Tag Archives: Centers For Disease Control And Prevention

How HIV became a matter of international security

Governments around the world were slow to get to grips with HIV/AIDS. But a big change came when they started understanding it not just as a health issue but as a security threat too. Alexandra Ossola investigates.

Richard Holbrooke sat in a blue striped chair in the meeting room of the United Nations Security Council. It was a rainy, unseasonably warm January day in New York City, just ten days into the new millennium. Many people were still relieved that the Y2K millennium bug hadn’t wreaked havoc on computers, as some experts had feared. And yet, during the council’s seven-hour meeting, it was clear that a bigger, real threat was looming.

Doctors had identified HIV/AIDS more than 15 years before, but only by 2000 was its true global impact beginning to become clear. Holbrooke, the US ambassador to the UN, then sitting as president of the Security Council, had pushed for this meeting because he had seen first-hand how AIDS could devastate communities. In 1992, he had visited Cambodia and saw UN peacekeepers who, at the end of the day, would get drunk and visit brothels. Holbrooke was sure this behaviour was spreading HIV locally, and that the peacekeepers would bring the disease back with them to their home countries.

He had seen the impact even more dramatically in 1999, when he and his wife visited Africa. Children whose parents had died of the disease slept in gutters; even AIDS activists were so stigmatised they arrived to meet him in a curtained van. Conversations with leaders in countries like Namibia and South Africa showed Holbrooke they weren’t doing nearly enough to combat the disease. The trip galvanised him. AIDS was spreading, regardless of borders, in a way that threatened the stability of states. So, if national governments weren’t taking action, perhaps the world could.

But Holbrooke was met with resistance. Congressmen criticised him on television; friends and dignitaries warned him privately not to confuse humanitarian issues with national security. How could a disease be an issue of national security, they argued – no disease ever had been. “I was told by everyone, including my own staff, ‘You can’t do this; it’s not done; it’s not in the UN charter,’” Holbrooke said in a 2006 interview with PBS. “And I said, ‘But AIDS is a security issue, because it’s destroying the security, the stability of countries.’”

Luckily, Holbrooke found the Security Council more amenable as he pushed to discuss HIV/AIDS. Only Russia was opposed, which Holbrooke thought was ironic since the prevalence of HIV/AIDS in Russia and its surrounding countries was rising rapidly.

Eventually, Holbrooke prevailed. Russian representatives agreed to sit in on the meeting, but wouldn’t speak or participate. That suited Holbrooke just fine. And on 10 January 2000, representatives from all 15 countries took their blue seats in the Security Council meeting room to hear 40 speakers discuss the threat and impact of HIV/AIDS.

AIDS became the first epidemic in modern history to morph beyond a topic of public health into an issue of national and even international security. Without collaboration between countries, between scientists and military personnel, between industry and government, the disease would have claimed more than the 35 million lives it has to date.

There are other events that could qualify as turning points in the fight. The 2000 conference held in Durban, South Africa, at which Nelson Mandela delivered a heartfelt appeal to the international community. Or the 2002 G8 summit in Alberta, Canada, at which global leaders rolled out a plan to support Africa, in it mentioning their dedication to eradicate HIV/AIDS. Or 1987, when the US Food and Drug Administration announced AZT as the first approved treatment for HIV, due in large part to lobbying from gay activists. Or 1995, when the agency approvedHAART, the drug cocktail that most people with HIV/AIDS take every day to stop the progression of the disease.

But the Security Council meeting was critical. The meeting on that balmy January day marked the first formal discussion of HIV as an issue in which the government and military must get involved to protect a country and its interests. Seven months later, the Security Council passed a resolution calling for more training in AIDS prevention for UN peacekeeping forces and encouraging member states to work together for better prevention and treatment policies.

The rhetoric of national security has shaped the way activists and officials address epidemic diseases today, solidifying partnerships and funding streams. And though there are clear advantages to this large-scale, top-down approach of military involvement, there is much to learn about the best way to stop a pandemic.

By the early 1980s, diseases that ravaged the human population seemed like they might become a thing of the past. Smallpox had been eradicated worldwide by 1980; vaccination campaigns during the 1960s and 70s meant that diseases like polio, mumps and measles affected far fewer people. “People were talking about conquering infectious disease once and for all,” says Joshua Michaud, the associate director of global health policy at the Kaiser Family Foundation. “Nobel Prize-winning biologists were saying that we could see the end of infectious disease in our lifetime, and there were reasons to believe that.”

But when AIDS was discovered in 1981, that illusion was shattered. “We had a lot of magic bullets, we had technical fixes to everything. Then HIV happened,” Michaud says.

HIV/AIDS made for a scary assailant. It surfaced mostly among gay people in San Francisco and New York, a death sentence that catalysed activism among the gay community. This activism became critical in helping people gain access to experimental treatment. HIV became highly stigmatised, a “moral” disease, a plague of philanderers and drug addicts.

The disease hits hardest among adults of reproductive age who are otherwise healthy. It’s a threat that respects no border, as George Tenet, then director of the CIA, noted in 2003. And though the effects of AIDS can feel overwhelming when concentrated within communities, they are even more disastrous when taken at a macro scale.

“AIDS is a long-wave event,” says Simon Rushton, a lecturer in politics at the University of Sheffield. “It’s cross-generational. The impacts on societies are long-term, and they accumulate over time.”

