Number two

An item in the news over the last week that some of you may have seen - a second case of AIDS apparently 'cured' and by a completely different route to the first. From the New York Times:

Doctors announced on Sunday that a baby had been cured of an H.I.V. infection for the first time, a startling development that could change how infected newborns are treated and sharply reduce the number of children living with the virus that causes AIDS.

The baby, born in rural Mississippi, was treated aggressively with antiretroviral drugs starting around 30 hours after birth, something that is not usually done. If further study shows this works in other babies, it will almost certainly be recommended globally. The United Nations estimates that 330,000 babies were newly infected in 2011, the most recent year for which there is data, and that more than three million children globally are living with H.I.V.

The Berlin Patient

I was looking for updates on Timothy Ray Brown (aka 'The Berlin Patient' aka 'The man cured of AIDS') when I came across this interview he did with Democracy Now (which is broadcast locally on KCSB).

The interview also includes Dr. Jeffrey Laurence an AIDS researcher who clearly explains why this is a good step forward but not a cure for everyone:

(T)he way it was done in Mr. Brown is off the realm of practicality. It’s way too expensive. You’re going to need another fatal disease in order to get one of these things. The risk of dying from such a bone marrow transplant or stem cell transplant is about 20 percent in the first hundred days after the transplant, and it’s very expensive. And also, I should emphasize that finding the donors are not easy. This mutation that causes this disruption of the door, CCR5, that the AIDS virus needs to get into a cell, is found in about 1.5 percent of all Caucasians in America, about 4 or 5 percent of all Scandinavians and northern Russians, but it’s found in no African Americans, in no blacks, in no Africans, in no Oceanics, in no Asians, in no American Indians. So, it’s—for large portions of the population, it’s not even going to be helpful.

She speaks for me

The world's largest AIDS conference (22,000 people) met in the United States for the first time in 22 years this week after President Obama lifted travel restriction on HIV positive people allowing the conference to be held here. However travel bans were still in place on foreign sex workers, under laws passed two centuries ago. This led to several disruptions at the conference as protesters brought attention to the absence of one of the key groups in stopping the epidemic.

Barbara Lee ( U.S. Representative for California's 9th congressional district - most famous for being the only member of either house of Congress to vote against the authorization of use of force following the September 11 attacks) was instrumental in getting the travel ban on HIV patients lifted and last week introduced a proposed law in the House of Representatives to do the same for sex workers.

"I don't know how we're going to ever see an end to AIDS in our lifetime -- and we believe we can, especially with scientific advances -- and have an AIDS-free generation, without including all of those populations who must be involved as part of this solution." U.S. Rep. Barbara Lee of California.

AIDS campaigns

Two very different approaches.

 
 

History of AIDS

The Washington Post has a photographic history of the AIDS epidemic in the United States to mark the three decades that have passed since Robert Gallo and Luc Montagnier identified HIV as the virus that causes AIDS in 1983. It's a poignant reminder of how much this epidemic has affected our society.


Many of the iconic images of the US AIDS epidemic are there but the classic photograph above was missing. It didn't take long to find it though, at CNN: The photo that brought AIDS home.

Why can't mosquitoes transmit HIV?

In a recent survey of young Australians (18 to 29) 43 per cent believed they could get HIV from mosquito bites.

Although this is NOT the case, it does raise the question of exactly why not given that mosquitoes do vector a range of other diseases. I found this website at Rutgers that provides a very clear description of three possible mechanisms for transmission and then clearly describes why each one is simply not possible or is beyond the bounds of likely probablity. For example:

