’s Ministry of Health is aware of the impact that the country’s homophobic stigma has on individual willingness to seek treatment for HIV/AIDS. Likewise, they have noted that a key priority area is the development of human rights policies and legislation to protect individuals with HIV/AIDS. However, such policies have still not been developed. In 2001, the Caribbean Community (CARICOM) established the Pan Caribbean Partnership on HIV/AIDS (PANCAP). The PANCAP focuses on AIDS prevention, treatment, care, support, and ensuring the incorporation of international human rights protections in legislation and policies on HIV/AIDS. In late 2006, youths in Jamaica created radio public service announcements to reduce the stigma and discrimination linked to HIV/AIDS and to promote the rights of infected children. Such efforts like the PANCAP and public service announcements are some of the first steps in the reduction of the stigma associated with HIV/AIDS and the development of human rights protections in Jamaica. However, until the Jamaican government health care, law enforcement, and popular culture take active steps to end the stigmatization associated with HIV/AIDS and homosexuality, there will be no progression against the discrimination.

Courtesy of Jamaica Forum for Lesbians, All-Sexuals, and Gays.
This picture shows a Jamaican man attacked with machetes and
sticks because he was thought to be gay.

The Plight of AIDS Orphans

2008-01-04T10:37:00.000-08:00

Since the 1980’s, our knowledge of HIV has expanded greatly. However, in developing countries this information is either lacking or has not been taken to heart by the people who live in these cultures. One of the main reasons people are so clandestine in conducting conversations about AIDS is due to the fear and stigma attached to the word. AIDS orphans have a particularly difficult experience. An AIDS orphan is defined as someone who has lost one or both parents to HIV/AIDS. These children struggle to obtain even the basic necessities of every day life.

Children whose lives become entangled with people infected with HIV/AIDS have a difficult time coping and understanding their situation. Currently, there are more than eighteen million children who have been orphaned as a result of losing someone to HIV/AIDS. More than an estimated twelve million live in sub-Saharan Africa. Although inaccurate, the projected number of orphans as a result of HIV/AIDS in Zambia was 710,000. Zambia had fifty seven percent of all orphans nationally in 2005. In sub-Saharan Africa more than 55% of people living with either HIV or AIDS are women and young girls. However, these numbers are severely inaccurate for reasons which range from reporting to people failing to get tested. The children often suffer physical and emotional neglect long before the passing of their parents. Many of these children observe their parents wilting away right before their eyes. This would no doubt present a traumatic experience for anyone. In speaking with the only social worker in Mwandi, I was told that many of these orphans suffer abuse and exploitation at the hands of the very people who are entrusted to care for them. Other children experience what is known as the “sugar-daddy/momma” phenomena. This occurs when young children perform favors, which are usually sexual in nature, for older adults. It is not uncommon for these children to have several sugar daddies/mommas. Many of these adults infected with HIV believe that by having sex with a virgin they would somehow cure themselves of the disease. Both the social worker and the head clinical officer stated to me that these children undergo a great deal of psychological distress. Many of the children must be treated for bouts of depression, anger, as well as anxiety. Orphaned children often experience greater anxiety and depression when they are separated from their siblings and placed in different homes.

HIV/AIDS has put such a strain on the family structure and had such an impact on household situations, that establishments like the Orphans and Vulnerable Children’s Center has become a necessity in Mwandi, Zambia. In Mwandi alone, there are an estimated one thousand three hundred orphans or vulnerable children. With thirty-five percent of the Mwandi population infected with HIV/AIDS, the number of orphans in the area is certain to rise. These establishments have provided a safe haven for AIDS orphans for approximately four years. The OVC met some opposition from townspeople when the idea was first brought to the forefront. Now a few members of the community assist the OVC by bringing firewood for the oven. In many cases, the one meal that the OVC provides on a daily basis is the only meal some of the children will eat all day. The objectives of the OVC are to provide nutritional support by utilizing the feeding a program that provides one meal a day for children ranging in ages from six months to fifteen years old. The Orphan and Vulnerable Children Center also provides children with a daily multivitamin, to keep them from becoming ill often. They also assist in the continuance of good health and hygiene, by conducting health checks as well as teeth cleaning. Children in the OVC who are HIV-positive are given extra food and must get monthly checkups at the local hospital, the UCZ Mission Hospital. Although the program is designed to feed well over one hundred children, there are still many children in Mwandi who go to work and school with little to eat. The director, Fiona Dixon, of the OVC in Mwandi has implemented a vegetable garden as a means of assisting the feeding program. They have also begun selling extra tomatoes in the village in order to raise more money for the OVC.
Clothing has also another problem that confronts children in the rural area of Mwandi. Most of the clothes children wear are third or even fourth generation clothing. The criteria for receiving clothing and becoming a part of the feeding program, consists of being listed as one of the following: a double orphan, child-run household, single orphan-no father, single orphan-no mother, or a vulnerable child. However, the OVC is more than just a place where children can come and eat. This past August, the center began a bathing program in which the children were afforded the opportunity to shower every Saturday with soap. In Mwandi, soap is a luxury item that many parents and guardians can not afford. The OVC also received containers filled with hygiene bags that consisted of soap, toothpaste, a toothbrush, nailbrush, a towel, and a face cloth. The OVC also covers the educational costs for some of the children to attend school in either Mwandi or Sesheke. These costs include items such as boarding fees, school fees, uniforms, shoes, as well as stationary.

It also serves as a place where the children of Mwandi can gather and enjoy recreational and educational activities. Many of the children play football, known in the United States as soccer. I had the opportunity to play soccer with a group of young boys one day. As I played, I had to remind myself that these children were potential AIDS orphans and that they could possibly have HIV themselves. I found that these children were living with loss and possibly HIV to be incredible because they seemed to be so happy playing and interacting with their peers. Later on, I was astounded to be informed that the children at the OVC are not told of their status if they are HIV-positive until they are eighteen years old. This is the harsh reality of AIDS orphans in Mwandi, Zambia with the OVC as their only refuge.
The orphans must undergo a great deal of emotional and physical hardships after the loss of one or both parents to AIDS. Plainly put, HIV/AIDS orphans are not stable. Many of them tend to be rough in nature and do not relate well with their peers. In their formative years AIDS orphans tend to be very agitated. Overall, AIDS orphans need to be seen as more than damaged goods. The discrimination they face on a daily basis needs to be put to rest, and their rights need to be acknowledged and enforced. Unless these steps and many others are completed, there will be a generation of young people who are affected financially, emotionally, and socially. Their status may also play a role on the future of politics.

My name is James Hammonds. Thanks for listening.

HIV Research Funding

2007-12-19T11:25:00.000-08:00

It is often said that we know more about HIV than any other virus, and it’s likely to be true. In the 1980’s a staggering amount of scientific research regarding the genome, viral receptors, transmission of HIV, and drug development – including the FDA’s approval of AZT was accomplished. Scientists were hopeful that a vaccine could be developed within a few years, and it seemed that HIV might soon become a problem of the past. However, there is still much to be learned about the virus – and we have yet to see a successful vaccine. Since the 1980’s billions of dollars have been allocated for HIV/AIDS research and drug development. For 2007 alone, 2.6 billion dollars was allocated by the federal government for research on HIV.

Funding for HIV research is higher than for any other virus. But is it in the right places?
Image coutesy of the National Institutes of Health

Most of the funding for HIV research today can be categorized as either marketable and cure-finding, or non-marketable. Marketable research includes research to find a vaccine, drug development, and microbicides. These can be called marketable because they include research that has a potentially huge payback in the form of drug sales or scientific reputation. Global vaccine funding in 2006 was a whopping 933 million dollars, with significant contributions from the NIH (around 600 million), the European Commission, and the Gates foundation. Drug development still takes the largest chunk of the NIH’s HIV research budget at a little over 620 million dollars. Global funding for microbicide development in 2006 was roughly 222 million dollars – significantly less, but still an extremely substantial proportion of HIV research in total. Alone, vaccine and microbicide development take the great majority of research funding both globally and domestically, leaving little for other, less marketable research. Research concerning prevention for at-risk populations and highly impacted communities (especially those in poor nations) remains lacking as compared to budget increases for microbicide development. Without the potential payback that drug sales and vaccine development present, research is much harder to fund and therefore, less gets done. Even though HIV is the most researched virus by any measure, there are still aspects of its actions that are both poorly understood and poorly funded.

2.6 billion dollars is a huge sum of money for research, and not all of it is used by labs operated by the government. The NIH awards some of their allocated budget to other laboratories (often academic laboratories), thereby increasing the amount of researchers involved in HIV science. What can we do with our budget? Recently researchers have experienced a huge setback in vaccine development, as the most advanced vaccine in drug trials was scrapped because test subjects with the vaccine were contracting AIDS at the same rate as a placebo group. With the failure of the most promising vaccine so far, researchers are less hopeful that a vaccine can even be developed. Microbicides are a more recent addition to the field and have become popular recently as an alternative to traditional vaccines, as they are meant to be applied before intercourse to prevent the virus from taking hold. In their proposed budget for 2008 (which differs little from the 2.9 billion dollar budget of 2007), the NIH notes microbicides as an exciting field of research that will receive the most increased funding of any area of research. No matter what the immediate outcome, it seems that we’ll be spending many more billions of dollars before research rewards us with a solution to the AIDS crisis.

Merck announces failure of V520 HIV vaccine candidate

2007-12-07T13:06:00.000-08:00

On September 21, 2007, Merck announced the disappointing news that the Phase IIb testing of it’s V520 as an HIV vaccine candidate would be cut short per recommendations of the study’s Data Safety and Monitoring Board. The National Institute of Health and the National Institutes of Allergy and Infectious Diseases worked with Merck in a clinical trial that began in 2004 named the Step Study involving 3,000 HIV-negative, but “high-risk” individuals in North America, South America and Australia. During a preliminary review of data, the DSMB found 24 of the 751 volunteers who received one dose of V520, and 19 of the 672 who received two doses became infected with HIV. They found nearly identical rates of infection in those who had received placebo. Moreover, those who became infected after being vaccinated with V520 did not show significantly reduced viral loads, indicating that the vaccine did not have the desired therapeutic effects.

Also put on hold was a study of the same vaccine candidate in South Africa. The so called Phambili study (from the Xhosa word for ‘moving forward’) began in February 2007 and involved around 800 candidates. V520 had been developed against the B subtype of HIV that is more common in the Americas, but smaller trials had shown that the vaccine had the potential to produce cross-clade immunogenicity to the C subtype that is prevalent in South Africa. The Phambili study also differed from the Step study in that in was aimed primarily at heterosexuals at high risk for infection, while the Step study centered on homosexuals. No more volunteers in either group will receive vaccinations, but those who have already been vaccinated will continue to be monitored.

Most previous vaccine attempts focused on the stimulation of production of antibodies capable of neutralizing the virus before infection is able to occur. This tactic makes successful vaccination difficult because of the high level of diversity that exists in HIV envelope proteins. The highly conserved portion of gp120 that binds with CD4 is not easily accessible to antibodies and so far current vaccination methods have not been able to produce a high enough titer of antibodies to provide immunity. In the V520 vaccine, Merck followed a different approach, aiming not for the production of neutralizing antibodies, but for a strong cytotoxic response capable of killing HIV-infected cells.

V520 is a modified adenovirus, the class of virus often responsible for the common cold. It was altered to display three synthetic HIV genes, gag, pol, and nef. The virus was changed in such a way that it was unable to replicate, and did not contain other HIV genetic information, so there was no chance of accidental infection. Gag, pol, and nef, code for HIV viral core proteins, enzymes necessary for replication and integration, and transcription regulatory proteins. By infecting human cells with a virus coding for these internal proteins of HIV, Merck sought to prime a cytotoxic T cell response directed against cells displaying these more conserved antigens, rather than trying to stimulate antibodies to HIV surface proteins. The vaccine was designed to stimulate the replication of enough cytotoxic T cells specific to gag, pol, and nef antigens that should HIV enter the body, infected cells would be killed before the virus spread to other cells. It was thought that if infection was still viable after vaccination, then the primed cytotoxic response might at least slow the rate of viral replication. Unfortunately, neither of these outcomes occurred.