More people would die from AIDS than from any other disease outbreak in human history, including the global influenza pandemic of 1918–19 and the bubonic plague in the 1300s, wrote Peter W Singer, then a postdoctoral fellow at the Brookings Institution, in a 2002 essay. If the disease continued to spread at the same rate in places like South Africa and Botswana – where 20 per cent and 38.5 per cent of the population respectively was infected in the year 2000 – life expectancies would plummet by more than 20 years and child mortality would triple within a decade, Singer said.

Intelligence experts estimated that AIDS would wipe out a quarter of all adults in Sub-Saharan Africa.

“[They] were making a logical case that this was going to keep getting worse and worse, that it will threaten viability of most infected states,” Rushton says. Researchers were struggling to understand the epidemic. “There was a fear, perhaps a well-grounded fear.”

Effects like that would put the political stability of these countries at risk, argued innumerable reports and assessments.

The disease would wipe out government officials and educated, trained professionals that make up the backbone of a society, leaving elderly people to care for orphaned children, a process the experts called “hollowing out”. Militaries, which have higher infection rates than civilian populations (in theory because as young, virile men move around, they engage in sexually risky behaviours, swapping diseases with locals and bringing them to the next deployment), would crumble. Destabilised states leave room for extremist groups to take hold, powered by armies of child soldiers under the command of some of the surviving adults.

This worried American intelligence officials. The US would be called upon to provide costly aid to failing states, according to a declassified CIA report from 1987. The Soviet Union would threaten the US’s strategic positioning in Africa – a key concern during the Cold War – by encouraging rumours that American scientists had created HIV and were spreading it throughout the continent to eliminate black people. The disease also seemed likely to spread to places considered geopolitically more important, such as India and China. The Cold War ended, but, as the epidemic persisted after 9/11, the potential rise of more extremist groups seemed even more threatening. Of course, US officials also feared the disease taking a stronger hold at home, affecting more than those groups relegated to society’s fringes. It could weaken the military and put America’s own stability at risk.

Intelligence agencies had been predicting the destabilising effects of AIDS since the 1980s, yet the world didn’t present a cohesive response until 2000. There’s no single reason why it took so long, but one was that the science on treatment and prevention was still murky, says Mitchell Warren, the executive director of AVAC, a global HIV/AIDS advocacy organisation. By the late 1990s, scientists had shown it was possible to treat and prevent the disease, which was enough to spur activists and political leaders to act. Short of a cure, the only way to stop the epidemic from ballooning was prevention.

§

A 25-year-old woman living in rural Malawi found herself very ill. She had shingles and malaria that wouldn’t go away; her weight had dropped precipitously. Though programmes to diagnose and prevent HIV had been running in the country for several years, this woman had never been tested, and neither had her four-year-old son. “She was living in denial, she didn’t want to discover she was HIV positive,” says David Odali, the director of the Umunthu Foundation, a non-profit that offers HIV testing and treatment and runs education campaigns in Malawi. The woman’s family encouraged her to go to Umunthu’s clinic in the small town of Bangwe, where both she and her son tested positive for HIV and started receiving treatment.

It saved her life; in the years since, the woman has had two more children, both of whom are HIV negative. The mother is able to do some work, more than she could do when she was ill, and the son is thriving in school. “He’s brilliant in school,” Odali adds. “He does come here sometimes on his own to get his treatment,” though his mother only recently helped him to understand why he was taking medicine every day when he didn’t feel sick.

Cases like this one are no longer uncommon. There’s no denying the huge impact that AIDS has had on the world population – in 2015, the World Health Organization (WHO) estimated that about 70 million people have been infected with the virus, and 35 million have died. And yet the effects have not been as dire as once feared; in 2001, experts predicted that 100 million would be dead from the disease by 2005.

Bold, creative individuals – scientists, activists, NGO workers, healthcare professionals – made this happen. But they wouldn’t have been there, their organisations unfunded, the research not conducted, without support from national governments.

The US government, for instance, allocated $6.6 billion to fight HIV/AIDS abroad in 2016 (independent of the $26.4 billion it spends on domestic programmes), making its budget many times larger than those of the UK, which allocated $980 million to fight AIDS in 2015, and Germany, at just over $200 million.

The bulk of the US money comes under the President’s Emergency Plan for AIDS Relief (PEPFAR), and trickles down through different government departments, such as Defense, State, and Health and Human Services, and diffuses into smaller agencies and non-profit organisations, or directly to foreign governments for their own treatment and prevention programmes, says Warren. About a fifth is carved out for the Global Fund. “Both of these organisations were the result of this call in 2000 of a need to change the way the world responded to HIV,” Warren says.

To Warren, it’s clear that the response would not have been as robust if HIV had not been considered a matter of national security. The reframing compelled tight-fisted government officials to make room in the budget. “At the end of the day, the most important people at the country level were not ministers of health. They’re ministers of finance,” Warren says.

The security dimension makes it a bigger political issue than public health, Simon Rushton says. It’s high politics. Peter Piot, who was director of UNAIDS for 13 years, says that this helped establish HIV/AIDS as an exceptional epidemic, requiring an unprecedented level of resources and coordination across sectors.

This produced real results. More than 18 million HIV/AIDS patients worldwide were receiving treatment in 2016, and the number of new cases per year dropped by 40 percent between 1997 and 2015.