Many people think of mosquitoes as tiny, flying hypodermic syringes, and if hypodermic needles can successfully transmit HIV from one individual to another then mosquitoes ought to be able to do the same. We have already seen that HIV-infected individuals do not circulate enough virus particles to result in infection by contamination. However, even if HIV-positive individuals did circulate high levels of virus, mosquitoes could not transmit the virus by the methods that are employed in used syringes. Most people have heard that mosquitoes regurgitate saliva before they feed, but are unaware that the food canal and salivary canal are separate passageways in the mosquito. The mosquito's feeding apparatus is an extremely complicated structure that is totally unlike the crude single-bore syringe. Unlike a syringe, the mosquito delivers salivary fluid through one passage and draws blood up another. As a result, the food canal is not flushed out like a used needle, and blood flow is always unidirectional. The mechanics involved in mosquito feeding are totally unlike the mechanisms employed by the drug user's needles. In short, mosquitoes are not flying hypodermic needles and a mosquito that disgorges saliva into your body is not flushing out the remnants of its last blood meal.

The only thing we have to fear...

It is notoriously difficult to change people's behavior. However it is quite easy to frighten people.

Is it acceptable to exaggerate a risk in order to frighten people into changing their behavior?

Watch the following video and discuss.

Pneumocystis Pneumonia --- Los Angeles

Julio sent me this CDC report, from June 5 1981, about 5 cases of Pneumocystis Pneumonia in Los Angeles, which was the first published report about what would, a year later, be known as AIDS and would, thirty years later, have killed 25 million people.

All the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis and candidiasis. 

If you would like to read more about this period in history when AIDS was first being discovered and invesitagted  then Randy Shilts book, And the Band Played On, is thoroughly recommended:

"An exhaustive account of the early years of the AIDS crisis, this outlines the medical, social and political forces behind the epidemic's origin and rapid spread. The book stands as a definitive reminder of the shameful injustice inflicted on this nation by the institutions in which we put our trust."  Publishers Weekly

Researchers believe they may be a step closer to HIV vaccine

Researchers are hoping they are one step closer to a HIV vaccine – using HIV. At the 6th International AIDS Society Conference on HIV Pathogens, Treatment, and Prevention in Rome, researchers with the Maryland-based VirxSys Corporation announced the findings of their VRX1273 vaccine.

The vaccine is a genetically altered version of SIV, the version of HIV found in non-human primates. Over the course of six months, five infected monkeys were injected with the vaccine three times, while five others were given a placebo vaccine. After 18 months, it was found that 40% of the vaccinated monkeys had very low to undetectable amounts of virus in their bodies.

Pills to prevent HIV

Pills found to be highly effective in preventing HIV transmission
Experts hail a pair of trials involving heterosexual couples in Africa as a breakthrough in AIDS prevention. The studies show that taking a pill containing one or two drugs each day can decrease transmission of HIV by as much as three-quarters.

The report above is from the LA Times. The report from the Guardian seems a little more realistic:
Daily pill can prevent HIV infection
Groundbreaking studies suggest tablets could help partners of people with HIV protect themselves – secretly, if necessary.

The Emerging Race to Cure HIV Infections

 A recent article in Science, The Emerging Race to Cure HIV Infections, describes the effect that Timothy Ray Brown's cure has had on the research community. The abstract is below but the full article is fairly short and very interesting.

Four years after Timothy Ray Brown received bone-marrow transplants to fight leukemia, the most sophisticated labs in the world cannot find any trace in his body of the HIV that had infected him for 12 years. Brown is the only living human, a growing consensus contends, to be cured. Brown's treatment clearly does not offer a road map for many others. After all, the expensive, complex, and risky transplant only made sense because Brown was dying from leukemia. Nor is it clear exactly which components of the extensive transplant regimen cleared the virus from his body. But Brown's case has moved the much-ridiculed idea of curing HIV onto the most scientifically solid ground it has yet occupied, say leading AIDS researchers. Brown's case showed for the first time that it is possible to rid the body of the virus—even from the minuscule reservoirs where the virus can hide out for years, evading both the immune system and antiretroviral drugs (ARVs). His astonishing turnaround also raised hopes that other, more practical drugs and immune system modulators might find and destroy every last bit of virus—or at least reduce it to such low levels that people no longer need ARVs.

