Intersecting Epidemics: HIV/AIDS and Tuberculosis

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

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

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

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

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

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

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”

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

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

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

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

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

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

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

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

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. .