While the failure of the vaccine was a disappointing setback in the quest for a cure, the study may still provide a useful example for future vaccine candidate trials. In most cases, the efficacy of a vaccine is not put to the test until phase III studies. These studies generally require around 10,000 volunteers and can cost more than $100 million to conduct. The Step study was what is often referred to as phase IIb, or a ‘test of concept’ study. While not in itself sufficient to license a vaccine, test of concept studies provide a less costly intermediate between phase II and phase III studies that allow researchers a relatively quick way of determining if it is worth it to proceed to phase III testing.

Despite this setback, other HIV vaccine research is still proceeding as planned. Sanofi-Aventis currently has a potential vaccine in a phase III trial in Thailand. The vaccine is also aimed at generating a cytotoxic response, but uses a modified canarypox virus as the vector and contains additional gene insertions. Sanofi-Aventis is expected to release data from the study in 2009.

I'm Andrew Johnson. Thanks for listening.

Cognitive Dissonance Theory & HIV/AIDS Prevention

2007-11-30T12:38:00.000-08:00

Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Ali Cundari.

Beyond the obvious physical symptoms associated with AIDS, there are many psychological and social implications surrounding this debilitating disease that we don’t often consider. Mass media efforts and expensive awareness campaigns have done a good job at spreading information to the general public, however, these programs have not been highly successful in reducing risky sexual behavior. Talking about sexuality and proper protection is a topic very uncomfortable to many people, even in today’s world, and this is the reason why many people fail to practice safe sex despite the vast knowledge about how this disease is transmitted. Additionally, a perplexing phenomenon exists among individuals outwardly preaching safe sex, but in reality, not using protection in their own sex lives. This type of insensible behavior is particularly prevalent among sexually active college students, who are aware of the risks and severity of AIDS, but proportionately, very few of them actually use condoms. Recently, several social psychologists have examined this hypocrisy by researching the effects of cognitive dissonance theory on safer sex practices.

Cognitive dissonance theory has been an integral component of social psychology for nearly 50 years, and according to this theory, dissonance arises when a person possesses two contradictory beliefs, or when a person’s attitude conflicts with an action that they chose to perform. This clash between attitude and behavior results in feelings of discomfort, and subsequently the conflicted individual strives to change either their beliefs or behavior to reduce this tension. Hypocrisy is considered a special type of cognitive dissonance, produced when a person decides to promote a behavior that in actuality, they do not practice. Several experiments have been conducted in an attempt to apply this theory to AIDS prevention.

Elliot Aronson was the major contributor to this field of research, and his original study (1991) placed young college students in the role of a HIV prevention educator, who is asked to advocate condom-use to others, but hypocritically does not use condoms in their own sex life. Half the students were asked to compile a list of their past failures to use condoms, when they had deemed it to be too awkward or impossible to do so. Each subject was then asked to compose a speech about the dangers of AIDS and the importance of using condoms for every sexual encounter. The students were quite willing to take on this role, believing it was a good idea to encourage sexually active people to use protection. Then, some of the students recited their speech in front of a video camera, after being informed that this tape would be played in a high-school sex-education class. This produced a high level of dissonance in the subjects. They were now preaching condom-use to others, but hypocritically had failed to practice this at earlier points in their lives. In order to remove this dissonance, the subjects would have to change their attitude to bring it in line with the position they were advocating. Essentially, they’d have to start practicing what they preached. Sure enough, Aronson’s results supported this hypothesis, and after the conclusion of the experiment, the students were far more likely to purchase condoms, which were available on a display table outside the experimental room. Several months later, Aronson followed up with these same students, and they reported that they were regularly using condoms and practicing safer sex.

Many further studies have been conducted, all producing results quite similar to Aronson’s findings. The results of these experiments could have a profound impact on the future of AIDS education and risk reduction efforts, forcing people out of a state of denial and into safer sex practices. Although almost everybody today would agree that AIDS is a huge danger and using condoms is important, the reality is very few of these people actually use condoms themselves. Aronson suggests that the solution to this problem is relatively simple. Society attempts to insulate themselves from a state of dissonance through denial, so in order to cut through this denial, we must directly confront people with their own hypocrisy. Whether it’s through personal and direct surveys or questionnaires, we need to make people realize their past failures and strive to regularly practice safer sex. People need to realize that AIDS is not just a problem for other people, but they themselves are at risk as well. Overall, cognitive dissonance seems to have a strong impact on human behavior, and we can hope to use such theories to encourage safer sex and address the growing social problem that is AIDS.

Thanks for listening. Until next time, this is Ali Cundari.

Testing and Treatment of HIV/AIDS in Children

2007-11-09T14:56:00.000-08:00

According to a 2006 UNAIDS/WHO AIDS Epidemic Update, there are approximately 39.5 million people living with HIV/AIDS throughout the world. Of those infected, 2.3 million are aged 15 or younger. Approximately 90% of children infected with HIV acquire the virus perinatally, meaning it is transmitted from a mother to her child during pregnancy, labor, delivery or through breastfeeding. According to the CDC, the prevalence of mother-to-child transmission of AIDS in the US has dropped significantly due to effective testing of pregnant women and treatment of those found to be infected; in resource poor settings, however, the testing and treatment of infected women is far less common. In 2005, the UNAIDS/WHO AIDS Epidemic Update found that only 9% of pregnant women in resource poor countries were offered any sort of prevention services, leading to a higher prevalence of pediatric HIV/AIDS infection in less developed countries. As the prevalence of women of childbearing age who are infected with HIV increases in resource poor settings, it can be expected that the number of babies infected from mother-to-child transmission will likewise increase.

Children infected with HIV/AIDS are confronted with an extremely high rate of illness and death. The World Health Organization has found that because of their unique metabolic and immunologic circumstances, HIV progresses rapidly in children, with an estimated one third of infants dying by the time they reach their first birthday and half dying by their second birthday. Although in most developed countries identification and treatment of HIV infected babies is quite successful, which allows those children to lead healthier and longer lives, the situation is quite different in resource poor countries where testing, much less treatment of infants and children is relatively unavailable. To begin with, testing may be unavailable to individuals in developing countries due to the distance, expense and impracticality of reaching those hospitals and clinics that provide testing. Even when testing is locally available, parents may be unwilling to test their babies for fear of stigma and prejudice associated with an HIV positive status. Furthermore, testing of infants in developing countries can require far more time than in developed countries. PCR tests are among the fastest and most effective ways to diagnose infants as they can be done within 48 hours of birth and results are available to the mother within 6 weeks of the completion of the test. PCR tests are rarely accessible and prohibitively expensive in resource poor settings where antibody tests are the norm. These antibody tests only begin to give accurate results 18 months after birth, and so babies in developing countries are oftentimes diagnosed far later than in developed countries, if they are diagnosed at all.

Aside from the difficulties in testing infants and children for HIV in resource poor settings, there continues to be a dearth of treatment for children found to be positive for the virus. Although both prophylaxis and HAART or highly active antiretroviral therapy can be extremely effective in treating HIV/AIDS and preventing opportunistic infections in children, the unique difficulties associated with treating children in resource poor settings mean that these therapies are widely underused. UNAIDS found in 2006 that “an estimated 380,000 children died of AIDS-related causes” and that, “the vast majority of these deaths could have been prevented either by treating opportunistic infections or providing HAART.” Similarly, a UNAIDS/WHO report found that nearly 90% of children who could benefit from ARV treatments are not currently receiving it. This lack of treatment can be attributed to several factors.

In many resource poor settings, antiretroviral treatment may simply be unavailable. Those countries where the HIV/AIDS burden is greatest such as in Sub-Saharan Africa are oftentimes the least able to provide treatment, and so a lack of resources oftentimes translates into a lack of prophylaxis and/or antiretrovirals. Prophylaxis has been found to be extremely effective in staving off opportunistic infections in HIV positive children and is useful in delaying the need for HAART in pediatric populations. Although prophylactic drugs are widely available and relatively cheap, a UNAIDS/WHO study has found that currently nearly 4 million children who could benefit from such treatment are not receiving it. This is probably the result of lack of available treatment sites and infrastructure in resource poor settings. This dearth of available treatment translates to ARVs as well as prophylactic treatments. Even in areas where adult ARV treatment is present, there is rarely a comparable pediatric treatment site. This is due to the fact that suitable pediatric drug formulations are oftentimes prohibitively expensive and impractical. Little research had been conducted in the area of pediatric dosages because in the developed world effective mother to child prevention had limited the need for pediatric ARVs. Because so few drugs are available in pediatric dosages, and those that are available tend to be far more expensive than those made for adults, most caregivers in resource poor settings are limited to providing either expensive and unpleasant tasting syrup formulas or cutting and crushing adult tablets to provide ARVs for their pediatric patients. Crushing the pills provides an inexact measure of the amount of medication that is administered. Since under dosage can result in resistance of the virus to the drugs, and over dosage can result in amplified side-effects, the lack of correct dosages inherent in using adult drugs for pediatric patients means this mode of drug administration is far from ideal.

Important steps have been taken to begin to provide better treatment for pediatric AIDS patients. In August of 2007 the US Food and Drug Administration (FDA) approved a special tablet for children with HIV that combines three antiretroviral drugs into one pill. The tablet can be dissolved in water for ease of administration which is required only twice a day. The drug is produced by the manufacturer Cipla Limited, a generic pharmaceutical company based in India. Though unapproved for use in the US, the drug has been authorized for use in developing countries where the need and demand is greatest. Despite the enormous implications for successful treatment of pediatric AIDS that this drug will bring, there are still substantial obstacles to be overcome before pediatric care and treatment of AIDS is fully complete. Mother-to-child transmission must be diminished in resource poor settings. In situations where prevention of mother-to-child transmission is not achieved, suitable infrastructure for administration of prophylactic and antiretroviral drugs to pediatric patients must be established. Movements and groups such as the “Stop AIDS in Children” campaign are working towards prevention of mother-to-child transmission and improvement of treatment for infected children. With support of both developed and resource poor countries, the relatively ignored problem of HIV/AIDS in children can be successfully addressed.

Until next time, this is Dominique Maietta for the AIDS Pandemic Podcast.

PRODUCT(RED): Philanthropy or Exploitation?

2007-11-03T07:19:00.000-07:00

Product(RED)

An earlier installment of this podcast from a year ago called attention to the launch of PRODUCT(RED) in the United States. Since the brand’s introduction, (RED) watches, sunglasses, t-shirts, cell phones, and iPods have been extensively marketed and sold, with some of the revenues going to support the fight against AIDS in Africa. Nevertheless, the (RED) brand has been a target of criticism for its commercial approach to a philanthropic endeavor. In this installment, I intend to take a close look at PRODUCT(RED) and its impact on the AIDS pandemic.

(RED)’s business model embodies the strategy of cause marketing, where for-profit companies and non-profit organizations collaborate in a joint initiative for their mutual benefit. (RED) currently has partnerships with several distinctive consumer goods companies, including Motorola, The Gap, Converse, Apple, and Emporio Armani. PRODUCT(RED) gives its partners permission to brand certain products as (RED), and in return the partners send a share of their profits from those products to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Hip, humanitarian, and business-savvy, PRODUCT(RED) panders simultaneously to Americans’ munificence and to their conspicuous consumption.

According to the PRODUCT(RED) website, as of September 2007 the sale of (RED) products has generated more than $45 million for the Global Fund. This money has been directed toward AIDS treatment and prevention programs for women and children in Ghana, Swaziland, and Rwanda. (RED) points out that its contribution to the Global Fund will be a steady, constant stream of revenue rather than a one-time lump sum donation, ensuring that the brand will have a sustained impact on its beneficiaries.

