The AIDS Global Health Crisis: Strategies for Policy and Science for its Resolution

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Date(s) - 9/16/200312:00 pm - 1:30 pm

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AIDS is the largest and deadliest epidemic in medical history. Sometimes comparisons have been drawn with recurrent epidemics of the plague (“the black death”), but there are great differences. Like a tornado, the plague came quickly, devoured everything in its path, and just as suddenly vanished. AIDS is more akin to a lightning storm hitting selectively, but a storm that will not go away without scientific resolution. AIDS then differs from all past epidemics in this regard. There are other fundamental differences of AIDS from past viral infections or the recent SARS outbreak that presented far greater challenges for the discovery (1983-84) of its causative agent, the virus known as human immunodeficiency virus, or HIV: first, because the clinical manifestations of AIDS become apparent only after exposure to HIV; second, because patients with AIDS have numerous other (secondary) infections associated with their immune deficiencies. Consequently, the bar to jump over was much higher. Third, the necessary technology to discover and characterize the virus had just been developed as well as the right intellectual framework. If AIDS had to come, it was fortunate it did so just after these developments, since the technology was not initially widespread in the scientific community and combined with the fear of working with a mysterious and deadly virus, reduced the number of laboratory scientists addressing the problem. It is both ironic and rather amazing that the AIDS epidemic came just at a time when much of medical science had dismissed serious epidemics as problems only for the “Third World” and when the class of virus (retrovirus) of which HIV is a member was barely acceptable as a possible infection of humans. We would soon learn that there is now only one microbial world and that no class of virus can be ruled out as a potential threat to humans.

HIV originated in African rainforests, likely entering humans periodically from some chimps and monkeys, perhaps first to hunters exposed to their blood. It became epidemic when the rainforest arrived in cities by mass migration associated with societal changes. The rainforest rapidly became global. This was facilitated by post-World War II societal changes such as marked increase in distant travel, increased sexual contacts, intravenous drug abuse, and the use of blood products going from one nation to another for medicinal purposes.

The epidemic still remains dynamic and unpredictable. It has already killed some 23 million people with another 40-45 million more currently infected. It destroys families and leaves an unimaginable number of youths without guidance, youths who may become a major new danger for the future. The destabilization of several African nations is predictable, and HIV now seriously threatens Russia, China, and India.

The first major practical advance against AIDS was the development of the HIV blood test in 1984. The blood test not only protected the blood supply, thereby preventing a far greater epidemic in the industrial world, but also allowed public health officials to follow the epidemic for the first time. (Prior to the blood test the infection could not be known. The first clue occurred only years later when the clinical features of AIDS appeared). Tragically, however, the test was delayed in some nations due to political and/or economic reasons. The other major advance has unexpectedly been in therapy. Beginning in 1986 but culminating in the 1994-96 period anti-HIV combination therapy has converted HIV from a sure fatal and savage end to one usually of a much more chronic disorder and has all but ended mother to child transmission in the developed world. However, mortality in HIV infected people due to co-infections with hepatitis C virus, cancer, and heart disease is rising

What are the major problems we are still confronted with today with HIV/AIDS?

1. The failure to develop a preventive vaccine to end the problem;

2. the continuous need to develop new anti-HIV drug approaches because of the development of HIV drug resistant mutants and because of drug toxicities;

3. bringing proper therapy to the undeveloped nations. The latter requires enormous financial help to supply drugs, but often overlooked it also requires assurances that the drugs are given properly or new multi-drug resistant epidemics may be increased. This requires some clinical sophistication and a constantly educated patient population. An alternative is the development by medical science of safe, logistically feasible, inexpensive new forms of therapy, but this is not in hand as yet and it has not been a research priority.

Lessons and Recommendations

1. Microbes are here to stay. New ones may emerge at any time, and humans are not uniquely privileged in being able to avoid any.

2. From 5 to 10 Centers of Excellence in Virology (CEV) should be formed which collectively provide sophisticated coverage of every major class of virus. When the AIDS epidemic began, no individuals or groups had the responsibility of quickly responding, find the causative agent, proving to the scientific community that the candidate causative agent was indeed the cause, and developing diagnostic tests for it. The exception was the CDC, but the CDC, though able to survey for virtually every class of virus, can in no way have sophistication with most. Each CEV would relate to a few centers in developing nations, thereby adding greatly to the capacity of the CDC to monitor global infections, as well as aiding the training of people in undeveloped nations. The CEV would have direct responsibility for finding and proving the cause of new epidemics as called for by the CDC and NIH Director, with input from CEV staff, and according to the nature of the epidemic would determine which CEV would become involved. For each center some $10 million per year should be appropriated to each CEV. Their remaining funding would be like any other academic center, i.e., competing for public and private grants.

3. A crash program for a preventive vaccine should be a high priority. I suggested this in the late 1980s. The time is now more than ripe. The objective cannot be left in the hands only of the Gates Foundation and their few advisors.

4. Research should be promoted aimed at practical approaches to therapy for developing nations much more so than currently undertaken.

5. The current anti-HIV drugs, of course, should be made available to undeveloped nations as rapidly and expeditiously as possible. In this regard President Bush has already taken leadership and has made a historical commitment with his planned financial aid to developing nations for this purpose. However, we should learn from our mistakes in treating HIV infected people in the U.S. and Europe. The current drugs must be given judiciously and with planned close collaboration with centers in the industrial world and adequate education of the patient population

6. Though bioterrorism research has its importance (and indeed HIV itself could easily be adapted as a bioterrorist weapon) it is not to be forgotten that HIV is already by nature a leading “bioterrorist”. Thus, long term interest in and support of HIV/AIDS research and prevention programs are a must.

 

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