AIDS turns 25

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AIDS turns 25

AIDS: A Mayo Clinic expert looks at a 25-year-old catastrophe.

photo of Stacey Vlahakis, M.D. Stacey Vlahakis, M.D.

Twenty-five years ago, when the world first became aware of AIDS, the disease seemed confined to a relatively small group of gay men, drug users and hemophiliacs who were unlucky enough to have received contaminated blood. Today, nearly 40 million women, children and men worldwide have AIDS.

The disease has taken its greatest toll in southern Africa (South Africa, Swaziland, Zimbabwe and Botswana), where infection rates, averaging around 35 percent, are the highest in the world. Twelve million African children — 15 million children overall — have lost one or both parents to AIDS and in many regions have a better than even chance of dying of the disease themselves. And although the number of Africans receiving life-prolonging drugs has increased sharply in the last few years, only 17 percent of people needing treatment actually get it.

In wealthy countries, the news is not as unrelentingly grim. There, advances in treatment have changed AIDS from a fatal illness into one that's chronic and treatable, much like diabetes or heart disease. And simpler, less toxic regimens have made living with AIDS more tolerable.

Stacey Vlahakis, M.D., an infectious disease specialist and AIDS expert at Mayo Clinic, Rochester, Minn., answers some questions about the complex, changing and inequitable face of AIDS.

Twenty-five million people have died of AIDS since 1981, and 5 million were newly infected in 2005. Have we made any progress at all in the last 25 years?

The numbers are so staggering that it's easy to lose sight of the strides we've made in taming this disease. But yes, there has been progress. Just 10 years ago, there were few drugs to treat the virus. Since then, we've developed many more medications. Today, most people receive a combination of three or more AIDS drugs, a treatment called highly active antiretroviral therapy, or HAART. When HAART is effective, it can reduce viral load — the amount of virus in the blood — to undetectable levels. To realize how significant this is, you have to understand how the virus works.

HIV, the virus that causes AIDS, enters healthy white blood cells, inserts its genetic material into the cells and makes copies of itself. By hijacking cells and then replicating in them, the virus can churn out billions of new HIV particles every day. It also slowly — over a period of 10 years or more — destroys your immune system so that your body loses the ability to fight infection. HIV infection turns into AIDS when you develop a very low level of white blood cells — usually less than 200 per microliter of blood. This makes you vulnerable to certain cancers and opportunisitic infections that your immune system would normally fight off.

We have several classes of drugs that target HIV at different points in its life cycle. None of these drugs can cure HIV/AIDS, but for many people, HAART can keep the virus and opportunistic infections at bay and help preserve the immune system.

Does this mean people on HAART will have a normal life span?

We've only had these combinations of drugs for a decade, so we have no way of knowing that. One thing we do know is that AIDS drugs can cause serious health problems, including high blood sugar, high cholesterol and the redistribution of body fat. We can suppress the viral load but at a high cost. Yet even that is changing. In 1996, people treated with HAART had to take as many as 15 or 20 pills a day at different times, and often with many side effects. Today, the newest and simplest regimen requires only one pill, and the side effects are becoming easier to tolerate. We now know that certain side effects are specific to particular medications. Protease inhibitors, for instance, cause metabolic problems, whereas the newer non-nucleoside reverse transcriptase inhibitors have fewer side effects. Easier regimens — with fewer medications and side effects — mean that people are more likely to stick with treatment. And that, in turn, means that we're better able to suppress the virus. For the first time, we can talk about people "living with AIDS," rather than just dying of it.

There seems to be a real disconnect between what you're talking about: AIDS as a manageable, chronic disease — and the suffering the pandemic continues to inflict around the world.

The disconnect is less apparent in the Western world, where most people who want treatment receive it. That doesn't mean that inequities don't exist. In the United States, women with AIDS are less likely to receive combination therapy and to have private health insurance to pay for treatment than men are. Women's ability to take care of their own health is further complicated by the fact that many have young children at home. But in general, people in wealthy nations have received, and continue to receive, very good care. This is not true in most low- and middle-income countries, in spite of recent advances.

What kinds of advances?

For one thing, there has been a huge jump in global AIDS funding — from $250 million in 1995 to $8 billion in 2005. And some pharmaceutical companies have lowered prices, making AIDS drugs somewhat more affordable. This has had an especially big impact in Africa, where the number of people receiving AIDS treatment increased eightfold in the last two years alone. But in spite of that, only about 20 percent of people worldwide who need treatment get it.

Why is that?

Many aspects of life in developing nations play a role: governments that aren't equipped to distribute AIDS money and drugs; a shortage of trained doctors and nurses; fragile health care systems; instability and dislocation caused by war and natural disasters; and, perhaps most important, social attitudes. From the beginning, people living with HIV and AIDS have been feared and sometimes ostracized. That's true everywhere, but attitudes about AIDS in developing nations are particularly widespread and entrenched, and the impact on women and children is tremendous. Women are often already economically and socially disadvantaged. Add to this traditional belief about sexuality and disease transmission, and you have women who are afraid to admit they're sick or seek treatment. All too often, people who are known to have HIV or AIDS are abandoned by their families and communities and die for lack of care. Meanwhile, some government leaders still refuse to admit that AIDS even exists.

Do you think AIDS will continue to devastate developing countries?

Right now, India is on the brink of an AIDS crisis that may someday equal the one we see in Africa. In a way, that doesn't make sense because India has more resources than Africa does. It's a democracy with a strong infrastructure, and excellent technology and doctors. But the lack of knowledge about AIDS and the stigma attached to the disease are tremendous obstacles to prevention and treatment. Ninety percent of people in India with HIV don't know they're infected. Many of these are women and young girls living in rural areas. And there is no incentive for people to learn their HIV status because if they have the infection, they're likely to be shunned and denied treatment. India is making efforts to cope with this problem, but changing thousands of years of social and cultural practices isn't easy. The next five years will be critical.

Can anything be done? What about an AIDS vaccine?

An AIDS vaccine isn't imminent. And a vaccine may not help people already living with AIDS. Instead, one of the major goals of current research is to learn how to coax the virus out of hiding. You see, what makes eradicating HIV so difficult is that although HAART can effectively suppress the virus, it doesn't eliminate it because the virus can hide in the DNA of infected cells, out of reach of both the immune system and current medications. The cells act as a hidden reservoir of the virus, which comes back as soon as the medication is stopped. Now researchers are trying to develop new strategies to prevent and eliminate these reservoirs. That might make treatment more successful or allow people to stop taking medication altogether. It may also make the virus less infectious. Of course, we are hoping that this doesn't take another 25 years.

The greatest tragedy of all is that AIDS doesn't have to happen. Unlike some diseases, we know how to prevent it. HIV could theoretically be eradicated in a generation without a vaccine.

Yes, that's true. Consistent condom use and clean needles are the definitive ways to prevent HIV spread. Unfortunately, even in the United States there is still a great deal of denial and ignorance about both. Complicating matters further are the efforts of some special interest groups to limit sex education and condoms in schools and government-sponsored programs. The result is that we're seeing an increase in HIV among young people and minorities. There's also an attitude that HIV "isn't that bad" because we have medications to treat it, leading some people engaging in high-risk activities to become lax about using condoms. In the developing world, economic and social factors limit condom use — prophylactics are expensive or they're not readily available. And many women won't ask their husbands to use them because they're afraid of being punished or forced to leave their village. So it is sad. There are effective ways to stop HIV, but it just isn't happening.

Last Updated: 06/05/2006
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