It’s impossible to know what would have happened if the national security appeal hadn’t had this effect. As Warren puts it, if something didn’t happen, they’d succeeded. Some feared that the framing would divert funds from other public health issues, such as tuberculosis and malaria. Others said it would further stigmatise people. In Europe and Russia, for instance, people from Africa already faced discrimination in housing and the job market because they were feared to carry disease. The same happened to Haitians in the US.

And though it pulls in more money in the short term, framing one disease as a security issue may absolve countries from engaging with future epidemics that don’t present a security risk, wrote Susan Peterson, a professor of international relations at the College of William and Mary in Williamsburg, Virginia, in 2002.

The security framing may also shift the focus of the HIV/AIDS spending itself. When PEPFAR launched in 2003 with a budget of $15 million, its efforts initially focused on 15 countries. These were not the top 15 countries affected by AIDS at the time. “People have looked at that initial list,” says Rushton, “and it looks like it’s at least partly motivated by security concerns.” He notes that Vietnam, one of the 15 countries on the original list, had only 220,000 cases of HIV/AIDS in 2004 – a mere fraction of the number of people infected in Malawi (940,000), which did not receive initial attention from PEPFAR, and far less than Russia (more than 320,000), which similarly received no support.

And though countries like South Africa were at the centre of the AIDS epidemic and deserved the funding and attention they received, critics have suggested that global powers, including the US, might have been more invested in their political stability.

David Odali still struggles to get enough funding for Umunthu’s ambitious programmes, although a six-year partnership with the NGO AVERT has enabled them to reach out to more patients. Though he and his collaborators have had many successes, there were still 33,000 new cases of HIV in 2015 in Malawi. “As we are talking, someone out there is contracting the virus, through unprotected sex, through rape, through caring for a patient,” he says. “The infection is still there with us.”

§

When West Point was first dredged from the sea, in the 1940s, it was probably a beautiful place. This neighbourhood at the most northwestern point of Monrovia, Liberia, is a peninsula, cut off from the rest of the city by two rivers to the north and east, and with the Atlantic Ocean to the west. Its beaches are a sandy yellow, and a few palm trees dot the shore. But today, that beauty is only visible in fleeting moments, like afternoon light through slanted blinds. West Point is a slum, home to 75,000 people who live in densely packed houses cobbled together from roofing tin. Its beautiful beaches are coated with a layer of garbage. Many former child soldiers, disabled by war, live here; drug use is common. There is a market on the one main road that connects the neighbourhood with the rest of the city, on which patrons can buy shark freshly caught by the fishermen who shove off the beaches in long, narrow boats.

Since there’s only the one road, it wasn’t hard for the Liberian army to quarantine the neighbourhood one cool night in the heat of the Ebola crisis in August 2014. The week before, health officials quietly converted a school building into an Ebola holding centre; when the locals found out, some looted the facility, carrying off items that had likely been contaminated. So when the Liberian president issued a curfew on 20 August, West Point was also put under quarantine. Residents awoke that Wednesday morning to find their commutes thwarted by barbed wire; fishermen were stopped from pushing off in their boats.

The locals rioted. They rattled barricades and threw rocks at soldiers, who responded by opening fire. Food and water were hard to find, medical care was even rarer. After 10 days, the president lifted the quarantine. A 15-year-old boy died of complications from bullet injuries in his legs. “You fight Ebola with arms?” a 34-year-old resident yelled at the soldiers, according to the New York Times. No one in West Point was diagnosed with Ebola.

In the wisdom and comfort of hindsight, experts can assess the world’s response to emerging pandemics. The 2009 H1N1 (swine flu) outbreak was well-contained, partly because of good communication and partly due to simple luck: the disease wasn’t as deadly as feared. The Middle Eastern respiratory virus (MERS), which hit South Korea in 2015, didn’t spread because it didn’t evolve and was quickly contained.

But to many experts, the world’s response to Ebola was wanting. Public health officials admit that action wasn’t fast enough, that misinformation spread quickly among a largely illiterate population, that foreign policy makers lacked a cultural understanding, which allowed the disease to spread, and that governments in the most affected countries used too much force. As a result, more than 11,000 people died of the disease in West Africa.

And yet the death toll would have certainly been higher if not for the lessons learned from HIV.

The engineers of the world’s HIV response in the early 2000s knew that they were laying the groundwork to combat future epidemics. Richard Holbrooke, who died in 2010, said in his 2006 PBS interview: “There’s a possibility that we’re entering into an age where new diseases are beginning to break out… If that’s true – and a lot of friends of mine in the field think it is true – the first lesson is you’ve got to move really fast. The second lesson is you have to get away from mythology, stigmatisation and all these other things that created such a slow, slow reaction to AIDS.”

Because of HIV and those discussions that began in 2000, governments and international organisations have logistical protocols to address new epidemics. Emerging diseases are now discussed at the Security Council, as AIDS was. Should a new one arise, officials in the US government, along with international organisations such as the UN and the WHO, have designated procedures for assessing the threat and working with experts on the best way to respond. Time, they have learned, is of the essence – the slow growth of HIV diagnosis programmes meant that many people spent a long time unknowingly infected – during which time they infected others; physician and radio show host Stanley Monteith wrote in 1997 that the AIDS epidemic would have been preventable had health organisations acted earlier.