Most criticism against the brand has centered on the belief that its partners are taking advantage of the AIDS problem in order to turn a profit. Early detractors of the brand encouraged consumers to donate their money directly to charity and thereby bypass the middle-men (RED) partners siphoning off most of the revenues. Later, a particularly scathing article in the magazine Advertising Age cited the disproportionately large amount of money spent by the brand’s partners promoting their (RED) products compared to the amount the partners actually raised for the Global Fund from the product sales. More recently, Ben Davis, creator of a parody campaign called BUY(LESS), has written an open letter to (RED) CEO Bobby Shriver requesting both more transparency in the distribution of profits from (RED) products and a more direct way for consumers to contribute directly to the Global Fund without having to buy (RED)-branded products.

In the end, it is important to consider what PRODUCT(RED) really is. It is not a charity, but “an economic initiative”, according to its website. Accordingly, its partners’ financial interest in the (RED) brand gives them an incentive to ensure its continued success. So what if the amount of money spent by the partners promoting their (RED) products exceeds the amount they turn over to the Global Fund? The money is already designated for their advertising budgets and would be spent anyway. This way, it at least goes toward publicizing a good cause. And besides, strictly fiscal measurements of PRODUCT(RED)’s impact (in terms of dollars alone) understate the heightened general awareness that the brand engenders among consumers.

Debating whether (RED) is more philanthropic or exploitative in nature misses the point. Even its most ardent critics would agree that the brand is making a positive contribution to the fight against AIDS. The question is, could PRODUCT(RED) do more to achieve its stated goal to “expand opportunities for the people of Africa”? I think it could.

Thanks for listening. I’m Bill Stokes.

References:
Bennett, J. Does Shopping for a Good Cause Really Help?. Newsweek. 14 March 2007.
Davis, B. Buy (Less), Give More. accessed 09 October 2007.
Kim, R. Africa’s Poor Had the Best Week Ever. The Nation. 15 October 2006.
The Persuaders, LLC. 2006. (RED). accessed 09 October 2007.
Vallely, P. The Big Question: Does the RED campaign help big Western brands more than Africa?. The Independent. 09 March 2007.

Integrase Inhibitors: A New Hope

2007-10-26T12:12:00.000-07:00

I’m Bevin English.

On October 12th, the Food and Drug Administration (the FDA) announced that it had approved a New Drug Application for a completely new kind of medication in the fight against AIDS. This drug, called IsentressTM, is the first integrase inhibitor and comes in 400 mg tablets that are taken twice daily. Produced by Merck & Co., Inc., Isentress, whose generic name is raltegravir and whose in-development name was MK-0518, has impressed many leading AIDS researchers, including Dr. Amneris Luque, medical director of the AIDS Center at the University of Rochester, who called the new drug “the road to hope for people who have failed all other AIDS medications.”

Before raltegravir’s approval, there were three oral anti-retroviral drug classes approved by the FDA: nucleoside reverse transcriptase inhibitors (also called NRTIs), non-nucleoside reverse transcriptase inhibitors (also called NNRTIs), and protease inhibitors (also called PIs). These drugs block two of HIV’s three enzymes that are necessary for infection: reverse transcriptase and protease. When HIV infects a cell, reverse transcriptase converts the viral genetic information from RNA to DNA. Integrase then inserts this viral DNA into the host cell’s genome. After the viral DNA has been translated by the host cell, protease cleaves the proteins into the functional units that come together to form protein coats for new viruses. These three classes of drugs have been used to treat HIV positive patients for many years. Nucleoside reverse transcriptase inhibitors have been used since 1987, when the FDA approved AZT. One of the most prominent non-nucleoside reverse transcriptase inhibitors, efavirenz, has been in use since 1998. And three common protease inhibitors, saquinavir, indinavir, and ritonavir, were approved by the FDA in 1996.

In Phase III clinical trials, raltegravir was administered to over 600 people who had viral loads greater than 1000 copies/mL and resistance to at least one drug in each of the three oral antiretroviral classes. In all trial groups, patients receiving raltegravir tended to have lower viral loads and higher CD4 cell counts than the control group, which consisted of patients receiving optimized background therapy (OBT) and a placebo. OBT is a personalized combination of different antiretroviral drugs that will most effectively increase an individual’s CD4 count and decrease his or her viral load; OBT is based on the patient’s history, current viral load and CD4 count, and any resistance tests. In raltegravir’s Phase III trial, the most dramatic result was seen when the drug was combined with one or two other active drugs, with 98% of patients’ viral loads below 400 copies/mL after 16 weeks. Data from on-going Phase II clinical trials show that raltegravir in combination with OBT maintains low viral loads over an extended period of time, with 64-71% of individuals achieving loads below 400 copies/mL and 46-64% of patients having loads less than 50 copies/mL after 48 weeks of the therapy.

Side effects of raltegravir were generally reported as mild to moderate and caused fewer than 2% of participants to discontinue therapy; nausea, headache, and diarrhea were the most common. Currently, there are no known drug interactions, although further studies must be conducted to investigate any possible drug interaction issues. Because of raltegravir’s efficacy, safety, and tolerability, the FDA gave this new drug priority review status, meaning that the Administration promised to review the drug within six months of their reception of the New Drug Application because it could potentially help with unmet medical needs.

However, it is important to note that “[t]he fight will not end with raltegravir,” as AIDS activist and participant in raltegravir clinical trials Matt Sharp stated to the FDA. One problem is that the drug simply has not been around long enough for scientists to understand its long-term effects in vivo. It has been less than four years since the drug was first used in humans and less than three years since it was first used in HIV positive individuals. During clinical trials, researchers observed more cases of different cancers, including lymphoma, squamous cell carcinoma, and hepatocellular cancer, among individuals who received raltegravir. Upon analysis, researchers claimed that the increase in the occurrence of cancers was not significant. However, any patient receiving raltegravir must be observed for the long-term to ensure that the drug does not lead to an increased risk of cancer.

Another important issue that must be taken into consideration is viral resistance to the new drug. In vitro data has shown that HIV can become resistant to raltegravir, but resistance generally occurs after serial passage in cell culture for several months. During clinical trials, 16% of patients were virological failures in the raltegravir group after 24 weeks. However, researchers remain hopeful that second-generation integrase inhibitors, such as Gilead’s elvitegravir, which is currently undergoing Phase II clinical trials, may help overcome resistance.

Despite the uncertainty of raltegravir’s long-term effects in vivo and the possibility of resistance, this breakthrough drug marks a milestone in AIDS treatment. The first integrase inhibitor, raltegravir, in combination with other drugs, has shown to be extremely effective in reducing viral loads and increasing CD4 counts, even in patients whose treatment options are severely limited by multi-class resistance.

Integrase Inhibitor Isentress Provides a New Way to Treat AIDS Patients

2007-10-26T11:31:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I’m Mike Neri.

In this podcast, I will talk about the optimism surrounding the recently FDA approved AIDS drug Isentress, including how it works, what step in the HIV replication cycle it affects, and what preliminary data show about the drug’s effectiveness and side effects. Ever since the discovery of HIV as the causative agent of AIDS, scientists have searched for weaknesses in its life cycle that they can exploit. As early as 1990, scientists had identified 13 pathways in the life cycle of HIV where the virus was susceptible to treatment. Unfortunately, due to the years of trial and error necessary to produce safe and effective drugs, new AIDS medications are developed slowly, and often have many side effects.

But optimism is high after the new drug Isentress showed very promising results when acting on a novel pathway to inhibit HIV replication. Isentress, also called Raltegravir, was developed by the Merck Corporation. It’s the first drug in a new line of AIDS medications called integrase inhibitors. As the name suggests, these drugs target an enzyme called integrase that the virus brings with it into an infected cell. Integrase, along with two other enzymes called reverse transcriptase and protease, is essential for HIV’s replication within the host. Therefore, scientists believe that if they can find a compound that stops integrase, they may be able to stop HIV from replicating.

After HIV has entered the cell by fusing with the membrane of its target cell, the virus dumps its genetic material and enzymes inside. It then makes copies of its own genetic material and uses integrase to insert them into the DNA of its host. This allows the virus to replicate its genome using the host’s machinery, and essentially take over the infected cell for its own reproductive purposes. The goal of integrase inhibitors is to prevent integrase from working correctly, therefore keeping the HIV genetic material out of the host’s genome and hindering viral replication. Previously, there had been only four pathways that drugs target in the HIV life cycle, and none of them had targeted integrase. However, integrase is an attractive target molecule for drug development for a number of reasons. First of all, integrase does not resemble any known human proteins, meaning the chances of side effects are reduced. In addition, by going after a new viral pathway for infection, doctors can combine integrase inhibitors with drugs targeting different pathways, which prevent the virus from becoming resistant to an entire class of drugs.

Scientists have long wanted to develop an integrase inhibitor, but the road to creating an effective drug and gaining FDA approval for it is a long one. According to Merck’s website, research into integrase inhibitors began in 1993 and eventually resulted in the identification of a class of compounds that could impede the function of the enzyme. These compounds work by binding to the active site of the integrase, thus preventing it from binding and cutting the host DNA, which prevents the viral genome from being inserted. After this discovery, researchers worked with these compounds in the lab to create the best integrase inhibitor, and tested it in virus cultures and animals. The use of animals allowed them to get an idea of the severity of the side effects and an approximate idea of the appropriate drug dosage. The final product of this drug testing was named Isentress. After emerging from the laboratory phase, Isentress was put through three phases of clinical studies involving groups of healthy and sick people. Results from the studies of Isentress given with a combination of other AIDS drugs were compared to a placebo given with the same drugs. From these data, researchers were able to get an idea of the effectiveness of the drug in treating the virus and fine-tune dosage information, all while closely monitoring side effects. At the end of this process, Merck submitted the data from all of the tests and clinical studies to the FDA for it to decide whether the drug was safe to be offered on the market. And on October 12, 2007, Isentress was officially approved by the FDA for treatment in AIDS patients, specifically those with HIV strains resistant to all other drugs. Most of the optimism surrounding the approval and release of the drug comes from the data obtained in the clinical studies. In the later phases of these trials, Isentress and a standard combination of other drugs were given to the most drug-resistant patients and compared to a placebo group. After 16 weeks, the Isentress treatment reduced the viral load to almost undetectable amounts in nearly 80% of patients, compared to only 43% in the placebo group.

While questions concerning Isentress still remain, such as whether the drug will work over longer periods of time and what the long term side effects might be, the preliminary results suggest that Isentress will have a significant impact on the treatment of AIDS immediately. As mentioned before, Isentress is initially expected to be used in patients who have exhausted all other drug treatment options. However, the overwhelming success of the drug so far has medical professionals wondering whether it can eventually be used as a front-line treatment against HIV. The true impact of Isentress cannot be known until it has been used by all types of AIDS patients over long periods of time. Nevertheless, the approval of Isentress is a sure sign for optimism in the AIDS community and a great success for the drug and pharmaceutical companies that have spent years producing and testing it.

I’m Mike Neri, and thanks for listening.

HIV/AIDS: The Brazilian Response

2007-10-21T12:49:00.000-07:00

In the arena of HIV/AIDS prevention and treatment, Brazil has become a beacon of hope, particularly among developing countries. Countries around the globe are now looking towards their system of universal AIDS care for guidance.

In the early 90’s it was estimated that within a decade, the number of HIV+ people in Brazil would be near 1.2 million. Instead, recent estimates suggest that only half that amount (about 660,000 people) are infected. How have they been so successful in limiting the spread of this deadly disease? With a three pronged government program focusing on prevention, treatment, and reducing the stigma associated with AIDS patients.

