AIDS: We're Not There Yet
Last Friday was World AIDS Day. People across the planet held hands in solidarity against a lethal microbe hellbent on finding a warm human body in which to incubate, replicate, and from which to transmit itself to others. The HIV virus has killed 25 million people since its appearance in 1981; today, at least 40 million people worldwide are infected. The awareness day stems from a United Nations initiative (its slogan: "Keep the Promise") intended to help nations cope with the epidemic. Governments, private foundations, and corporations have committed billions of dollars to make the highly active antiretroviral drugs, which can turn AIDS into a chronic manageable disease, available to poorer nations. The promise is powerful, especially if one looks at how the drugs have transformed the face of AIDS in the United States. But there's something odd going on: Despite the commendable enthusiasm for helping victims beyond our borders, a strange complacency has set in at home. Many people think the new blockbuster drugs have solved the AIDS problem. They're wrong. HIV is alive and well in America and spreading vigorously, with 42,000 new cases of HIV infection a year.
To be sure, the obituary pages are no longer filled with the names of AIDS victims. The infected are living long and productive lives with survival times exceeding 20 years or more. The sick don't look so sick either, though drug side effects can be debilitating. And the practice of AIDS medicine is mostly about outpatient visits, focused on the doctor determining just the right level of drugs to suppress the virus in the patient's blood to undetectable levels. This is far from the crisis medicine of years gone by that still prevails in poorer parts of the world: overwhelming pneumonia and septic shock, heart failure and dementia, rotting gums and emaciated bodies.
Unchecked, the disease moves swiftly with a looming threat of death so powerful that AIDS doctors even through the mid-'90s felt they were on a battlefield, says Jerome Groopman, a professor of medicine at Harvard and an AIDS expert. That's not so today but, Groopman adds, the medical problems are just as important. For one thing, about 25 percent of patients are becoming resistant to the multiple antiviral drugs in use. So far, the pharmaceutical pipeline has been able to churn out new drugs in the nick of time. And the needs are great, since 1.2 million Americans are infected by the virus, and the number is growing.
A study in the current issue of the American Journal of Pathology by scientists at Inserm, France's version of the National Institutes of Health, highlights the ongoing threat. Semen is the prime fluid that transmits HIV to others. The researchers show that testicular tissue is a welcoming site for viral replication, an important finding since the testis is known to be a pharmacological sanctuary that blocks entry of the high-powered antiviral drugs that so effectively penetrate and suppress the virus in other parts of the body. Thus, treated men may feel great and have virtually no virus in their blood, but they can still disseminate lethal semen if they engage in unprotected sex.
A big no-no. Despite relentless abstinence campaigns, endless preaching about safe sex, and the condoms delivered with pizza on many a college campus, the National Center for Health Statistics reports that some 14 million Americans flunk Social Disease 101–by engaging in sexual practices and drug use that put them at risk for HIV. Chlamydia is a good measure of this. In the United States, there are an estimated 2.8 million new cases annually of this highly infectious sexually transmitted disease (which causes pelvic inflammation that can lead to infertility in women). That's an awful lot of young people who are having unprotected sex.
An added problem is that a quarter of those who contract HIV don't even know it. This dilemma has led to a recent turnaround by the Centers for Disease Control and Prevention on routine HIV population screening. In the past, this was a big no-no, since a positive test brought only social stigma and a death sentence. The new guidelines, calling for everyone ages 13 to 64 to be screened for the virus, allows for earlier and more effective treatment. And the screening will uncover several hundred thousand silent HIV carriers who account for over half of the nation's new cases each year. The World Health Organization chimed in last week with a similar proposal.
Sure, testing will no doubt scare people, but maybe that's a good thing. Fear might be the best way to counteract complacency, not to mention the risky impulses that often trump the best of promises.
This story appears in the December 11, 2006 print edition of U.S. News & World Report.