Now experts know that early response is key. By April 2003, six months after the severe acute respiratory syndrome (SARS) epidemic started, the US had 289 suspected cases, But the disease didn’t spread because of good planning and communication between local and federal health workers, public health officials told the New York Times. And the impetus for that was laid in the framing of the disease as a threat to national security.

In the process of meeting the need for HIV testing and treatment in remote areas, many African countries developed sophisticated systems to monitor emerging diseases. Ebola would have been a disaster if it had spread throughout Nigeria, the most populous country in Africa and a hub for international travel. But it didn’t, Warren says, because of systems put in place to combat HIV which were then used to fight Ebola. “The surveillance system and treatments of those Nigerians with Ebola was so rapid that the disease didn’t spread,” Warren says. “If you look at why, it’s because the health system had been developed and strengthened from the HIV response.”

Researchers are also in a better position to meet the challenge of a new infectious disease. Epidemiologists developed new techniques, such as contact tracing, in which scientists work backwards from a newly diagnosed patient to determine where else the disease might spread. Teams of scientists brought together to discover treatments for HIV have used their expertise to treat other rapidly mutating diseases – a team of HIV researchers at Walter Reed Army Institute of Research, based in Maryland but with facilities in Africa and South-east Asia, created one of the most promising vaccines to fight Zika virus. And when it comes to disease research within communities, scientists have found that they get much more cooperation if they work with local governments and community advisory boards before starting a project.

Charged by the national security argument, militaries – especially the US military – have become the quickest and most efficient force for quelling emerging infectious diseases. “The only institution that was felt could address Ebola at the scale at which it was needed was the US military,” Joshua Michaud says – the army had the communication, infrastructure and transportation to get the job done.

But that can come with a cost. The need to act quickly can sometimes elevate issues past the normal democratic checks and balances, so they are subject to less scrutiny. When security is at risk, it gives militaries licence to infringe on civil liberties. That’s what happened to West Point during the Ebola outbreak. It happened elsewhere, too – in the US, many questioned the quarantine practices of the Centers for Disease Control and Prevention. One woman, a nurse quarantined for two days after she returned from treating Ebola patients in Sierra Leone, tried to sue the governor of New Jersey for unlawful detainment (a judge dismissed the lawsuit in September 2016).

“One downside is that the security discourse can be misappropriated by those in power and used improperly to justify punitive policies and laws, which are only likely to fuel stigma, fear and spread of disease further,” Peter Piot says. “The military has a role to play, we just have to think in a considered, nuanced manner about how they can best support civilian-led efforts to contain pandemics.”

Each new pandemic will be different – where it starts, how contagious it is, how it’s transmitted. But as government agencies push to act quickly, more officials are realising that the first actions taken to fight a disease can determine whether the efforts are successful. If misinformation spreads early on, it can lead infected people to be stigmatised, which may inhibit them from receiving the best possible care. Warren recalls photos from the early days of the fight against Ebola in which healthcare workers were reluctant to touch patients.

“For a lot of us working with HIV, some of those pictures were harsh reminders for what it meant to be patient-centred in our care,” Warren says. “The stigma and culture around disease, around clinical research, is really intense. We need to be sensitive to that.” Public health workers had collaborated with community leaders before, but they had never tried to create these partnerships on such a massive scale until the HIV response. Ceremonies surrounding stages of life, such as birth and reaching sexual maturity, create different ways for disease to spread. Only with sensitivity to local cultural practices – what purpose they serve, and how they can be modified while still keeping the main point of the ritual intact – could doctors and researchers stop the spread of disease. Officials were faced with a similar challenge during the Ebola epidemic, when they discovered that traditional burial practices, such as the communal washing and cleaning of the dead body, were spreading the infection.

§

Public health emergencies come and go, but HIV appears to be here to stay, at least for the next few decades. Some fear that, as health workers settle in for a long fight, governments will no longer prioritise HIV as they did a decade ago, limiting the funding to support their efforts. Progress in reducing the number of new infections has slowed. “AIDS is slipping down the policy agenda because we’re also now in the long slog phase,” Simon Rushton says. “We know it’s not something that will be solved in the next five to 10 years – it demands a continued commitment for another 20 to 30 years at least. That’s a much less sexy policy sell. Policy makers like problems they can solve during their term.”

With the election of Donald Trump as President of the United States, the country’s role in the continued fight against HIV/AIDS is further called into question. During much of Trump’s campaign, no one was certain where the candidate stood. There were reasons to feel optimistic about the country’s continued support. In a 2008 speech, Vice President Mike Pence, then serving in the House of Representatives, had said that the US had a “moral obligation to lead the world in confronting the pandemic of HIV/AIDS”, bolstering his stance with a security argument.

But early signs from the new administration have not been heartening. In his first week in office, Trump signed an executive order that withholds funding from organisations that perform abortions or provide information about them. In the past, similar but less expansive policies have resulted in the closure of many rural clinics, often the only place where locals could receive drugs to treat HIV and AIDS. Now many organisations fear the effect will be even more dramatic.

In some ways it’s harder than ever to imagine a world in which infectious diseases no longer exist, the idealistic bubble burst by HIV. And yet in other ways, the world is better poised than ever before to make that fantasy into reality. That single January 2000 meeting set the stage for leaders within countries to have their own discussions about how to respond to the epidemic, about how to spend money to counter it within their own borders and beyond.

As the then US Vice President Al Gore said at the meeting, AIDS “is a security crisis because it threatens not just individual citizens, but the very institutions that define and defend the character of a society”.