Clean needles in California

Although needle exchange systems are fairly widespread another important part of the equation is the simple ability to buy clean needles in the first place. There is clear evidence that the availability of clean needles helps prevent the spread of diseases like AIDS and hepatitis. Last October the California Senate passed Senate Bill 029 that allowed pharmacists and physicians to provide up to 30 syringes without a prescription and allowed adults to possess the same number for personal use.

But Governor Schwarzenegger vetoed the bill, instead signing a law to continue a pilot program that allows counties to opt into a program that allows pharmacies to sell syringes without a prescription. This is a shameful political move allowing the Governor to appear strong on drugs whilst adding a token measure that continues the status quo which is not working.

Laura Thomas, the Drug Policy Alliance’s deputy state director, said the governor’s veto is “tragic and infuriating”
“It is an irrational attachment to drug war hysteria, at the expense of human life and fiscal responsibility to the California taxpayer,” she said. “Nothing would have worked better and cost less in reducing the spread of HIV and hepatitis C than SB 1029.”


California is now one of only three states that prohibit pharmacies from selling syringes without a prescription on a Statewide basis.

AIDS and concurrency

As we move through the course you will probably notice that there are whole topics that I don't have time to cover. I hope that some of you are interested enough to follow up on some of these topics and use some of the knowledge from the class to better understand your research. Don't believe everything you read on a website, especially on controversial topics, and try to trace research back to the original research papers

Two very big, and related, questions we did not address this week are why is AIDS such a massive problem in Africa and why is AIDS largely a heterosexual disease in Africa?

One theory for this relates back to the sexual partner networks I showed you. It turns out that if you have say 3 sexual partners in a year it makes a big difference to disease transmission if you have these partners serially (ie one after the other) or concurrently (ie with some overlap).

One theory for the difference between Africa and other countries such as the US is that sexual partner networks in Africa may tend to have more concurrency even when the mean, and frequency distribution of sexual partners is not that different to the US.

This theory, as you might imagine because it involves topics of race, sexuality and perceived morality, is far from universally accepted but there are a number of papers supporting it and Helen Epstein's book, The Invisible Cure: Africa, the West, and the Fight Against AIDS, puts together a strong case for this theory and the implications of it for best dealing with AIDS in Africa.

She charges that Western governments and philanthropists, though well-meaning, have been wholly misguided, and that Africans themselves, who understand their own cultures, often know best how to address HIV in their communities. Most significant is Epstein's discussion of concurrent sexual relations in Africa. Africans often engage in two or three long-term concurrent relationships—which proves more conducive to the spread of AIDS than Western-style promiscuity. Persuade Africans to forgo concurrency for monogamy, and the infection rate plummets, as it did in Uganda in the mid-1990s. On the other hand, ad campaigns focused on condom use helped imply falsely that only prostitutes and truck drivers get AIDS.

Others disagree with Epstein:  Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence. The debate is likely to continue. This is more than just an academic debate since it potentially affects how billions of dollars of aid are spent in Africa.

More viral chatter

Virus hunter Nathan Wolfe is outwitting the next pandemic by staying two steps ahead: discovering deadly new viruses where they first emerge -- passing from animals to humans among poor subsistence hunters in Africa -- before they claim millions of lives.

Check out Nathan Wolfe's talk at the 2009 TED conference last year. TED (Technology, Entertainment, Design) invite some of the world's most fascinating thinkers and doers, and challenge them to give the talk of their lives. The best talks and performances are available on their website. You should all check out this talk, it is very interesting, very well presented and hugely relevant to this class.

Research on New AIDS Treatment

At Barcelona’s Hospital Clinic researches have been able to reduce the level of HIV in infected patients using a personalized treatment that they believe could potentially replace the more expensive antiretroviral drug treatment widely used today.

After a 24 week clinical trial on 24 AIDS patients, the majority in the trial displayed a significant decrease in their viral load, although the hospital cautions that it is still not a viable treatment in its current stage.