The first aspect of Brazil’s plan hopes to prevent the spread of HIV, particularly among the highest risk groups. After a brief stint of abstinence education failed early in the epidemic, the government looked towards other alternatives. Surprisingly, even in a country that is dominated by the Catholic Church, promoting condoms has proven very effective. The government has plans to distribute millions of condoms through local clinics, particularly to those involved in the commercial sex industry. Condom distribution is intensified during Carnival, a lively celebration before Lent where “free condoms are passed out like candy.” They have even encouraged the adult films industry to incorporate condoms into their films, and have produced prime time TV ads promoting condom usage in homosexuals. Additionally, a government funded needle exchange program hopes to slow down the spread among IV drug users.

A particularly intriguing aspect of Brazil’s treatment program has been their ability to supply anti-retroviral drugs to any AIDS patient needing them. As of September 2005, over 170,000 patients who required treatment were receiving it for free from the government. On a recent visit, the head of Uganda’s Parliamentary Committee on HIV/AIDS affirmed that “being able to provide the same standards of care to all citizens irrespective of their status in society is something to emulate.” This program, which began in 1997 as the first of its kind in the developing world, has lead Brazil to seek cheaper prices in order to keep costs down. A government sponsored company produces generic forms for many of the most widely used drugs. They have even broke patents on some of the newer drugs as costs have continued to skyrocket. Under fear that the Brazilian government will bypass the patent system, many companies have opted to cooperate and lower their prices. Even still, treatment makes up about 80% of their AIDS budget.

Contrary to many aspects of the US AIDS program, the Brazilian government has worked to gain the support of many of the most at risk groups. In 2005, Brazil rejected over $40 million from the United States because they would have had to pledge that they oppose commercial sex work; having the support of the sex industry has been integral in their fight against AIDS. Additionally, focusing on treatment instead of solely on prevention has encouraged testing and reduced stigma for those suffering with AIDS.

The model system that Brazil has implemented is envied by many countries around the world. Even the United States could learn from Brazil’s focus on condom distribution and treatment, as well as their support for constructive dialogue about the disease.

For more information about the current status of HIV/AIDS in Brazil, go to Brazil’s page of the UNAIDS website.

I’m Ben Young, thanks for listening.

The AIDS Pandemic - Your Thoughts

2007-07-30T10:37:00.000-07:00

Welcome to this installment of The AIDS Pandemic. I’m Dave Wessner.

Last week, I was invited to speak about this blog and podcast at the annual meeting of the American Society for Virology in Corvallis Oregon. Based on questions and comments I received, I’d like to try something a little different with this installment. I’d like to ask for your opinion of this project.

Before getting your feedback, though, I’d like to remind everyone about the genesis of this podcast. I began it during the summer of 2006, just over a year ago. Throughout the fall, students enrolled in my course on HIV/AIDS at Davidson College developed and recorded installments, which we then posted throughout the academic year. Beginning in September, a new group of students will continue this project, recording and posting more interesting installments. My goals for this class assignment were two-fold. First, I hoped that the creation of podcast installments would provide a good learning experience for my students. It would give them an opportunity to explore in detail some aspect of the pandemic – scientific, social, political – that truly interested them. Second, I hoped that the podcast itself would be some benefit to the outside world and, in some small way, increase public understanding of HIV/AIDS.

I can assess the impact of this class assignment on my students. And I am convinced that it is a worthwhile exercise. But I’m less sure how to assess the broader impact of this podcast and blog. That’s where you come in. I’d appreciate feedback from you. Please tell me if you listen to the podcast and/or read the blog. How did you first hear about it? How regularly do you listen/read? What topics have you found most interesting? Is it a worthwhile source of information? Are there things we could do better? Have you ever looked at our AIDS and pop culture website? Is it a worthwhile source of information?

You can email your responses to dawessner@davidson.edu.

Thanks for your input.

National HIV Testing Day

2007-06-22T11:26:00.000-07:00

Welcome to this install of The AIDS Pandemic, a podcast hosted by Dr. David Wessner of Davidson College. I’m Dave Wessner.

June 27 is the 15th annual National HIV Testing Day, an event sponsored by the National Association of People with AIDS to encourage people to get tested and learn their HIV status. Today, I had the pleasure of participating in a Webinar hosted by the Department of Health and Human Services and the Centers for Disease Control and Prevention about this important event.

During this Webinar, we were reminded of the CDC’s new recommendations about HIV testing – all individuals between the ages of 13 and 64 should be tested routinely on an opt-out basis. In other words, testing for HIV should be included in normal health care, unless a person specifically asks not to be tested. The reasons for this recommendation are several-fold. Most importantly, a majority of new infections result from transmission of the virus from an individual who does not know his or her HIV status and studies have shown that if people know their status, they tend to modify their behavior to reduce the risk of transmission. So increased testing should lead to decreased transmission rates.

Of course, there are important issues that need to be addressed. How can we reach underserved populations, including the homeless and uninsured? How can we reach young people? How will the costs of the test and necessary follow-up counseling be absorbed by our health care system? Despite these obstacles, though, the goal of universal, routine testing is admirable. I encourage everyone to get tested.

More information about National HIV Testing Day can be found at www.hivtest.org. This site contains information about HIV testing and has an easy to use test center finder. Simply type in your zip code and a list of local testing sites will be provided.

As the CDC testing campaign slogan states: Take the Test. Take Control.

Until next time, I’m Dave Wessner

Bush advocates $30B for PEPFAR

2007-05-31T08:53:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from Davidson College. I’m Dave Wessner.

Yesterday, President Bush implored Congress to extend PEPFAR, the President’s Emergency Plan for AIDS Relief, for an additional 5 years and allocate an additional $30 billion to the program. Initially proposed in the President’s 2003 State of the Union address, PEPFAR targets HIV/AIDS treatment in 15 countries with high HIV/AIDS burdens.

As President Bush noted, the $15 billion allocated to PEPFAR thus far has resulted in antiretroviral drugs for 1.1 million people in these resource limited countries and the increased funding could result in treatment for as many as 2.5 million people. This drug therapy, obviously, will extend and improve the lives of these lucky individuals. Arguably, then, PEPFAR is changing the HIV/AIDS landscape.

The plan cannot, however, be considered an unqualified success. Approximately 30 million people in sub-Saharan Africa alone are HIV positive. Providing treatment to 2.5 million of them is not enough. Until all people, in all countries, have access to the life-saving antiretroviral drugs, we can not be satisfied with any existing plan.

More importantly, we need to examine the restrictions associated with PEPFAR funds. One third of allocated funds must be spent on abstinence programs, despite the clear evidence that condoms are the most effective means of preventing the sexual spread of HIV. No funds can be spent on clean needle exchange programs, despite the clear evidence that needle exchange programs prevent the transmission of HIV and do not lead to increased injection drug use. The $15 billion currently allocated to PEPFAR has made a difference. And the additional $30 billion proposed by President Bush will make an even greater impact on the pandemic. President Bush should be commended for this initiative and his leadership. But President Bush also should be admonished for ignoring the scientific evidence. When it comes to the AIDS pandemic, decisions need to be based on evidence, not one person’s faith-based morality.

Until next time, I’m Dave Wessner

True Colors Tour for the Human Rights Campaign

2007-05-18T07:58:00.000-07:00

Welcome to this installment of The AIDS Pandemic, a podcast hosted by Dr. David Wessner from Davidson College. I’m Dave Wessner.

We opened this installment with a short segment from True Colors, by Cyndi Lauper, the iconic voice of ‘80s pop. Long supported by and a supporter of the gay, lesbian, bisexual, and transgender communities, Lauper recently announced her plans for this summer’s True Colors tour in support of the Human Rights Campaign. Along with Debbie Harry, the Dresden Dolls, Erasure, and others, Cyndi Lauper will headline this tour that opens June 8th in Las Vegas. A portion of all tickets sales will go to the Human Rights Campaign.

Throughout its 25-year history, HIV/AIDS has been inextricably linked to human rights issues. Sexual violence against women, stigma associated with men who have sex with men, young girls forced into prostitution – all of these human rights violations have contributed to the spread of HIV/AIDS. The Human Rights Campaign fights tirelessly to rid the world of these injustices. You certainly can help by becoming a member of the HRC and contributing to them directly. And this summer, you also can help simply by attending a great concert.

As Cyndi Lauper states on the Tue Colors Tour web site, “We should all have the right to live with the same dignity, opportunity and safety. It shouldn’t matter what anyone’s sexual orientation is.”

Until next time, I’m Dave Wessner.

Microbicides: Empowering women

2007-05-06T13:26:00.000-07:00

Current global AIDS statistics are staggering, to say the least. Approximately 40 million people worldwide are living with the disease, while 14,000 new infections occur each day. Women make up almost 50% of adult infections, but this figure is higher in sub-Saharan Africa, where women are 30% more likely to be HIV-positive than men. Due to physiological differences, women are twice as likely as men to contract HIV from an infected partner, but many lack the necessary tools for protection. Even if the tools are available, poverty and inequality can make it impossible for women to have control over their sexual interactions. The ABCs of prevention (abstain, be faithful, and use condoms) are useless without male cooperation. The ABCs are even more ineffective for married women with non-monogamous husbands because, as Melinda Gates states, “abstinence is unrealistic, being faithful is insufficient, and the use of condoms if not under their control.”
Microbicides are a new and important HIV prevention method that can put the power of protection in the hands of women. Microbicides are formulated as gels, creams, suppositories, or films that can kill or neutralize viruses when applied before sexual intercourse, thus preventing infection. Because women could apply the microbicide without the cooperation or awareness of their partners, they would have more control over preventing an HIV infection. Ideal microbicides would also protect against other STDs that can facilitate HIV transmission and come in spermicidal or non-spermicidal formulations that allow pregnancy while still offering protection. An ideal microbicide should be active upon application, remain active for an extended period of time, and be tasteless, odorless, and invisible in order to prevent detection and interference with sexual activity. Finally, for distribution and accessibility, an ideal microbicide must be cheap and easy to store.
There are three major approaches a microbicide can use to prevent infection. Some microbicides act as physical barriers that prevent HIV from entering tissue. They are liquid at room temperature, but become gel-like inside the body and work like a condom. Others contain molecules that inhibit the virus itself. They might create an acidic environment in which the virus cannot survive, or contain known anti-HIV drugs, such as AZT. Still others prevent infection by interfering with viral surface proteins, therefore preventing attachment. Researchers hope that multiple methods of prevention will be combined into one microbicide to increase effectiveness.
While no microbicides have been approved for general use, twelve versions are currently undergoing various phases of clinical trials. However, there are several important issues that stand between microbicide development and widespread use. Most microbicides are developed by small biotech companies and educational research institutions. Only 1% of federal research funding goes toward microbicide research, and pharmaceutical companies are unwilling to invest because the women who need their products will be unable to pay for them. Once microbicides are developed, they must go through a series of clinical trials. International support to build the necessary infrastructure for trials in developing countries is crucial so testing can occur in the locations where products will be most used. Microbicide producers are concerned about the low efficacy of first-generation microbicides and the potential for increased risk behavior, such as condom substitution. However, most agree that since condom use is rarely consistent, microbicides can provide better protection than nothing at all. Finally, only 20% of the population at high risk of infection currently has access HIV prevention methods. Even a 100% effective product does little good if it cannot be distributed to those who need it most.
While microbicide development is currently facing many challenges, there is no doubt that microbicides are a powerful HIV prevention tool. By giving women more control over HIV protection we can drastically reduce the number of new infections each year and save millions of lives.

I'm Page Bomar. Thanks for lsitening.

VIRIP: A new anti-HIV compound?

2007-04-20T10:01:00.000-07:00

Welcome to this installment of The AIDS Pandemic. I’m Dave Wessner.

Could our own bodies be producing potent inhibitors of HIV? According to research published in today’s issue of Cell, the answer may be ‘Yes.’ And these interesting findings eventually may lead to the development of new anti-retroviral drugs.

