Advances in the Fight Against AIDS
“Never in the history of humans has so much been learned about so complex an illness in so short a time,” writes Dr. Gerald J. Stine in his book AIDS Update 2003. He claims that “the history of HIV/AIDS is one of remarkable scientific achievement.” What has been achieved?
MODERN medical knowledge and expertise have enabled researchers to develop drug combinations that offer new hope to HIV-infected people. Additionally, AIDS education programs have yielded results in several countries. But does the success of such efforts signal the beginning of the end of this deadly epidemic? Can current scientific and educational endeavors halt the spread of AIDS? Consider the following.
“A Ray of Hope in the Fight Against Aids,” read the headline in the September 29, 1986, issue of Time magazine. This “ray of hope” was generated by the results of a clinical trial using azidothymidine (AZT), an antiretroviral drug, to treat HIV. Remarkably, HIV patients who took AZT were living longer. Since that time, antiretroviral drugs (ARVs) have prolonged the lives of hundreds of thousands of people. (See the box “What Are ARVs?” on page 7.) How successful have they been in treating HIV infection?
Despite the initial enthusiasm surrounding the release of AZT, Time magazine reported that AIDS researchers “were confident that AZT [was] not the ultimate weapon against AIDS.” They were correct. Some patients were unable to tolerate AZT, so other ARVs were developed. Later, the U.S. Food and Drug Administration approved a combination of ARVs for advanced HIV patients. Combination therapy, which came to involve the taking of three or more antiretroviral drugs, was enthusiastically welcomed by AIDS workers. In fact, at an international conference on AIDS in 1996, one doctor even announced that the drugs may be able to eliminate HIV entirely from the body!
Sadly, within a year it was evident that even strict adherence to the three-drug regimen could not eradicate HIV. Nonetheless, a report by UNAIDS says that “combination ARV therapy has enabled HIV-positive people to live longer, healthier, more productive lives.” In the United States and Europe, for example, ARV use has reduced AIDS deaths by over 70 percent. In addition, several studies have shown that selected ARV treatment can dramatically reduce HIV transmission from an infected pregnant woman to her child.
Yet, millions of HIV patients are denied access to ARVs. Why?
“A Disease of Poverty”
ARV therapy is widely administered in high-income countries. However, the World Health Organization (WHO) estimates that in some developing lands, only 5 percent of those who need ARV therapy have access to the drugs. United Nations envoys have gone so far as to describe this imbalance as “a serious injustice” and “the grotesque obscenity of the modern world.”
Unequal access to therapy can also exist among citizens of the same country. The Globe and Mail reports that 1 in 3 Canadians who die of AIDS has never been treated with ARVs. Even though the drugs are available free of charge in Canada, certain groups have been overlooked. “Those missing out on proper treatment,” says the Globe, “are those in most desperate need: aboriginals, women and the poor.” The Guardian quoted one African mother who is HIV-positive as saying: “I don’t understand it. Why do these white men who have sex with men get to live and I have to die?” The answer to her question lies in the economics of drug production and distribution.
The average price of a three-drug ARV regimen in the United States and Europe is between $10,000 and $15,000 a year. Even though generic copies of these drug combinations are now being offered in some developing countries at a yearly rate of $300 or less, this is still far beyond the reach of many who have HIV and live where ARVs are needed the most. Dr. Stine sums up the situation this way: “AIDS is a disease of poverty.”
The Business of Making Drugs
Developing generic versions of patented drugs and selling them at reduced prices has not been easy. Strict patent laws in many countries prohibit the unauthorized reproduction of brand-name drugs. “This is an economic war,” says the head of one large pharmaceutical company. Producing generic drugs and selling them to developing countries for a profit, he says, “isn’t fair to people who have discovered those drugs.” Brand-name drug companies also argue that diminishing profits could result in reduced funding for medical research-and-development programs. Others worry that low-cost ARVs destined for developing countries could actually end up on the black market in developed lands.
Proponents of low-cost ARV drugs counter that new drugs can be produced at between 5 and 10 percent of the costs suggested by the pharmaceutical industry. They also say that research and development by private pharmaceutical companies have tended to neglect diseases afflicting poorer countries. Thus, Daniel Berman, coordinator of the Access to Essential Medicines project, states: “For new drugs, there needs to be an internationally-supported enforceable system that reduces prices to affordable levels in developing countries.”
In response to this global need for ARV therapy, WHO has developed what is described as the three-by-five plan to provide ARVs to three million people living with HIV/AIDS by the end of 2005. “The three-by-five target must not become another unmet UN target,” warned Nathan Ford of Médecins Sans Frontières. “It is only half the number of people with HIV/AIDS estimated to need treatment today and this number will be much greater [by 2005].”
Even if enough ARVs were supplied to developing lands, other obstacles would have to be overcome. Some drugs need to be taken with food and clean water, but hundreds of thousands of people in some lands can eat only every other day. ARVs (often 20 or more pills daily) need to be taken at a certain time each day, but many patients do not own a timepiece. Drug combinations need to be adjusted according to a patient’s condition. But there is a critical shortage of physicians in many lands. Clearly, providing ARV therapy to developing countries will be a difficult hurdle to surmount.
Even patients in developed lands face challenges in using combination therapy. Research reveals that failure to take all prescribed drugs at scheduled times is alarmingly common. This may lead to drug resistance. Such drug-resistant strains of HIV can be transmitted to others.
