06 June 2006

How HIV has changed

In the late 1970s, New York City physician Dr Jeffrey Laurence said he began to see a new kind of patient showing up, very ill, at his midtown Manhattan hospital.

In the late 1970s, New York City physician Dr Jeffrey Laurence said he began to see a new kind of patient showing up, very ill, at his midtown Manhattan hospital.

Those patients were mostly young men who should have been in the prime of health. Instead, they arrived with a list of serious, but seldom-seen conditions: PCP pneumonia, cytomegalovirus retinitis, or even a rare skin cancer called Kaposi's sarcoma.

First published reports in 1981
Two years later, the first case reports describing this "mystery" illness - occurring in five young men from Los Angeles - were published in the June 5, 1981, issue of Morbidity and Mortality Weekly Report, the US Centres for Disease Control and Prevention's epidemiological journal.

"But I know, now, that we were already seeing it - HIV/Aids - in the late 1970s," said Laurence, who is now director of the Laboratory for Aids Virus Research at Weill Medical College of Cornell University in New York City.

In late 1982, Laurence met noted French virologist Dr Luc Montagnier, who spoke to a group of New York physicians on the possibility that this new disease might be caused by a primitive retrovirus.

Culprit pinpointed in 1983
"I had collected blood samples from 70 to 100 patients," Laurence recalled, "and he invited me to bring them and go back with him to Paris." Their work together helped lead to Montagnier's landmark 1983 article in Science that pinpointed the human immunodeficiency virus (HIV) as the cause of this new disease.

Much later, Laurence retrieved frozen blood samples from patients seen in New York even earlier than 1979. "The earliest sample I have of patients infected with HIV came from 1975," he said.

HIV contracted from chimps
The earliest sample to date anywhere was taken from a man in Cameroon in 1959. A study published this May strongly suggests that the virus leapt from chimpanzees to humans in that West African country sometime during the mid-20th century.

Now 25 years - and 22 million lost lives - after that 1981 CDC case report, HIV/Aids "is here to stay - possibly forever," Laurence said. But the epidemic, like the virus, has mutated along the way.

"We've seen enormous changes, not only globally but here in the United States," said Rowena Johnston, director of research at The Foundation for Aids Research (AmFAR). "Aids was first identified, and was thought of, as a gay white man's disease. We see now that the fastest-growing groups of people getting HIV are women - especially women of colour - African-Americans, Hispanics, often young."

Not the death sentence it was before
And Aids itself is no longer the automatic death sentence it once was, at least for patients lucky enough to have access to life-extending antiretroviral combination drug therapies.

"We've come a long way from 25 years ago, from when Aids first came out and people were dying like flies," said 55-year-old Peter J. LaMarca, a retired gay New Yorker who was first diagnosed with HIV in 1990. "Then, you'd see somebody get sick and then two weeks later they were dead," he said.

LaMarca almost died from Aids-linked pneumonia himself, twice. But in the mid-1990s, when the "miracle" of HIV-suppressing drug cocktails arrived, he got them. "I'm doing pretty good now," he said. "The meds have helped me and other people live longer."

ARVs are extending lives
The advent of effective drug therapy is the silver lining: According to the CDC, the proportion of people in the US living more than two years after being diagnosed with HIV rose from 44 percent in 1992, to 85 percent by 2000.

LaMarca's doctor, Dr Frank Spinelli, has witnessed these remarkable changes firsthand. "In the past five years, we've seen incredible changes in medication - less pills to take, more tolerable meds that are better for you," said Spinelli, who is clinical director for HIV at Cabrini Medical Centre. He said he now treats HIV infection as a chronic condition, much as he would diabetes or heart disease. "It's no longer about these Aids-defining illnesses - I can't tell you the last time I saw a case of CMV retinitis."

Sadly, that's not the case in the developing world, where the vast majority of the world's estimated 40 million HIV-positive people now live. Hardest hit is sub-Saharan Africa, where UN experts now fear the death toll could top 100 million by 2025.

"Aids has been able to draw a very stark dividing line between the haves and have-nots of the world," said Philip Alcabes, an associate professor at the School of Health Sciences at Hunter College, in New York City.

A tragic failure of caring
Alcabes, who's tracked the social and epidemiological history of the virus for decades, called the West's relative inaction against the spread of AIDS in poorer countries "a dramatic and tragic failure of care and caring.

"When you know that just 9 to 10 percent of all pregnant women with HIV are getting antiretroviral prophylaxis that would prevent transmission to their newborns - it's a criminally low number," Alcabes said.

But AmFAR's Johnston said slow progress is finally being made. "Recently we've seen global bodies like the World Health Organization and UNAIDS at least attempt to get therapy out to more people," she said. "Not nearly enough people are covered yet, but the number, at least, is growing."

Of course, a vaccine that prevented infection would go a long way to ending the crisis. But Johnston said the challenge there is enormous, because HIV mutates at such a rate that it's almost impossible for any one vaccine to cover all the millions of possible permutations.

"Also, the virus destroys the very immune cells that you're trying to boost to make a vaccine," she said. "So it becomes a race between the virus and the immune system, and frankly, the virus always wins."

Research has paid off in other ways, however, and everyone agreed that the science of HIV has forged new insights into not only viral illnesses, but cancer, Alzheimer's and a host of other diseases. "Unfortunately, necessity was the mother of invention in this case," Alcabes said. "It's just too bad the necessity was so deadly."

Attitudes are changing
Social attitudes toward people with HIV have changed, too, as Johnston found out when she recently gave a speech to a group of American high school girls.

"In the 1980s, when I was a teenager and the news of Aids was just coming out, there was a lot of ignorance, stupid jokes about gay men, nonsense and stigma," she said.

By 2006, her young audience was having none of that.

"I was blown away at how little blame they assigned, how well they understood that this is not a gay disease, that people shouldn't be stigmatised after having gotten HIV," Johnston said. "In that respect, I'm really impressed at the amount of progress we've made." – (HealthDayNews)

Visit our HIV/Aids Centre for more information.

June 2006


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Dr Sindisiwe van Zyl qualified at the University of Pretoria in 2005. She is a patients' rights activist and loves using social media to teach about HIV. She is in private practice in Johannesburg.

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