Since the isolation of HIV in 1983, numerous naturally occurring human factors have been postulated to have anti-HIV properties. Today, a group of researchers in Germany have added another factor to this list. By studying hundreds of small molecules isolated from human blood, the researchers identified a short peptide, or protein fragment, that effectively blocked HIV from infecting cells. Termed Virus-Inhibitory Peptide, or VIRIP, this peptide represents a small piece of a larger protein normally found in our blood – alpha1-anti-trypsin.

To demonstrate the inhibitory effects of VIRIP, the researchers infected cell lines with HIV-1, added VIRIP to the cells, and then determined how many additional cells subsequently became infected. VIRIP decreased the infection rate in a dose-dependent manner. In other words, when higher concentrations of VIRIP were used, the effect was greater. The effect also was very specific for HIV; the peptide did not block the infectivity of other types of viruses. Interestingly, the researchers showed that if they altered the VIRIP peptide slightly, it’s inhibitory properties increased dramatically. Finally, VIRIP was equally effective against strains of HIV that were resistant to other anti-retroviral drugs, yet resistance to VIRIP was not observed.

Mechanistically, it appears that VIRIP blocks HIV infection by binding to the viral protein gp41 and preventing fusion between the viral envelope and the cell membrane. An existing drug, T20, or Fuzeon, works in a similar manner.

The path from an initial discovery like this and a marketable drug is a long and winding path, filled with potholes. Promising candidate molecules rarely become FDA-approved drugs. So, the odds are against VIRIP. But, based on this report, it’s certainly worth keeping our eye on it.

Until next time, I’m Dave Wessner.

Kiva: Using microfinancing to help people in developing countries

2007-04-14T10:53:00.000-07:00

Paul Farmer, one of the founders of Partners in Health, describes the ‘great epi divide,’ the epidemiological divide that exists between developed countries and developing countries, between affluent neighborhoods and less well-off neighborhoods, between the haves and the have-nots. Morbidity and mortality associated with infectious diseases, Farmer notes, correlate well with economic disparities.

HIV/AIDS is no exception. Certainly, HIV can, and does, infect people of all walks of life. Increasingly, though, the HIV burden is highest among developing countries and the poor within developed countries. The reasons for this correlation are many. In economically challenged areas, medical care and treatment often are unavailable or unaffordable. In these areas, access to education may be limited. The list goes on.

One could argue, then, that improving the economic independence of people is the ultimate weapon against the spread of HIV. One group addressing the issue of economic independence in developing countries is KIVA. Kiva, Swahili for ‘agreement,’ is a non-profit organization designed to help people gain economic independence through microfinancing. Individuals can search the Kiva web site for people in Africa, central Asia, eastern Europe, and other parts of the world, who have great ideas, but need some initial capital. Through Kiva, one can make small, interest-free loans to these individuals. In some cases, a few hundred dollars may be all that a person needs to open a small bakery or expand a pottery shop.

The loans aren’t guaranteed; as a donor, you may never be repaid. But the results could be transformative. A little seed money may be all a person needs to become self-sufficient and cross the great epi divide.

Find out more about Kiva and help someone make their dreams a reality.

Until next time, I’m Dave Wessner.

Refrigeration and HIV Meds in Resource-limited Settings

2007-03-30T12:23:00.000-07:00

I'm Charlie Raver.

One of the distinguishing characteristics between the AIDS epidemic in the developed world and that in Africa and the developing world is a simple lack of the infrastructure to deal with the disease. Infrastructure includes everything from roads to electricity to hospitals. One example that most of us rarely think of as a gift, couldn’t dream of walking into a home and not finding, and would be lost without is something to which many in the developing world do not have access. What am I talking about? Refrigeration. Without this amazing piece of technology we would not be able to easily enjoy fresh meats, fish, dairy, and many simple nutritional luxuries that we as Americans take for granted. In addition to problems with food preservation, hospitals and health clinics would be unable to store blood, vaccines, heat intolerant medicines, and many laboratory supplies.

For many in the developing world that is exactly the problem. Without refrigeration they have no means to store many of the supplies necessary for maintaining a health clinic. Without this infrastructure, access to basic care, essential for the treatment of AIDS, is extremely limited. Recently, the WHO recommended the use of a ritonavir boosted protease inhibitor as part of the drug regimen. Aside from being able to obtain the drug, one problem is that ritonavir requires refrigeration in hot climates. Currently only one of the ritonavir boosted PIs is available in a heat stable form which, obviously puts a huge constraint on the availability of the drug in the developing world. A confounding issue is the high rates of coinfection of diseases such as tuberculosis and malaria in these resource poor areas. In addition to proper care, access to testing for HIV and TB has been cited as one of the first obstacles to fighting the epidemic. The WHO estimates that less than 10% of people living with HIV/AIDS in parts of Sub-Saharan Africa are aware of their HIV status.

In addition to poor access to health care, the epidemic is only made worse by the staggering rates of malnutrition. In their recommendations for antiretroviral therapy, the WHO emphasized the importance of nutrition not just for the overall health of the affected individuals but also because of the link between nutrition and the effectiveness of ART. However, in some parts of Sub-Saharan Africa, it is estimated that as much as 50% of the population is malnourished. Many Africans do not even have the means to buy or grow the most basic foods. This problem is again only made worse by the lack of refrigeration. Some form of food preservation could allow rural communities and individuals to grow crops in excess and store the surplus to either sell and trade with other communities or even just maintain a supply during the non-productive parts of the year. However, when you consider that over 500 million people in Sub-Saharan Africa do not have access to electricity the idea of refrigeration is a long shot.

Unfortunately providing those in rural Africa with electricity is a problem unto itself. Without economic stability there is little room for expansion and improvement of infrastructure whether it is roads, electricity or health care. These lacks in infrastructure only make the AIDS epidemic harder to fight which further hinders economic growth. However, small improvements like access to refrigeration could be a catalyst for change.

One type of refrigeration that requires no electricity is sorption refrigeration. This form of refrigeration works by having two chambers connected by some type of tube. One chamber, the hot side, contains an absorbent material. The other chamber, the cold side, contains a refrigerant. The tube connecting the two would be filled with refrigerant vapor. The vapor in the tube is then absorbed on the hot side causing a drop in pressure in the connecting tube. This causes evaporation of the refrigerant which in the process absorbs heat and causes cooling on the cold side. This continues until all the refrigerant has vaporized and been absorbed on the hot side. To restart the cooling process, the hot side must be heated gently to drive the refrigerant vapor out of the absorbent material and back to the cold side. In the late 1920s, Powell Crosley Jr. developed a commercial version using ammonia and water that was used throughout the rural United States prior to wide-spread access to electricity. Although this is by no means a large scale solution to the infrastructure problem, adaptation of these ideas for use in the developing world could provide one of the basic necessities for health care and food preservation.

AIDS Orphans in Sub-Saharan Africa

2007-03-23T11:34:00.000-07:00

I'm Christie Brough

According to the AIDS Epidemic Update of December 2006, about 25 million people are living with HIV in sub-Saharan Africa, comprising 63 percent of all individuals with HIV globally. Approximately 13.3 million, or 59 percent, of these individuals are women, most of whom have children. Although considerable efforts have been made to provide these individuals increased access to antiretroviral therapy, 2.1 million Africans died in 2006, resulting in an increased number of AIDS orphans.

In 2001, 14 million children had already lost one or both of their parents to AIDS. Because of the difficulty of obtaining antiretroviral therapy, many more children will be affected. In fact, one estimate projects that the number of AIDS orphans will increase by approximately 150 percent by the year 2010, leaving 20 million children to raise themselves.

As children watch their parents succumb to AIDS, they often suffer psychological and emotional harm. Once a parent becomes too sick to work, children are forced to work themselves in order to raise money for their families or to take care of younger siblings, causing them to drop out of school. Another factor forcing children to drop out of school is their inability to pay for required items, like school uniforms, pencils, textbooks, and exam fees, which they no longer can afford. If they do not have these items for school every day, they may be sent home and told not to return until they have the proper materials. Children that continue to attend school despite their parent’s illness often display a lack of attention or inappropriate behavior in the classroom, which is thought to result from emotional stress. Academic performance is also negatively affected by child malnutrition. Malnutrition is common in AIDS-related poverty since most of the family’s resources must be spent on medication for the ill parent. As a result, school enrollment rates in sub-Saharan Africa are dropping as the death toll from AIDS continues to rise.

Children that grow up without parents and without an education are “trapped in a social and pedagogical vacuum.” These children are not only more vulnerable to contract HIV/AIDS, but they are also at higher risk of unemployment, exploitation, and other forms of social inequalities. In order to change the outlook for AIDS orphans in sub-Saharan Africa, international and national agencies must aid in providing greater access to antiretroviral treatment. One relatively successful example is the World Heath Organization’s 3-by-5 program. The 3-by-5 plan aimed at providing 3 million individuals worldwide antiretroviral treatment by 2005. Although the program did not meet its goal of treating 3 million HIV positive individuals in the 2-year period, the program successfully provided access to many individuals who were not receiving treatment before. According to the World Health Organization, the number of individuals receiving treatment in sub-Saharan Africa increased by more than 800 percent, increasing the distribution of antiretroviral drugs from 100,000 individuals to 810,000 individuals.

Although the success of the 3-by-5 program will decrease the number of AIDS orphans in future generations, programs must be implemented to save current AIDS orphans. One option is the development of vocational training programs, which could help orphans stay off the streets (especially, young girls who are forced into sex work). If funds from debt relief programs are channeled directly into schools, school enrollment might increase. Another option is to offer government subsidies to extended families, which might help children stay out of work and stay in school. Additionally, providing government subsidies would maintain a family structure for children, keeping them out of orphanages. While these appear to be wonderful programs, the effectiveness of these programs would be difficult to monitor. Thus, before any programs are employed, local, national, and international governments and agencies want to ensure their success. However, it is imperative that these agencies act quickly before it is too late.

Stigma in the Lives of HIV+ Healthcare Workers

2007-03-16T12:10:00.000-07:00

I'm Pete Levandoski

Advances in HIV related pharmacology have given HIV patients extended lifetimes, turning them from dead men walking to living individuals with a debilitating condition. In treating any patient, HIV status not withstanding, the American Dental Association states that dentists should practice, “high ethical standards which have the benefit of the patient as their primary goal” (Rhode Island Dental Association, 2006). If the maxim is adhered to, dentists should have no problems treating HIV positive individuals who come to them seeking care. The fear of exposure to the virus however, has led some dentists to refuse treatment. In these instances, the Supreme Court has stepped in, ordering treatment and protecting the rights of patients. However, in jumping to the aid of patients, the High Court may have inadvertently aided efforts to discriminate against those living with HIV.

A landmark case for HIV patients was the 1998 affirmation of the ruling in Abbott vs. Bragdon. Sidney Abbott, an HIV positive individual, successfully argued that in refusing to treat him because he was HIV positive, Dr. Rondon Bragdon had violated the Americans with Disabilities Act. Bragdon’s unsuccessful defense was that Abbott’s HIV represented a “direct threat” to his own health (Sfikas, 2002).

In May of 2002, the “direct threat” defense was again used, this time in the case of Waddell vs. Valley Forge. The Court ruled that Spencer Waddell, an HIV positive dental hygienist, could be removed from his job because his disease was a “direct threat” to the health of his patients (Sfikas, 2002). The sum of these two decisions is that the idea of “direct threat” can legally be used to protect patients but not to protect dentists.

The same code of ethics that puts patients first also claims that this goal has lead to, “…society affording to the profession the privilege and obligation of self-government” (Rhode Island Dental Association, 2006). Above all, dentists want to retain autonomy and self regulation. In the process of trying to protect patients, these two court decisions have reduced the autonomy of dentists. Decisions in the cases of Waddell and Abbott should have been made by dental professionals, argues Peter Sfikas in his article in the March 2002 Journal of the American Dental Association (Sfikas, 2002).