“It was one of the most exciting days we had in the UN,” Richard Holbrooke told PBS, “and I think history shows that it helped redefine the issue.”

This article first appeared on Mosaic and is republished here under a Creative Commons licence.

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Gonorrhea Is Now One Antibiotic Away from Being Untreatable

A close-up illustration of the Gonorrhea bacteria on a petri dish

Back in October, we told you that Gonorrhea could possibly become untreatable, well, unfortunately, the disease is closer to untreatable than it has been since doctors devised a way to treat it in the first place.

We’re down to just one antibiotic that can effectively fight the disease!

The cause for alarm comes from the CDC’s cheerily named “Morbidity and Mortality Weekly Report,” which has reported this month:

Gonorrhea is a major cause of serious reproductive complications in women and can facilitate human immunodeficiency virus (HIV) transmission. Effective treatment is a cornerstone of U.S. gonorrhea control efforts, but treatment of gonorrhea has been complicated by the ability of Neisseria gonorrhoeae to develop antimicrobial resistance.

In everyday terms, gonorrhea has gradually grown resistant to nearly every antibiotic we’ve created over the past several decades to destroy it. Nowadays, our last stand against the disease is injections of the antibiotic ceftriaxone, which then need to be be followed up with oral doses of either zithromycin or doxycycline.  According to a statement from the CDC’s Director of STD Prevention, Dr. Gail Bolan, it is now “only a matter of time” until gonorrhea is resistant to our final, antibiotic regimen. After that, we’ll have nothing to stop it, which is not good news considering that gonorrhoea is a common STI in the UK.

It was diagnosed in over 16,500 people in 2010 and there are likely to be many more people who remain undiagnosed, because up to half of women and one in 10 men have no symptoms of gonorrhoea so don’t seek advice from a doctor.

So, in line with our advice in protecting yourself from contracting HIV, if you’re not using condoms already—(and, really, you should be using condoms if you’re having sex with people) maybe you should start now, there are other dangers out there besides HIV.

More information about gonorrhoea is available from the NHS and Bupa from the following links:

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A History of HIV & AIDS – 1994

As we prepare to enter our 25th year, we are reflecting on the global HIV events from the last three decades.  HIV has swept across the globe touching communities on every continent.  Here’s an introduction to some of the key moments in the early global history of HIV.  Catch up on the story using the ‘Recent Posts’ link to the right.

We focus on 1994 today, when The Centre for Disease Control (CDC) released 13 hard hitting AIDS advertisements which was a significant move from their more subdue approach. The prevention method was the use of condoms, which were rarely seen or even mentioned on television.

“One of the television ads, entitled Automatic, features a condom making its way from the top drawer of a dresser across the room and into bed with a couple about to make love. The voice-over says, ‘it would be nice if latex condoms were automatics. But since they’re not – using them should be. Simply because a latex condom, used consistently and correctly, will prevent the spread of HIV.’ (Library Reference)

In February, Secretary Shalala announced the eighteen members of the National Task Force on AIDS Drug Development, which includes experts in AIDS drug development issues from academia, industry, medicine, the HIV/AIDS-affected communities, and Government.  The Chairman of the Task Force is the Assistant Secretary for Health. The FDA (Food & Drug Administration in America) provides administrative and managerial support for the Task Force.

In March, the actor Tom Hanks won an Oscar for playing a gay man with AIDS in the film Philadelphia.

Philadelphia was was the first big-budget Hollywood film to tackle the medical, political, and social issues of AIDS.  Tom Hanks plays Andrew Beckett, a talented lawyer at a stodgy Philadelphia law firm. Andrew had contracted AIDS but fears informing his firm.  The firm’s senior partner, Charles Wheeler (Jason Robards), assigns Andrew a case involving their most important client. Andrew begins diligently working on the case, but soon the lesions associated with AIDS are visible on his face.

I won’t tell you more in case you’ve not seen it yet, (spoilers are never nice)! Suffice to say it’s all about prejudice and discrimination in legal setting in the early 90’s.  It’s nice to see that laws have since changed but today, 18 years on we still have a long, long way to go in order to stop the ignorance and stigma left behind!

On March 29, The FDA asked condom manufacturers to begin using the air-burst test on all brands of latex condoms. This new test measures a condom’s strength, and may be an indirect indicator of its resistance to breakage during use.

By July 1994 the number of AIDS cases reported to the WHO was 985,119. The WHO estimated that the total number of AIDS cases globally had risen by 60% in the past year from an estimated 2.5 million in July 1993 to 4 million in July 1994.

It was estimated that worldwide there were three men infected for every two women, and that by the year 2000 the number of new infections among women would be equal to that among men.

At the end of July, it was announced that the WHO’s Global programme on AIDS would be replaced. The UN Economic and Social Council approved the establishment of a new “joint and cosponsored UN programme on HIV/AIDS”.  The separate AIDS programmes of the UNDP, World Bank, UN Population Fund, UNICEF and UNESCO would have headquarters with the WHO in Geneva.  Later in the year it was announced that Dr. Peter Piot, the head of the research and intervention programme within the Global Programme on AIDS, would be the head of the new UN program.

Official statistics for Brazil, with a population of about 154 million, indicated that some 46,000 cases of AIDS had been recorded, but estimates put the actual number at anywhere between 450,000 and 3 million cases. Two thirds of the known cases were in Sao Paulo state where AIDS was the leading cause of death of women aged 20-35.

