'Worst Is Yet to Come'
By Carla Garnett
On the Front Page...
Towards the end of 1999, NIAID director Dr. Anthony Fauci recalled he was often asked if after 20 years of the epidemic, AIDS could finally go into the history books as the disease that was. After all, his questioners reasoned, we have many combinations of drugs both anti-HIV and those to combat opportunistic infections that are forestalling the onset of AIDS in HIV-infected people, and keeping people with AIDS alive longer. We may not have a cure, but the rate of new cases seems to be leveling off, and a vaccine is in our not-too-distant future, right? Fauci said time and again he'd have to shake his head. On the contrary, he told them, "the worst of the global pandemic has yet to occur."
That was his sobering conclusion at a recent lecture, "AIDS: Considerations for the 21st Century," hosted by the NIH Office of Education to kick off its 2000 Summer Lecture Series for Students.
Each year, the Office of Education plans several special activities including a lecture series designed to enrich the summer experience of students working on campus. The series offers students and all attendees the opportunity to hear leading NIH scientists present results of their work on the frontiers of biomedical research. For the first time, the annual series has a theme, "Domestic Health Disparities."
Fauci, cochair of NIH's program to develop a strategic research agenda to help close such health gaps, used the latest epidemiological data available on AIDS to show how the disease is spreading nearly unchecked in many regions of the world particularly sub-Saharan Africa and India.
Dividing his talk into several aspects, Fauci began by explaining the epidemiology and natural history of HIV infection. Recently, he said, scientists have been able to confirm that HIV, the virus that causes AIDS, had its origins in nonhuman primates in sub-Saharan Africa. The virus "jumped species from the chimpanzee to the human, which is not at all uncommon," he said, citing influenza as a classic example of a disease that jumps species from fowl and pigs to humans. He then offered startling epidemiological data.
"Look at what has happened in Africa particularly sub-Saharan Africa," Fauci said. "In the southern African countries of Botswana, Zimbabwe and South Africa the epidemic is truly out of control. We talk about disparities in health, this is the poster for disparities. In Botswana and Zimbabwe, about 25 percent to 30 percent of the entire adult population is infected with HIV. That's absolutely astounding."
In some southern African countries, 35 percent of pregnant women are infected with HIV. In the armed forces of such countries as Uganda and Zimbabwe, up to 45 or 50 percent of the troops are infected. "This is something that has national security as well as economic and humanitarian implications," Fauci said, noting that President Clinton and Vice President Gore both had addressed the issue recently at the Security Council of the United Nations.
Sub-Saharan Africa has more cases of HIV than any region in the world. India has more cases 4 million people infected than any other single nation. In the United States, in contrast, about 0.3 percent of the population is infected, Fauci said.
"We are very hopeful with regard to China," he said, "because we are having close interaction with our Chinese colleagues who are trying to adopt the public health measures of education, behavior modification, distribution of condoms, and better attention to injection drug use. We are hoping that if they put these mechanisms in place, we will not see an explosion of the epidemic in the most populous nation in the world."
Although he had given a global view of the HIV/AIDS pandemic, Fauci said, "That's not to diminish the extraordinary impact this disease still is having in this country."
There were about 730,000 cumulative cases of AIDS reported in the U.S. as of Dec. 31, 1999, according to the latest statistics provided by the Centers for Disease Control and Prevention; about 440,000 people with AIDS in the United States have died since the beginning of the epidemic. Up to 900,000 people are infected with HIV in this country; more than 200,000 of them do not yet know that they are infected.
The most disturbing number, Fauci said, is the 40,000 new cases per year in the U.S. Although the number of cases per year has reached a plateau compared to the mid-1980's, he said, the plateau is unacceptably high. Most of the new cases are found in individuals younger than age 25.
In terms of domestic health disparities, Fauci said "AIDS has evolved from a disease predominantly of gay white men to a disease of inner city minorities, mostly individuals who are geographically connected to an injection drug use population." Also increasing, he said, are the cases among women.
Showing a slide on U.S. AIDS cases by race/ethnicity, Fauci explained the concept of health disparities. In 1998, the rate of AIDS cases among African Americans was 82 per 100,000 people 10 times the rate among white people. Fauci then gave a brief, but comprehensive look at the disease's pathogenesis. "HIV is different than most other viruses," he said. "When you get exposed to most other viruses, the virus either kills you or you get rid of it completely. There are very few viruses herpes, or hepatitis B and C, as examples that continue to replicate. Most viruses either kill you or you get better. That's absolutely not the case with HIV. The virus itself doesn't kill you; it's the secondary infections that kill." The immune system partially controls the virus, but never completely clears it from the body.
Throughout the lecture, there were various opportunities for Fauci to reflect on his nearly 20 years of battling AIDS from the frontlines. He recalled how he and his colleagues were frustrated in the disease's earliest years. As infectious disease physicians, he said, they were accustomed to treating and most times, curing their patients. When the first people with AIDS began arriving at the Clinical Center, doctors were unable to cure them and despite physicians' best efforts all the patients succumbed to the relentless infection.
"This was a very disturbing time for us in those first few years before we knew that HIV was HIV," he admitted. "All of our patients were dying. The only thing we could do was treat the opportunistic infections and neoplasms."
Concluding his talk, Fauci mentioned the 16 FDA-approved antiretroviral drugs to treat HIV/AIDS. The first therapy, commonly known now as AZT, was approved in 1987. In the 13 years since, researchers have learned that HIV/AIDS is far too smart a disease to be controlled with any one drug; the virus quickly adapts to a single therapy and renders the drug virtually useless after a time. These days, combinations of HIV drugs often including a protease inhibitor are the standard treatments. Such combinations are known as highly active antiretroviral therapy (HAART).
Fauci also anticipated a question about developing an AIDS vaccine, explaining one of the "many stumbling blocks" that scientists have yet to overcome: Researchers have identified several different HIV subtypes called "clades" and a vaccine against one clade might not protect individuals from other subtypes. Many more studies will have to be conducted before the promise of a vaccine is realized, he said.
Following the lecture, Fauci stayed for nearly 20 minutes of questions from the audience.
"We chose a subject that we thought would be of considerable interest to you and of enormous value for you to consider later on in your careers," said NIH deputy director for intramural research Dr. Michael Gottesman, whose Office of Intramural Research oversees the Office of Education. "There are enormous health disparities that exist in this country among various populations. Some of these disparities are geographic, some are related to occupation, some to race, ethnicity or culture, genetic inheritance. In many cases, we simply do not understand why one population has an incidence of heart disease or hypertension or kidney disease many times higher than the remaining population. These are very troubling statistics about the United States and we're hopeful that the people sitting in this audience will decide one day to work on these subjects and how we can contribute to alleviating these disturbing disparities."
The weekly Domestic Health Disparities lectures series is held each Tuesday, from noon to 1 p.m. in Masur Auditorium. All are welcome. For more information on the series, call the NIH Office of Education at 496-2427.
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