In the Abbott case, the procedure being performed was a cavity filling, which involves little to no blood. In the Waddell case, root planning, which involves a large amount of blood, was being done. The courts made the correct decision in siding with the patient when looking at the evidence in each specific case (Sfikas, 2002). However, instead of maintaining a case by case system, the courts have set precedents which issue blanket statements without regard for case specifics. This has lead to the reality that the only way a dentist can refuse treatment is by preemptively providing evidence of a “direct threat” to his or her health from the patient (Sfikas, 2002).

These two court cases have gone a long way to advancing the rights of HIV positive patients. The Supreme Court stepped in and set a precedent to prevent HIV positive individuals from being denied healthcare. The Waddell case however, could be spun to deny rights to HIV positive individuals (Sfikas, 2002). The Court gave Spencer Waddell’s employer the right to fire him because he was HIV positive. In trying to protect the rights of patients, the court system has set a legal precedent which discriminates against HIV positive workers if they pose a “direct threat” to the health of their customers (Sfikas, 2002).
Waddell’s case was denied writ of certiorari by the Supreme Court, so it will be up to future cases to decide whether or not firing an employee because they have HIV is legal (Waddell v. Valley Forge Dental Assocs. 2002). Whatever decisions are made in future cases; these two examples highlight the complex interplay between human rights and stigma that HIV positive individuals still face in the United States today.

Sources
Sfikas PM. “HIV and discrimination: A review of the Waddell case and its implications for health care professionals”. The Journal of the American Dental Association. Vol. 133, March 2002. (pp. 372-374).
Rhode Island Dental Association. “Principles of Ethics & Code of Professional Conduct”. 2006.< http://www.ridental.com/ethics.cfm>. (29 November 2006).
Waddell v. Valley Forge Dental Assocs. 535 U.S. 1096. US Supreme Court. 2002.

AIDS dementia: Current findings

2007-03-09T09:33:00.000-08:00

Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Steve Halliday.

One of my most striking memories from my time spent in the hospital in Mwandi was towards the end of my stay when I saw a woman suffering from AIDS dementia who was in the courtyard screaming at the top of her lungs. I asked one of the hospital employees what was going on, and he responded “oh, she is confused.” Since that moment I’ve been interested in this symptom of late stage AIDS, and in today’s installment I am going to look at a paper that examines one possible cause of AIDS dementia, titled HIV-1 Promotes Quiescence in Human Neural Progenitor Cells by Krathwohl and Kaiser.

AIDS dementia is a purely clinical diagnosis, based on observations of cognitive decline and motor dysfunction, and occurs in approximately 6-15% of AIDS patients. The pathology of AIDS dementia remains elusive, however, and this article represents only one theory of how it is caused.

The article examines the possibility that HIV could inhibit the activity of recently discovered neural progenitor cells. These cells have been found to be capable of differentiating into new astrocytes and neurons, which are thought to then form synaptic connections with other neurons, increasing memory and replacing lost neurons in the hippocampus.
These progenitor cells exist in quiescent states until they are needed, and it has been found that these cells can be forced into quiescence by chemokines, which can be mediated by CXCR4 or CCR3. Because HIV-1 uses chemokine coreceptors it is thought that it may inhibit proliferation of progenitor cells and force them into quiescence.

To test whether HIV-1 could induce quiescence, the researchers used purified recombinant coat proteins from several stains of HIV-1 using proteins that signal through either CXCR4 or CCR3. They found that two strains caused plated progenitor cells to enter a quiescent state, reducing proliferation by 67 and 74%, while a third strain had no visible effect. They also discovered that by washing the plates the cells were able to begin differentiating again. The researchers went on to determine that the coat proteins of the effective strains induced expression of cyclin-dependent kinase inhibitors p21 and p27.

The researchers then sought to prove the HIV-1 coat proteins were mediated by chemokine receptor binding. They found that by adding pertussis toxin, which affects the G-proteins linked to chemokine receptors, the inhibitory effects of both effective strains were blocked, suggesting the suppressive effects of HIV-1 are mediated by chemokine receptors.
In addition to direct inhibition, HIV-1 was found to suppress phosphorylation of ERK, which stimulates neural progenitor cells. The two effective strains of HIV-1 were found on to inhibit ERK by 34 nad 77%. This was also shown to occur by signaling through chemokine receptors.

Having established that HIV-1 can inhibit neural progenitor cell differentiation, the researchers examined CerebroSpinal Fluid from patients suffering from AIDS dementia, and discovered that the CSF from patients suffering from dementia was able to suppress progenitor cells by 67% whereas CSF from patients without dementia showed no inhibitor effect.
They also determined that gp120 was responsible for this inhibition. Furthermore they determined that viral load for patients with and without dementia was similar, and presence or absence of antiretroviral therapy had no effect on the inhibitory effect of the CerebroSpinal Fluid.

The researchers then proved that both the HIV-1 coat proteins and the CSF from patients with dementia could reduce neural cell proliferation in human hippocampal tissue in vitro, and that autopsied hippocampal tissue from patients with dementia was found to contain 75% fewer neural progenitor cells than in patients without dementia.

This paper provides seemingly very conclusive evidence for the role of neural progenitor cells in AIDS dementia, but this is by no means the only area of research going on in AIDS dementia. Another paper, Pharmacological frontiers in the treatment of AIDS dementia by McGuire and Marder, discusses possibilities that reactants to viral products and macrophages may cause neuronal cell death, leading to dementia via a more direct route.

The pathology of AIDS dementia is complex and not easily deciphered, but hopefully with this continuing research an effective treatment can be found for this devastating AIDS related illness.

This is Steve Halliday signing off.

HIV/AIDS in Prisons

2007-03-02T13:47:00.000-08:00

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. 
Prisons have become a fertile ground for the HIV epidemic in the United States. In fact the Joint United Nation Programme on AIDS (UNAIDS) listed prisoners as one of the four "major at-risk and neglected populations" in the HIV/AIDS pandemic (2006 Report on the Global AIDS Epidemic). The other three categories included men who have sex with men, injection drug users, and sex workers (2006 Report on the Global AIDS Epidemic). Recent figures show that 2.3 percent of state prison inmates, and 1.0 percent of federal prison inmates in the United States are HIV positive, and an estimated 20 to 26 percent of people living with HIV have spent time in the correctional system (2006 Report on the Global AIDS Epidemic and Kantor 2006). The overcrowded and typically understaffed prisons in the United States are ideal breeding grounds for HIV. HIV is transmitted through bodily fluids with sharing needles and unprotected sex being the leading causes of virus transmission. Despite strict regulations against drugs in prisons, intravenous drug use still occurs. Clean needles are almost impossible to find and needles or improvised injection devices are often shared by inmates. These needles may also be shared for tattooing, another common practice in prisons. In addition to drugs, many inmates turn to sex to escape the boredom of prison life. Because distribution of condoms is prohibited in most penal institutions across the United States, safe sex is not even an option for most inmates. Sexual assault and rape, which are common intimidation tactics used by inmates, are also potential sources of transmission of HIV in correctional facilities (2006 Report on the Global AIDS Epidemic).

While high risk behaviors common to prisons put inmates at a higher risk for HIV infection while incarcerated, most HIV positive prisoners were infected before being sent to prison (HIV/AIDS Prevention). Indeed, the populations most vulnerable to the HIV infection are the same communities at high risk for criminalization and incarceration (HIV/AIDS Prevention). Fear of discrimination deters prisoners from accessing the voluntary HIV testing available in most prisons. Test result confidentiality is a major issue in a prison environment where even the suspicion of a positive test result can lead to stigmatization, bringing social isolation and violence from other inmates and sometimes even prison staff. The fear of stigmatization also discourages many inmates living with HIV from seeking medical services and treatment. Prison conditions also undermine the dosing schedules that are important for the effectiveness of antiretroviral therapy. Transfers of inmates to different correctional institutions or to and from courthouses can cause gaps in treatment. Searches for contraband may also result in medicine confiscation (Kantor 2006).

Addressing the problem of HIV and AIDS in prisons requires a multifaceted approach. UNAIDS believes that it is essential that prisoners be allowed access to prevention materials, including condoms, safer-sex supplies, and bleach kits for cleaning needles (HIV/AIDS Prevention). Increasing HIV and AIDS awareness through prisoner health education programs is crucial to decreasing the stigmatization of HIV inside prisons that prevents many inmates from seeking testing or treatment. For inmates living with HIV, provisions must be taken to ensure the regular interruptions of a prisoner’s life do not interrupt his or her antiretroviral therapy.

The Hampden County Correctional Facility in Massachusetts is a prison which is taking steps towards providing preventive education and effective health care to its inmates. This prison has adopted a health care program based on a public health model that provides inmates with a community-based standard of care (Kahn 2000). This program is based around five basic tenets: detection, effective and prompt treatment, education, prevention, and continuity of care. Prisoners undergo a three-day orientation upon admission and are given a full physical exam including tests for common communicable diseases. After attending an intensive peer-led educational session on HIV and AIDS, new inmates are encouraged to take an HIV test. Inmates that test positive for HIV then undergo additional tests to determine how best to proceed with treatment. Doctors, nurses, and case managers from the community are brought into the jail to deliver services to inmates. After the prisoners are released they have the option of continuing with the same primary care providers through a comprehensive discharge plan that includes Medicaid benefits and other supportive services (Kahn 2000).

The Hampden County Correctional facility is taking steps in the right direction, but fighting HIV in prisons is an uphill battle that will require revolutionizing prison health care. For changes to be made, Americans must first recognize that prisons are not isolated from the world, and that most inmates will eventually be released and infections acquired inside prison walls can be transmitted to the society outside. Preventing and treating HIV in prisons will benefit society as a whole and is important in the fight against AIDS.

Until next time, I am Justin Fried.
References

At Risk and Neglected: Four Key Populations. 2006 Report on the Global AIDS Epidemic. Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from http://data.unaids.org/pub/GlobalReport/2006/2006_GR_CH05_en.pdf

HIV/AIDS Prevention, Care, and Treatment in Prison Settings: A Framework for an Effective National Response. Health Organization and Joint United Nation Programme on AIDS. 2006. Retrieved Dec 2, 2006 from
http://data.unaids.org/pub/Report/2006/20060701_HIV-AIDS_prisons_en.pdf.

Kahn, Stanya. Fire in the belly: A model program stresses community involvement. AIDS Info NYC. January 2000. Retrieved Dec 2, 2006 from http://www.aidsinfonyc.org/hivplus/issue6/report/model.html.

Kantor, Elizabeth. HIV Transmission and Prevention in Prisons. HIV Insight. April 2006. Retrieved Dec 2, 2006 from http://hivinsite.ucsf.edu/InSite?page=kb-07-04-13

A Dual Epidemic: HIV/AIDS and Injection Drug Use in Russia

2007-02-23T13:18:00.000-08:00

I'm Meredith Prasse.

Before 1995, the total number of HIV infections in the entire region of central and Eastern Europe, with over 450 million inhabitants, was less than 30,000. The World Health Organization reported an estimated 0.6-1.9% prevalence, between 420,000 and 1.4 million cases, of HIV/AIDS in Russia in 2003. Between 1996 and 1998 alone, Russia experienced a 100-fold increase in new HIV infections, demonstrating the rapid onset of the epidemic in this region. Well over 70% of all HIV cases in Russia occur in injection drug users (IDUs), demonstrating the widespread exercise of unsafe drug-using practices among the IDU population in Russia. Sadly, only 10% of HIV-infected Russian IDUs currently receive HIV combination therapy, and only 15% of HIV-positive Russians receiving therapy are IDUs.

An epidemic of drug use is occurring alongside the HIV/AIDS epidemic in Russia. While the epidemic of injection drug use in Russia cannot be attributed to a single factor, there was a significant rise in drug use following the collapse of the Soviet Union. WHO estimates that between 1.5 and 3.5 million Russians are IDUs, and the prevalence of HIV in the drug-using population approaches 65% in some Russian cities, further demonstrating the connection between drug use and HIV in Russia. Between 1990 and 2002, the number of first-time drug users referred to treatment centers increased 6.5-fold, while the number of drug-associated deaths increased 5-fold between 1999 and 2000.