Dr. Stine points to another challenge faced by HIV patients. “The paradox of HIV treatment,” he says, “is that sometimes the cure feels worse than the disease, especially when treatment begins before symptoms arise.” HIV patients on ARVs commonly suffer from side effects including diabetes, fat redistribution, high cholesterol, and decreased bone density. Some side effects are life-threatening.
How successful have prevention efforts been in slowing the spread of AIDS and changing high-risk behaviors? Extensive AIDS education campaigns in Uganda during the 1990’s cut HIV prevalence rates in that country from an estimated 14 percent to approximately 8 percent in 2000. Similarly, Senegal’s efforts to inform its citizens about the risk of HIV infection have helped that country to maintain HIV prevalence rates below 1 percent among the adult population. Such results are encouraging.
On the other hand, AIDS education has not been so successful in other countries. A 2002 survey of 11,000 young Canadians revealed that half the students in their first year of high school believed that AIDS can be cured. According to a British study conducted the same year, 42 percent of boys between 10 and 11 years of age had never heard of HIV or AIDS. Yet, even youths who are aware of HIV and AIDS and the lack of a cure have grown complacent. “For many young people,” says one doctor, “HIV has become just one of the many problems in their lives, like if they are going to get a good meal, who they are going to live with, whether they are going to school.”
Not surprisingly, then, WHO states that “focusing on young people is likely to be the most effective approach to confronting the epidemic, particularly in high prevalence countries.” How can youths be helped to act on warnings they have received regarding AIDS? And is it realistic to hope for a cure?
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Last year 2 percent of those in Africa needing ARVs received them, compared with 84 percent in the Americas
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What Are ARVs?a
In a healthy person, helper T cells stimulate or activate the immune system to attack infections. HIV particularly targets these helper T cells. It uses the cells to replicate itself, weakening and destroying helper T cells until the immune system is severely compromised. Antiretroviral drugs (ARVs) disrupt this replication process.
Currently, four main types of ARVs are administered. Nucleoside analogues and non-nucleoside analogues prevent HIV from copying itself onto a person’s DNA. Protease inhibitors block a specific protease enzyme in infected cells from reconstructing the virus and producing more HIV. Fusion inhibitors aim to prevent HIV from entering cells. By suppressing HIV replication, ARVs can slow the progression from HIV infection to AIDS, dubbed the most severe clinical form of HIV disease.
a Antiretroviral therapy is not prescribed for all people who have HIV. Those who have or suspect that they may have HIV should see a health-care professional before embarking on any medical treatment program. Awake! does not endorse any particular approach.
KENYA—A doctor instructs an AIDS patient about ARV treatment
© Sven Torfinn/Panos Pictures
KENYA—An AIDS patient receives her ARV medicine at the hospital
© Sven Torfinn/Panos Pictures
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Women and AIDS
Women now make up 50 percent of adults living with HIV/AIDS
In 1982, when women were diagnosed with AIDS, it was thought that they must have been infected through intravenous drug use. Soon, it was realized that women could become infected through normal sexual intercourse and that they are at special risk of contracting HIV. Worldwide, women now make up 50 percent of adults living with HIV/AIDS. “The epidemic disproportionately affects women and adolescent girls who are socially, culturally, biologically and economically more vulnerable, and who shoulder the burden of caring for the sick and dying,” reports UNAIDS.
Why is the growth of the disease among women a special concern to AIDS workers? HIV-infected women often face more discrimination than men, especially in some developing lands. If a woman is pregnant, the health of her child is endangered; if she already has children, caring for them becomes a challenge, particularly for a single mother. Further, comparatively little is known about the unique characteristics of HIV-infected women and their clinical care.
Certain cultural factors make the situation especially dangerous for women. In many countries women are not expected to discuss sexuality, and they risk abuse if they refuse sex. The men commonly have many sexual partners and unknowingly transmit HIV to them. Some African men have sexual relations with younger women to avoid HIV or in the false belief that sex with virgins can cure AIDS. No wonder WHO states: “Interventions must be aimed at men (as well as at women) if women are to be protected.”
PERU—An HIV-positive mother with her HIV-negative daughter
© Annie Bungeroth/Panos Pictures
THAILAND—As part of their education, students visit an AIDS patient
© Ian Teh/Panos Pictures
KENYA—A meeting with members of the organization Women Living With AIDS
© Sven Torfinn/Panos Pictures
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Myths About AIDS
◼ HIV-infected people look sick. “On average, it takes about 10 to 12 years for someone infected with HIV to develop AIDS,” says Dr. Gerald J. Stine. “During this time, the HIV-infected will show few if any recognizable symptoms, but they are able to infect other people.”
◼ AIDS is a homosexual disease. In the early 1980’s, AIDS was initially identified as a homosexual disease. Today, however, heterosexual intercourse is the primary mode of HIV transmission in much of the world.
◼ Oral sex is “safe sex.” According to the Centers for Disease Control and Prevention, “numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases.” The risk of HIV transmission through oral sex is not as high as through other sexual practices. Nevertheless, the practice has become so prevalent that some doctors expect it to become a significant route for transmitting HIV.
◼ There is a cure for AIDS. Although antiretroviral therapy can, in some patients, slow the progression from HIV to AIDS, there is currently no vaccine or cure.
CZECH REPUBLIC—A blood test for AIDS, which is now treatable but not curable
© Liba Taylor/Panos Pictures
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ZAMBIA—Two young HIV-positive girls await their medicine
© Pep Bonet/Panos Pictures