HIV/AIDS in China

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

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

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

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.

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

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

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

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

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

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?

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

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

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

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

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

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

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

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

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.

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