The challenges facing the Russian HIV/AIDS epidemic are multifaceted. An estimated 30-40% of IDUs in Russia use non-sterile needles or share needles, demonstrating the widespread unsafe drug use in Russia. Many IDUs reportedly re-fill their syringes by front-loading from the dealers’ syringes, and many dealers are IDUs themselves who inject from that very supply. During the drug preparation process, dealers in several different Russian cities have also reported adding blood to the drug solution as a ‘cleansing’ process, believing that the blood neutralizes toxic substances used to produce the drugs.
There are also significant legal and political dilemmas which complicate the Russian HIV/AIDS epidemic in IDUs. A combination of harsh drug policies and regular harassment by the police force pushes IDUs underground and decreases their chances of accessing preventive resources or care in drug treatment facilities. The synonymously corrupt Russian police arrests IDUs for possession of minimal amounts of narcotics in order to fill quotas. As a result, drug users refrain from seeking treatment or accessing clean needles in fear of incarceration or simply being registered as a drug user. IDUs that access formal treatment centers are officially registered and monitored by that facility for five years, and this official registration can have further negative repercussions such as restrictions on employment, drivers’ licenses, and military service. While treatment for drug dependence is an effective way to both eliminate drug dependence and decrease the risk of contracting HIV, the distrust in drug treatment services has resulted in low utilization of these resources by IDUs. Another legal dilemma for IDUs is that methadone, a common substitution for heroine users and an important part of HIV prevention for heroine users elsewhere, is banned for treatment in Russia.

While IDUs comprise the majority of the at-risk population in Russia, the threat to non-IDUs is on the rise. A majority of IDUs in Russia are young heterosexual men. These men have the potential to spread HIV to their partners: commercial sex workers, girlfriends, wives, etc., many who do not have the power or awareness to demand condom usage. In addition, commercial sex work is on the rise in numerous Russian cities, and the overlap between injection drug use and commercial sex work is high. It is estimated that between 15 and 50% of female IDUs practice commercial sex work, and many of them do so as a means of obtaining drugs. HIV transmission from sex workers to their clients is high, and these male clients may subsequently infect their non-IDU sex partners. Thus, IDUs and sex workers act as a bridge for sexual HIV transmission between IDUs and non-IDUs in Russia, facilitating a more widespread epidemic.

In the face of the continually increasing rates of drug use and HIV infection, the Russian government needs to implement policy changes to slow these increasing rates. This dual epidemic can be fought on many different fronts. Primarily, the government must increase support for safe needle exchange programs to reduce the spread of HIV among the IDU population. In addition, the ban on methadone-substitution therapy for heroine users should be lifted to encourage treatment options and reduce needle use. More generally, the government needs to put more focus on drug prevention programs. Future HIV prevention strategies targeting IDUs should include sexual risk reduction to reduce the potential spread between the IDU and non-IDU populations. With such alarmingly high rates of HIV infection among the IDU population, this problem cannot be ignored. The longer it is disregarded, the more this epidemic will seep into the non-IDU sectors of Russian society, facilitating an epidemic with a wider scope and greater force.

Works Cited
Bobrova, Natalia, Tim Rhodes, Robert Power, Ron Alcorn, Elena Neifeld, Nikolai Krasiukov, Natalia Latyshevskaia, and Svetlana Maksimova. “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities.” Drug and Alcohol Dependence 82 (2006): S57-S63.
Dehne, Karl L., Lev Khodakevich, Francoise F. Hamers, and Bernhard Schwartlander. “The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.” AIDS 13 (1999): 741-749.
Human Rights Watch. “Russia: harsh drug policies fuel AIDS epidemic.” Available at http://hrw.org/english/docs/2004/04/27/russia8497_txt.htm. Accessed on 16 November 2006. Human Rights Watch: 28 April 2004.
Kalichman, Seth C., Jeffrey A. Kelly, Kathleen J. Koslov, P Andrei, Alla Shaboltas, and Juliana Granskaya. “The emerging AIDS crisis in Russia: review of enabling factors and prevention needs.” International Journal of STD & AIDS 11 (February 2000): 71-75.
Lowndes, Catherine M., Michel Alary, and Lucy Platt. “Injection drug use, commercial sex work, and the HIV/STI epidemic in the Russian Federation.” Sexually Transmitted Diseases 30 (January 2003): 46-8.
Luo, Robert F. and Joseph Cofrancesco Jr. “Injection drug use and HIV transmission in Russia.” AIDS 20 (2006): 935-936.
Rhodes, Tim, Lucy Platt, et. al. “Prevalence of HIV, hepatitis C, and syphilis among injecting drug users in Russia: a multi-city study.” Addiction 101 (February 2006): 252-266.
Shaboltas, Alla V., Olga V. Toussova, et. al. “HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia.” Journal of Acquired Immune Deficiency Syndrome 41 (15 April 2006): 657-662.
World Health Organization. “Summary Country Profile for HIV/AIDS Treatment Scale Up: Russian Federation.” Available at http://www.who.int/hiv/HIVCP_RUSSIA.pdf. Accessed on November 16, 2006. WHO 2005.

Male Circumcision and HIV/AIDS

2007-02-16T09:11:00.000-08:00

“When is it appropriate for public health practice to be on the side of an intervention that causes bodily injury?” (Franco)

I'm Erika Larson.

That is the question McGill’s Professor of Epidemiology, Eduardo Franco, asked when addressing circumcision as a possible method of reducing HIV prevalence. Circumcision has historically caused a polarizing debate across sectors of society including the pious, and the hygienic. Health workers have generally abstained from taking a side. However, new evidence that circumcision reduces infectivity of HIV may alter this precedent.

A recent study in the Journal of Infectious Diseases, Baeten et al. explore “Female to Male Infectivity of HIV-1 among Circumcised and Uncircumcised” in a cohort of Kenyan men. Unlike previous studies which did not isolate behavioral practices, this analysis designates per-sex act probabilities of HIV-1 transmission between circumcised and uncircumcised men.

Between 1993 and 1997, 745 Kenyan men, employed by six trucking companies around the Mombasa area, were recruited. After pre-counseling and informed consent, these men were examined for circumcision status, STD infection, and HIV-1 seropositivity using the ELISA antibody test. Follow-up visits included detailed accounts of sexual encounters and condom use. Each man attended a median of 4 follow-up visits over the span of 400 days. Risk reduction counseling and provision of free condoms accompanied follow-up visits.

Of the 95 uncircumcised men (13%), 11 experienced sercoconversion. Of the 650 circumcised men (87%), 32 seroconverted. Though the majority engaged in sexual activity with their wives, many were involved in extramarital sexual contact. The median number of sex acts per month (4.0) did not vary between circumcised and uncircumcised men. By using surveillance data to estimate prevalence for potential partners (wives, casual partners, and prostitutes), the researchers found an overall probability of acquiring HIV-1 through a single sex act was .0063. Female to male infectivity was higher for uncircumcised men than circumcised men (.0128 vs. .0051). Uncircumcised men were found to have over a 2-fold increased risk of HIV-1 infectivity per sex act.

Because the study could not trace the infection status or disease status of partners, some variants could not be isolated. However, ethnicity, occupation, and sexual risk behavior were statistically isolated. All results still revealed that uncircumcised men were at a higher risk for contracting HIV. The biological factors that cause this discrepancy could be the result of the thick skin that develops after circumcision which prevents HIV from targeting Langerhans cells.

Another study by French and South African researchers found results so dramatic that the control group was given the option to undergo the procedure. New research has created a wave of optimism in the scientific community. Dr. Seth Berkley, president of the International AIDS Vaccine Initiative, stated circumcision would be “an intervention that works over a person’s lifetime and could reduce HIV in a community setting.” Questions of acceptance as a risk-reduction policy were appeased in a recent South African study. In a survey of uncircumcised men, 70% stated they would undergo the procedure if it “proved to protect against sexually transmitted diseases.”

However optimism of community acceptance is marred by a false sense of security that circumcision could create. Increased risk behavior on the part of circumcised men could counter-act the benefits. For example 30% of uncircumcised men and 18% of circumcised men believed that the procedure would allow them to safely engage in sex with multiple partners.

Though we have already seen considerable risk-taking in prevention policy with needle exchange programs and safe injection facilities, circumcision continues to push the envelope on ethical approaches. Can we promote circumcision as a global policy to help weaken the horrifying forces of HIV? Is it feasible to pursue a worldwide circumcision effort especially in countries that rely on traditional practices (whose circumcision procedures may increase HIV-risk)? How can we prevent the unintentional consequences of viewing circumcision as a cure and the abandonment of safe-sex practices? Though circumcision does not affect HIV prevalence in men who have sex with men or IV drug users, it has huge possibilities on the African continent where heterosexual contact is the primary mode of transmission.

The Links between HIV/AIDS and National Security

2007-02-09T07:30:00.000-08:00

I'm Rebecca Jameson

In July of 2000, the UN Security Council passed Resolution 1308 stipulating that HIV poses a risk to the stability and security of the nations of the world. Since then, there has been considerable debate regarding the relationship between the AIDS pandemic and national security. According to expert analysts, the security implications of HIV’s rapid spread in Africa and other regions must be taken far more seriously by the industrialized West.
One concern expressed by security analysts has been the impact of HIV on individuals critical to the maintenance of state and international security: namely, soldiers and peacekeepers. AIDS is now the leading cause of death in military and police forces in some African countries, accounting for more than half of in-service mortality. The loss of highly trained, professional soldiers is not limited to Africa. Trained soldiers are difficult and expensive to replace, and their absence interrupts the training of younger recruits. Armed forces that rely wholly or partially on conscripts face a decreasing pool of healthy recruits as HIV continues to spread. The strategic impact of high HIV prevalence on the armed forces is complex and involves other country-specific factors as well.
There is growing evidence that the AIDS pandemic poses increasing challenges for the conduct of peacekeeping operations. These challenges include the spread of HIV by peacekeepers, the reduced ability of countries to contribute peacekeepers, and the decrease in willingness of some countries to accept peacekeepers who may pose a disease risk to them.
Security analysts also correlate high rates of HIV infection with state instability and failure, particularly in sub-Saharan African nations. The erosion of elite populations, political leadership and skilled labor forces undermines economic growth and exacerbates social tensions. Some argue that the growing number of children orphaned by AIDS is contributing to an impoverished orphan cohort that is vulnerable to exploitation and radicalization. Even though the involvement of HIV/AIDS in state failure remains unproven and is probably indirect, the perceived linkage has propelled regions once considered “peripheral” to Western security interests into national security agendas.
The impact of the HIV/AIDS pandemic on strategically important states is another major security concern. Analysts warn that a “second wave” of HIV could potentially destabilize powerful countries and regions that are critical to the US and, by extension, to global strategic interests. Particular emphasis has been placed on the effects of the worsening pandemic in Russia, India, and China, each of which has been declared a nuclear state. The security impact of HIV in these countries may not be immediate, but increased instability in any large and strategically significant state would have major economic, political and military consequences around the world.
Although arguments linking HIV/AIDS to national security have helped to elevate the disease to the highest levels of international politics, it is also important to recognize that there are a number of potential risks in adopting a national security approach to combat the pandemic. An inappropriate redirection of HIV/AIDS resources toward strategically important countries or those supportive of the “War on Terror” is one possible outcome of such a focus. Strengthening the evidence of linkages between the AIDS pandemic and national security is essential for successfully negotiating these risks and ensuring that the public health–national security nexus benefits the fight against HIV/AIDS.

History of HIV/AIDS in the United States

2007-02-02T11:39:00.000-08:00

In a speech given on December 1, 2006, World AIDS Day, Kofi Annan declared HIV/AIDS to be the greatest challenge of our generation. This dreaded infectious disease has claimed the lives of over 25 million people worldwide and infected 40 million more. In the United States alone, 1.2 million are infected with the HIV virus and more than 500,000 have died. No virus has been as well studied or understood as the human immunodeficiency virus, yet we are far from controlling this pandemic.