"This decrease was very significant in some of them but in no case did the virus become undetectable," the hospital statement said.

"However this is a very important improvement with respect to previous initiatives where with a similar vaccine there was a modest response in 30 percent of the treated patients. No therapeutic vaccine has achieved up to now the same level of response as in this study."

For the clinical trial, vaccines were made from each patient’s own dendritic cells (special cell that is a key regulator of the immune system). These cells were taken from the patients and “reeducated” to attack HIV using samples of HIV also taken from the patients. Each round of adjusted cells was injected back into the patients in three separate stages, two weeks apart.

This new treatment would cost around 3,000 Euros per year (a little over $4000) which is a large sum less than the price of antiretrovirals which cost about 8,000 Euros per year (almost $11,000).

Lisa Power, Policy Director at HIV and sexual health charity Terrence Higgins Trust, said: "Therapeutic vaccines are an exciting area of research. Current drug treatment is good at keeping HIV in check, but as people with HIV now routinely live well into old age, the lifetime cost of treatment can be high. An effective therapeutic vaccine could not only be less expensive, but people living with HIV might find it easier to manage.

"This trial is a step in the right direction, but until we find a vaccine that controls the virus as well as antiretroviral treatment does, we're not there yet. This research give us a good idea of where to concentrate efforts in the future."

To be directed to the Barcelona city Website: Health and Care click here

The Global Fund

Diseases like Tuberculosis, AIDS and Malaria are not just found in poor countries but can be a direct cause of that poverty as they take up valuable healthcare resources, reduce manpower and deter tourism. Many African countries have been heavily hit by all three of these diseases and it is often impossible to consider them independently.

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created to dramatically increase resources to fight three of the world's most devastating diseases, and to direct those resources to areas of greatest need. Since its creation in 2002, the Global Fund has approved funding of $ 21.7 billion for more than 600 programs in 150 countries.

Unfortunately the Global Fund is in the news recently for all the wrong reasons. Can the Global Fund weather the corruption storm?
Until a few days ago, the Global Fund to fight Aids, TB and Malaria had the enviable reputation of being one of the cleanest and safest channels of donor money to the poor in the developing world. Everybody knows there is corruption in Africa - but it never tainted the Global Fund. But now Germany, the third biggest donor to the fund after the US and France, has suspended the €200m it pledged for 2011, asking for an investigation into the fraud and misuse of money in four countries - Mauritania, Mali, Zambia and Djibouti. Ireland has also put its wallet away for the moment, delaying a decision on whether to continue its donations to the fund.
 ...
The total amount of money involved is US$34m. That is 0.3% of the $13bn the fund has dispensed for disease-fighting programmes since 2007. 
...
So given that 0.3% ended up in the wrong hands is pretty good going - as many an NGO or business working in Africa will tell you. This should have been a storm in a teacup. But the agency story was followed up by Fox News, which laid into the fund with both fists.
...
But the real fear for the fund's supporters will be that the storm may have been whipped up by those who want the US to slash its spending on foreign aid and will not only have the Global Fund in their sights, but also the UN. The Global Fund is already short of the money it hoped it would have to pass on to developing countries in the next two years. If the US cuts back, there can be no doubt that the cost will be measured in lives.

This is very depressing news. There is broad agreement between both democrats and republicans in this country that government spending needs to be cut. But no-one can agree on what should be cut. With one exception - there is strong public support for cutting foreign aid

The Psychological Impact of AIDS/HIV: People are More Than a Statistic

http://org.elon.edu/summit/essays/essay4.pdf

This essay addresses not only the devastating physiological impacts of the AIDS virus, but also the major psychological effects on both people living with this disease and their caregivers. The extent of this psychological impact varies between persons. However, facing catastrophic changes in their personal and professional relationships, as well as in their bodies and self-image can cause great distress to the patient and those who care about him or her. Sufferers may become aggressive or withdrawn to those close to them because they may feel victimized. Also, the social stigma against those infected with this disease often stirs up feelings of being devalued and lessened as a person, resulting in a loss of confidence in themselves and what they believe they can accomplish. The well-being of those infected, along with caregivers is dependent on their ability to confront unrelenting fear and denial while attempting to maintain hope, an uphill battle to say the least.