In early August 1994, the Tenth International Conference on AIDS was held in Yokohama, Japan. It was the first of the International Conferences to be held in Asia.  No major breakthroughs emerged, and it was announced that in future the international conference would be held every two years.

An exciting study, ACTG 076, showed that AZT reduced by two thirds the risk of HIV transmission from infected mothers to their babies.  It was the most stunning and important result in clinical acquired immunodeficiency syndrome research to date because it was the first indication that mother-to-child transmission of HIV can be at least decreased, if not prevented. And it will provide a real impetus for identifying more HIV-infected women during pregnancies so that they could consider the benefit of AZT treatment for themselves and their children.”

Meanwhile in the Russian Federation, deputies in the Russian Parliament, the Duma, voted at the end of October to adopt a law making HIV tests compulsory for all foreign residents, tourists, businessmen and even members of official delegations.

India by this time had around 1.6 million people living with HIV, up by 60% since 1993 (identical to the global figure). Local and state governments were accused of underusing and misusing HIV prevention funds.

In December, President Clinton asked Joycelyn Elders to resign from the post of US Surgeon General, following a remark during a World AIDS Day conference that children could be taught about masturbation.  She was asked whether it would be appropriate to promote masturbation as a means of preventing young people from engaging in riskier forms of sexual activity, and she replied, “I think that it is part of human sexuality, and perhaps it should be taught.”

This remark caused great controversy and resulted in Elders losing the support of the White House. White House chief of staff Leon Panetta remarked, “There have been too many areas where the President does not agree with her views. This is just one too many.”

Elders was fired by President Clinton as a result of the controversy in December 1994.

Perhaps this unfolds unhappy memories if you experienced this discrimination first hand but to our younger audience who may not have lived during these times, it’s important to understand that prejudice, stigma and discrimination remained significant obstacles for sex education, HIV prevention and AIDS awareness throughout the 1990s and into the new millennium.

In closing today, someone recently told me that Tim Radford (A freelance Journalist) wrote a special report “the progress being made in the fight against the cleverest and most malevolent virus scientists have ever seen”.  The report also examines issues of stigma, discrimination, and the effect HIV/AIDS has on families. – I’m afraid I can’t link to it, but if anyone has a copy, please get in touch!

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Aging & HIV

There’s no denying the life-extending benefits of antiretroviral therapy. While it has allowed many people living with HIV to plan for their golden years, it has also meant preparing to face age-related health problems. According to the CDC, 25 percent of those living with the virus are over 50 years old.  In turn, there’s a growing need for comprehensive  care to prevent and manage typical age-related maladies, such as heart disease, cancer, diabetes and osteoporosis—all of which can be complicated by HIV and its treatment.
You can find comprehensive information about treatment options from your GP and the people over at http://www.aidsmeds.com have written an excellent report into HIV & Ageing covering:
  • What is aging, and why do we become ill as we get older?
  • How does HIV affect the aging process?
  • Are people with HIV aging more rapidly?
  • Is it possible to slow down the aging process?
  • Are there experimental treatments to slow aging in people with HIV?

The good news is that most HIV-positive people can do quite a lot to slow the aging process and guard against the onset of age-related illness. So why not head over there and understand how aging works in the first place, and what you can do to help yourself..

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A History of HIV & AIDS

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The Red ribbon is a symbol for solidarity with...

The Red ribbon is a symbol for solidarity with HIV-positive people and those living with HIV. (Photo credit: Wikipedia)

We are here to to respond to the challenges of HIV, and over the next next few weeks, as we prepare to enter our 25th year, we’d like to take a moment to reflect on the past 25 years as HIV and AIDS have swept across the globe, touching communities on every continent.  Here’s an introduction to some of the key moments in the early global history of HIV.

On 5 June 1981, the US Centres for Disease Control (CDC) published a report describing cases of a rare form of pneumonia among five gay men in Los Angeles. Soon after, there are a number of reports of a rare skin cancer, Kaposi’s sarcoma, increase among gay men living in California and New York.

In 1982, the term A.I.D.S. (Acquired Immune Deficiency Syndrome) is used for the first time. Prior to this, it was called G.R.I.D. (Gay Related Immune Deficiency) and was associated with homosexuality because it was first documented among gay men in New York and California.  It was only in 1983 we began to get evidence that AIDS is caused by a virus (sic), this emerges from the Pasteur Institute in Paris. The US reports that more than 1,200 Americans have been affected by AIDS and more than one-third of them have died.

The number of cases doubles each six months, it is officially an epidemic and the deadliest since swine fever ravaged the US at the end of the first world war.
In Geneva, the World Health Organisation convenes the first meeting to discuss the international implications of AIDS, which has so far been found in dozens of countries, and has now been found in both women and men.

The Human Immunodeficiency Virus was isolated by scientists in the US and France (though it was not formally named as HIV until 1986). Later, a public controversy erupts over who first discovered HIV, and eventually over who would get the Nobel Prize for it.

Along with the discovery of the virus, the first diagnostic blood test, known as the Elisa test, is developed to screen for HIV infection.

This photo of Ryan White was taken by me (Wild...