When the first reference to AIDS was published in the CDC’s Morbidity and Mortality Weekly Report on June 5, 1981, physicians were taken aback by the presence of pneumocystis pneumonia in five previously healthy young men. As more and more cases of unusual opportunistic infections were identified, the medical community felt helpless in the face of this challenge. No one had any idea what was causing this disease, how it was transmitted, or how it could be treated.
Before long, pioneers in dealing with this disease discovered that it was transmitted through sexual contact, blood products, and needle sharing and could begin to discourage people from behavior that put them at risk. HIV was identified as the disease-causing agent in early 1984. The next year, the first test to detect antibodies to HIV was developed and the US blood supply was declared to be free of contamination. The numbers of new HIV infections in the US reached their height in the 1980’s at approximately 160,000. Since the 90’s, however, prevention and education efforts have stabilized infection rates around 40,000.

Doctors had nothing to offer their patients until AZT, a nucleoside analog, was approved by the FDA in 1987. By the end of the decade, the first candidate vaccine began testing, the first comprehensive needle exchange program was established, and the Americans with Disabilities Act was expanded to include people living with HIV/AIDS. The CDC announced measures that could be taken to prevent HIV infection and to avoid some of the opportunistic infections common among people with AIDS.
While they offered hope, none of these efforts really changed the reality for people living with the disease, and by 1994-1995, AIDS was the leading cause of death among Americans aged 25 to 44. The death sentence for AIDS patients was finally lifted in 1995 when highly active antiretroviral therapy was introduced with the first protease inhibitor, saquinavir. The following year, the FDA approved the first non-nucleoside reverse transcriptase inhibitor, nevirapine, and a viral load test to measure levels of HIV in the body. Since then, these developments have led to a 70% reduction in AIDS-related deaths.
While new treatments have revolutionized the face of the AIDS epidemic, drastic changes in epidemiology and populations infected have altered the way people view the disease. Originally seen as a highly stigmatized disease of the gay community and feared for its mystery and lethality, AIDS is now recognized as a controllable disease that preys on men, women, and children alike. Homosexual contact remains the highest mode of transmission in the US, but heterosexual contact has grown significantly as a mode of transmission. Women constituted 8% of new HIV cases in 1985, but rose to account for 27% of new cases in 2005. HIV is slowly becoming a plague of the minorities. Blacks disproportionately constitute over half of new HIV infections while the incidence among whites is decreasing.

Despite the many breakthroughs that have been made to alter the HIV epidemic, many challenges remain. Stigma still persists as a major debilitating factor of this illness. Over a quarter of a million people are living with HIV but do not know they are infected. While it is no longer the leading killer, AIDS remains the sixth leading cause of death in this country. There are currently 29 drugs on the FDA’s list of drugs approved for the treatment of HIV/AIDS, but a cure or an effective preventative vaccine remain elusive. The American public finally realized that this disease could not be ignored and has recently embraced it more than ever before. Billions of dollars have been allocated towards HIV programs in the US and abroad. Nonetheless, HIV/AIDS will continue to pose the greatest challenge to our generation as we strive to halt transmission, provide diagnosis and treatment to those in need, and develop a cure to this deadly virus.

Thanks for listening,

Lauren Finley

Pre-exposure Chemoprophylaxis

2007-01-26T07:11:00.000-08:00

Leaders from around the world in AIDS research and health policy gathered in Toronto in August 2006 for the XVI International AIDS Conference. A key theme of the conference was HIV prevention, including assessment of old standards as well as new strategies. Leigh Peterson of Family Health International presented preliminary data from a current AIDS prevention study of women in Ghana (2006). This new prevention strategy is called pre-exposure chemoprophylaxis, or PrEP. In the PrEP strategy, HIV-negative individuals with high risk behavior take a single daily dose of tenofovir, a widely prescribed anti-retroviral. Tenofovir is a nucleotide reverse transcriptase inhibitor, meaning tenofovir’s unique shape blocks the reverse transcriptase protein in HIV from making new copies of the virus. The FDA approved tenofovir in 2001 and was a good drug candidate for this study because it has few side effects and showed low levels of resistance. The idea of prophylaxis is not new. It is most commonly used to prevent malaria; but it has not been tested as a valid strategy for preventing HIV until now.

According to the Family Health International study, 936 HIV-negative women in Ghana, Cameroon, and Nigeria were enrolled into a double-blind, 1:1 randomized trial. Half of the women received a daily 300 mg dose of tenofovir and the other half received a placebo. Between June 2004 and March 2005, participants were evaluated monthly for adverse events, abnormal serum creatinine and phosphorus levels, were HIV tested, and were re-supplied with drugs. Before the study was completed, the Nigerian trial was stopped due to faulty laboratory monitoring; and the Cameroon site prematurely closed due to ethical concerns about the study. The preliminary results presented at the AIDS conference showed that only two out of 363 women in the tenofovir group contracted HIV compared with six out of 368 in the placebo control group. While those in the PrEP group were 65% less likely to become infected, the difference was not statistically significant due to a small population size. There were no significant differences in adverse events or laboratory abnormalities between the two groups. Gilead, the maker of tenofovir, has committed to making the drug available at no profit cost to the areas where the need for prevention is greatest (Kresge 2003).

The Centers for Disease Control and Prevention is currently sponsoring three clinical trials of PrEP in homosexual men in San Francisco and Atlanta, men and women in Botswana, and intravenous drug users in Thailand (2006). These trials divide each subpopulation into two experimental groups: one taking tenofovir and the other taking truvada, a combination of tenofovir and emtricitabine. The results from these trials will not be available for at least another year.

Both of these PrEP trials attempt to answer the same questions: will prophylaxis reduce the risk of HIV transmission, is tenofovir a safe drug for uninfected individuals to take daily, and how will PrEP affect HIV risk behavior? PrEP is intended to be a part of an integrated approach to HIV prevention and should be used in concert with condoms, AIDS education and counseling, rather than by itself. If the PrEP strategy proves to be effective, then it could result in millions of averted AIDS deaths globally. One reason PrEP studies target women in Africa is because they are currently the most vulnerable and unprotected victims of AIDS. Specifically, PrEP would offer protection for women who are unable to negotiate condom use during sex and represents a big step toward empowerment of women in the third world. Important obstacles under consideration with PrEP are: the development of tenofovir-resistant HIV, increased risk behavior of people taking PrEP, and the cost effectiveness of using medication as a prevention strategy. Nonetheless, the discussion of an HIV prophylaxis at the international AIDS conference represents an expansion of HIV prevention strategies and the potential to avert future AIDS deaths.

Thanks for listening, I’m Wes Fiser

Bibliography

Centers for Disease Control and Prevention. CDC Trials of Pre-Exposure Prophylaxis for HIV Prevention: Clinical Trials in Botswana, Thailand, and the United States. August 2006.

Kresge, Kristen. Tenofovir as Pre-Exposure Prophylaxis. American Foundation for AIDS Research. February 2003.

Peterson, L et al. Findings from a double-blind, randomized, placebo-controlled trial of tenofovir disoproxil fumarate (TDF) for prevention of HIV infection in women. XVI International AIDS Conference, Toronto. August 13-18, 2006. Abstract THLB0103.

Considerations for Real-World Use of Microbicides

2007-01-19T10:51:00.000-08:00

For more than ten years, the scientific community has been touting microbicides as the next big breakthrough in HIV/AIDS prevention. Microbicides are compounds that protect against sexually transmitted infections such as HIV and can be applied inside the vagina or rectum as a gel, cream, film, or suppository. Numerous strategies for microbicides are currently in development, including disruption of HIV’s viral envelope, maintenance of the normally acidic environment of the vagina, nonspecific inhibition of viral entry or fusion by creating a film over vaginal cells, and specific entry inhibition by providing competing ligands for receptors on CD4 cells. Despite the promise of various microbicides, results from efficacy trials will not be available for several more years. There are several areas of consideration when deciding which of the numerous microbicides in development will be realistic for real-world applications.
The first important factor to consider is the microbicide’s safety. Recent studies of nonoxynol-9 showed that the hopeful microbicide actually increased the risk of HIV infection. In vitro, N-9 disrupted the HIV envelope and prevented fusion. In vivo with prolonged use, however, the drug disrupted the vaginal epithelium, resulting in inflammation and a gathering of the immune cells. This aided HIV in overcoming the body’s natural defenses. This example shows that possible interactions with the body must be considered. Other safety issues should include complications from other sexually transmitted infections, drug resistance development in unknowingly infected women, and carcinogenicity of a compound continually applied to the vagina or rectum.
The next important real-world consideration is the acceptability of the microbicide. Many women will refuse to use something if it inhibits fertility. Thus, an effective microbicide should not also be a spermicide. In addition, the microbicide should be able to be applied well in advance of sex, in order to aid in secrecy of use if necessary. The microbicide should not be difficult to use or have an unusual consistency or smell. Finally, some countries in the world may not like microbicides based on genetically modified microorganisms.
One of the most important concerns is the efficacy of the microbicide. At the 2006 Microbicide Conference in South Africa, scientists began to push for drugs with higher potency towards HIV instead of drugs that are less effective but might prevent multiple sexually transmitted infections. In order to be truly effective, the microbicide would combine multiple methods of HIV prevention. A 2006 study by Robert Neurath found that some microbicides are extremely effective in vitro. However, development of these drugs did not take into account the nature of seminal plasma, a compound certain to be present in heterosexual intercourse. Neurath found that the plasma changed the pH environment significantly enough to alter the efficacy of the drug. This demonstrates just one of many possible interactions unaccounted for in current research and development.
The final factor in real-world use of microbicides is affordability. It is estimated that for microbicides to be available to donate to developing countries, each application must cost less than a dollar. Currently, only large pharmaceutical companies can afford the high cost of development of microbicides, which can cost up to tens of millions of dollars. Companies have little financial reason to develop these drugs when they are aimed primarily at poor women in developing countries. However, in 2003, the Bill and Melinda Gates Foundation pledged $60 million to aid with microbicide research aimed at HIV/AIDS, aiding the small laboratories struggling to develop these drugs. Ultimately, the investment will pay off. The World Health Organization estimates that a microbicide which only reduced the risk of infection by 40% and was only used in 30% of women in low-income countries would prevent approximately 6 million HIV infections in 3 years. This would reduce health care costs, not including the cost of antiretroviral drugs, by 3.2 billion US dollars.
More than 60 different microbicides are in development or testing currently. Not all of these, however, will meet the important criteria for real-world use. Even for those that do, data will not be available for several more years. The time and cost of development, however, is far outweighed by the hope that such a drug would give to the at-risk female population of the world.

This has been Cara Maguire.

The AIDS Pandemic: A note to our listeners

2007-01-11T10:53:00.000-08:00

Our podcast is now 6 months old. During this time, we have addressed many topics related to HIV/AIDS, including recent advances in treatment, the South African disability grant program, HIV in the Southeastern United States, and Bono’s Product (RED) campaign.

If you are a regular listener, you probably know that many of the episodes have been conceived, developed, and produced by Davidson College undergraduate students. Rebecca Jameson, a senior at Davidson, discussed violence toward women and the spread of HIV. Wes Fiser, another senior, talked about his personal experiences in Mwandi, Zambia.

Over the next several months, we will be posting additional episodes by these students on a weekly basis. I hope you stay tuned. If you have any questions about this podcast, please email me at dawessner@davidson.edu. If you would like to see other HIV/AIDS projects ongoing at Davidson College, please check my web site at www.bio.davidson.edu/people/dawessner.

Thanks.

HIV/AIDS Stigma in Rural America

2006-12-26T14:38:00.000-08:00

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

2006-12-13T12:54:00.000-08:00

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.