The Berlin Patient

Not surprisingly a number of you had good questions about the 'Berlin Patient', now known to be a U.S. citizen named Timothy Ray Brown, who was apparently cured of AIDS in 2007.

I found a really nice set of FAQ at WebMD that addresses a lot of the obvious questions (How was he cured? Will this cure work on other people etc). It is important not to underestimate the medical procedures required for a bone marrow transplant. Before the stem cell transplant he received chemotherapy treatment that destroyed most of his immune cells, as well as total body irradiation and received immunosuppressive drugs to prevent rejection of the stem cells. In an interview with the German news magazine, Stern, Brown was asked if might have just decided to live with HIV rather than undergo this lengthy and difficult process. “Perhaps,” he answered. “Perhaps it would have been better, but I don’t ask those sorts of questions anymore.”

I looked up Magic Johnson and apparently he continues to take antiretroviral drugs:

Johnson says he's anything but cured. He says he owes his well-being — and quite possibly his life — to the multidrug cocktail he takes everyday.

AIDS: the view from Africa

I thought this article from the Zambian Watchdog was an interesting perspective on AIDS in Africa: HIV/AIDS in Zambia: A Three Decade Burden.

Here is an excerpt. One in eight Zambians is now infected with the virus. Something needs to be done, but what?

There must be a total re-think of Public health policy in Zambia. We have spent millions of dollars ‘mopping’ the flooded floor while the causative leaking tap is running!

Here are a few suggestions:

1. HIV/AIDS must be declared a national disaster. I am glad that this was in the Patriotic Front Manifesto (2006). It is more than a partisan issue. We need the help of cooperating partners to deal with this, yes, but also ALL politicians and the highest office of the land must be directly involved. Awareness campaigns must extend beyond highlighting HIV infection alone, but other viral infections as well. This is why the issue of condoms is crucial.
2. Testing. When there was no treatment available, it was quiet right to be as discreet and confidential as possible while dealing with this pandemic. But now, the life saving drugs that are available, not only prolong life, but also reduce the risk of spread of infection. All gloves are off. Treatment centres can deal with the problem of confidentiality by using numbers alone for identification. These test results must be fed into a central database so that the exact extent of the problem can be known.
3. Treatment as a form of Prevention. It has been shown mathematically that treating every HIV positive person can lead to no new infections within ten years. If hospital staff were able to test universally, they could be able to commence treatment of patients, and if one million Zambians were on treatment it will go a long way in reversing our fortunes.

More new HIV research

An important paper in the Lancet today looks like it will change the way that HIV is treated. The paper, Death rates in HIV-positive antiretroviral-naive patients with CD4 count greater than 350 cells per μL in Europe and North America: a pooled cohort observational study
is reported on by the LA Times:
HIV can be deadly even before CD4 counts fall

An infection by the virus that causes AIDS can increase risk of premature death even before the immune system has deteriorated to the point where most physicians begin antiviral therapy, British researchers reported Thursday. The finding suggests that treatment should start even earlier than it is now and supports the current plans of world bodies to begin treating HIV infections in the developing world earlier.

The most common marker of an HIV infection is the level of an immune cell called CD4 that is the target of the virus. In a healthy individual, CD4 levels are generally over 500 cells per cubic millimeter and can go as high as 1,500. A level below 200 sharply increases the risk of the infections and other illnesses that are the markers for full-blown AIDS. Most physicians in the industrial world now begin treatment when a patient's CD4 levels fall below 350. In the developing world — at least in part because of the shortage of resources — treatment has generally begun when the level falls to 200, but UNAIDS announced last week that it would now begin treatment at 350.