This photo of Ryan White was taken in the spring of 1989 at a fund raising event in Indianapolis, Indiana. (Photo credit: Wikipedia)

Ryan White, a haemophiliac teenager who contracted HIV from contaminated blood products in 1985 is barred from school.  He soon becomes one of the most bravest, and well-known advocates for AIDS research and awareness in America.

1985 also marks the year that Hollywood actor Rock Hudson dies of an AIDS related illness. He had recently publicly disclosed his AIDS diagnosis.

The first international Aids conference is held in Atlanta, Georgia and 1986 marks the discovery of a second type of HIV, eventually named HIV-2, it’s discovered by US and French research teams. Jon Parker, a former drug user, starts the first needle-exchange programme in the US to combat HIV among intravenous drug users and The World Health Organisation launches the Global Programme on Aids. The programme will later end and be replaced by UNAids, the UN Aids agency.

Stay tuned over the next few days for more information as we reveal more, of the history of HIV and AIDS.

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Giving preventive drug to men at high risk for HIV would be cost-effective, study shows

A once-a-day pill to help prevent HIV infection could significantly reduce the spread of AIDS, but only makes economic sense if used in select, high-risk groups, Stanford University researchers conclude in a new study.

The researchers looked at the cost-effectiveness of the combination drug tenofovir-emtricitabine, which was found in a landmark 2010 trial to reduce an individual’s risk of HIV infection by 44 percent when taken daily. Patients who were particularly faithful about taking the drug reduced their risk to an even greater extent — by 73 percent.

The results generated so much interest that the Stanford researchers decided to see if it would be cost-effective to prescribe the pill daily in large populations, a prevention technique known as pre-exposure prophylaxis, or PrEP. They created an economic model focused on men who have sex with other men, or MSM, as they account for more than half of the estimated 56,000 new infections annually in the United States, according to the Centers for Disease Control and Prevention.

“Promoting PrEP to all men who have sex with men could be prohibitively expensive,” said Jessie Juusola, a PhD candidate in management science and engineering in the School of Engineering and first author of the study. “Adopting it for men who have sex with men at high risk of acquiring HIV, however, is an investment with good value that does not break the bank.”

For instance, using the pill in the general MSM population would cost $495 billion over 20 years, compared to $85 billion when targeted to those at particularly high risk, the researchers found. The study was published in the April 17 issue of the Annals of Internal Medicine.

Senior author Eran Bendavid, MD, assistant professor of medicine in the School of Medicine, said the results are a departure from a previous study, which found PrEP was not cost-effective when compared with other commonly accepted prevention programs. The new Stanford study differs in a few important respects, taking into consideration the decline in transmission rates over time as more individuals take the pill. The Stanford team also assumed individuals would stop taking PrEP after 20 years, not stay on the drug for life, as the previous study had assumed.

The pill combination, marketed under the brand name Truvada, is widely used for treating HIV infection. But it wasn’t until a landmark trial, published in the New England Journal of Medicine in November 2010, that individuals and their doctors began to seriously consider using the drug as a preventive therapy. The drug’s maker, Foster City, Calif.-based Gilead Sciences Inc., has filed a supplemental new drug application to market it for prevention purposes.

The CDC issued interim guidelines on the drug’s use in January 2011, suggesting that if practitioners prescribe it as a preventive measure, they regularly monitor patients for side effects and counsel them about adherence, condom use and other methods to reduce their risk of infection.

In developing their model, the Stanford researchers took into account the cost of the drug — about $26 a day, or almost $10,000 a year — as well as the expenses for physician visits, periodic monitoring of kidney function affected by the drug, and regular testing for HIV and sexually transmitted diseases.

“We’re talking about giving uninfected people a drug that has some toxicities, so it’s crucial to have them monitored regularly,” Bendavid said, who is also an affiliate of Stanford Health Policy, which is part of the Freeman Spogli Institute for International Studies.

Without PrEP, the researchers calculated there would be more than 490,000 new infections among the MSM population in the United States in the next 20 years. If just 20 percent of these men took the pill daily, there would be nearly 63,000 fewer infections.

However, the costs are substantial. Use of the drug by 20 percent of the MSM population would cost $98 billion over 20 years; if every man in this group took PrEP for 20 years, the costs would be a staggering $495 billion.

Given these figures, the researchers looked at the option of giving PrEP only to men who are at high risk — those who have five or more sexual partners in a year. If just 20 percent of these high-risk individuals took the drug, 41,000 new infections would be prevented over 20 years at a cost of about $16.6 billion.

At less than $50,000 per quality-adjusted life year gained (a measure of how long people live and their quality of life), that strategy represents relatively good value, according to Juusola.

“However, even though it provides good value, it is still very expensive,” she said. “In the current health-care climate, PrEP’s costs may become prohibitive, especially given the other competing priorities for HIV resources, such as providing treatment for infected individuals.”

She said the costs could be significantly reduced if the pill is found to be effective when used intermittently, rather than on a daily basis. Current trials are examining the effectiveness of the drug when used less often.

Other co-authors are Margaret Brandeau, PhD, the Coleman F. Fung Professor
of Engineering, and Douglas Owens, MD, MS, the Henry J. Kaiser, Jr. Professor at Stanford and senior investigator at the Veterans Affairs Palo Alto Health Care System. Owens also is director of Stanford’s Center for Health Policy/Primary Care and Outcomes Research.

The study was funded by the National Institutes of Health and the Department of Veterans Affairs.

Information about Stanford’s departments of Management Science and Engineering and of Medicine, which also supported the work, is available at http://www.stanford.edu/dept/MSandE/ and at http://medicine.stanford.edu/.

Original Article by Ruthann Richter at Standford School of Medicine

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Testing people with conditions suggesting HIV could pick up more recent infections, Europe-wide study finds

A pilot study in 14 European countries, in which groups of patients presenting with one of eight conditions strongly associated with HIV were routinely tested for HIV in various medical settings, found an HIV prevalence rate of 1.8%. This is far in excess of national rates and of the 0.1% prevalence rate suggested by the US Centres for Disease Control for routine HIV testing of the population, and suggests targeting people with these so-called indicator conditions (ICs) for HIV testing could be an efficient way of detecting infection.

The study found relatively high CD4 counts and a high prevalence in patients presenting with mononucleosis-like illness. These symptoms are usually caused by Epstein-Barr virus but may also be due to HIV seroconversion. This suggests that testing for indicator conditions might be a good way of detecting more people in early HIV infection.

The HIDES I study arose from the HIV in Europe conference in 2007, which debated how to improve HIV testing rates and reduce the amount of undiagnosed HIV in the region.

One method suggested was to draw up a list of indicator conditions (ICs) associated with HIV probability of HIV infection and recommend that people presenting of these should be routinely tested.

HIDES I drew up a shortlist of eight ICs and sent out a call to healthcare centres in Europe to participate in the study to test the feasibility and acceptability of routine IC-driven HIV testing.. This would involve them routinely test all patients consecutively presenting with a specific IC.

The eight conditions chosen were:

  • Acute STIs
  • Hepatitis B or C
  • Malignant lymphoma of any type
  • Anal or cervical intraepithelial neoplasia (HPV disease) grade 2 or above
  • Unexplained low platelets (thrombocytopenia) or neutrophils (neutropenia) for more than four weeks
  • Herpes zoster (shingles) in people under 65
  • Seborrhoeic dermatitis or exanthema (sudden rash)
  • Mononucleosis-like illness.

Results: demographics

Seventeen centres in 14 European countries spread over the whole continent from UK to Ukraine participated in HIDES I. They conducted 39 separate surveys on HIV testing in patients presenting with ICs between September 2009 and February 2011. There were one to six surveys conducted in each centre and between three to six surveys conducted for each indicator condition.

Altogether, 3588 patients were tested for HIV. They had an average age of 36, which varied according to condition from 24 for mononucleosis to 53 for lymphoma. Fifty-five per cent were men and a quite high proportion (36%) had had a previous HIV test.

Sex, age, sexuality and previous testing rates varied by European region. Patients were youngest (average 33) in northern Europe (UK, Netherlands, Denmark, Sweden) and oldest (43) in southern Europe (Italy and Spain). Roughly two-thirds were male in all European regions apart from northern Europe, where 44% were male.

Only two per cent of patients in eastern Europe (Belarus, Ukraine, Bosnia, Croatia, Poland) said they were gay compared with approximately 40% in south and west central Europe (Germany, Austria, Belgium) and 45% in northern Europe; and only 13% in eastern Europe had had a previous HIV test compared with 36% in southern, 45% in west central, and 60% in northern Europe.

Results: HIV diagnoses

There were 66 new HIV diagnoses (1.8% of patients). Eighty-three per cent of those diagnosed were male, 58% of them were gay, 42% heterosexual and 9% had injected drugs. The prevalence of newly-diagnosed HIV varied widely from 0.6% in northern Europe to 6.5% in southern.

It also varied widely per IC. Not unexpectedly the highest HIV diagnosis rate was in surveys involving STIs (4%) but it was not much lower in mononucleosis-like illness (3.8%), neutro/thrombocytopenia (3.2%), shingles (2.9%) and dermatitis/rash (2.1%).

In contrast HIV prevalence was only 0.4% in cervical/anal dysplasia and hepatitis B/C and 0.3% in lymphoma, possibly because the individuals with these diseases who have HIV are more likely to have already been diagnosed. These rates are still above the 0.1% rate considered cost-effective for routine testing, though.

Over the whole group, more than half of those diagnosed with HIV(52%) had been tested for it before, with a median time from their previous HIV test of 19 months. Their average CD4 count was 400. This may indicate that offering an HIV test as standard when ICs are diagnosed may detect more cases of early HIV infection, though presenter Ann Sullivan of London’s Chelsea and Westminster Hospital did not split this analysis into European regions. It is possible that the relatively high amount of recent infections may be driven by tests given to people presenting with STIs who might have tested anyway.

HIDES 1 found that 20% of patients had presented to healthcare with one of the ICs in the preceding five years and 4.6% had presented more than once.

Next steps

The HIDES project now intends to conduct a larger HIDES 2 study involving 12 indicator conditions, in order to establish better HIV prevalence figures for each. It also intends to conduct a separate audit of whether patients in Europe who present with ICs are offered HIV tests. Finally they intend to develop, in collaboration with the European Centre for Disease Control and the World Health Organization, a set of guidelines for HIV testing targeted at indicator conditions.

HIDES investigator Jens Lundgren commented from the audience that although HIDES 1 was a pilot study, its results were important because many physicians had been sceptical that using ICs to guide HIV testing would find higher than average rates of HIV or be cost-effective. These results showed that it was an efficient way to find undiagnosed HIV.

Original Article by Gus Cairns at NAM

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