After 25 years of AIDS, the news only gets worse

[Guest guest]

After 25 years of AIDS, the news only gets worse

By Loretta McLaughlin | June 5, 2006

AFTER A QUARTER CENTURY, the devastating outbreak of the human

immunodeficiency virus that causes acquired immunodeficiency syndrome

is still surging, a savage wonderment of microbiology.

Today, as when it was officially first recognized on June 5, 1981,

this vicious infectious agent remains unique even within its own

classification of retroviruses. More is now known about it than any

other microbe. Nonetheless, this anniversary in no way marks the end

of the Age of AIDS, though it may mark the end of the beginning.

There is little certainty about what this phenomenal virus may do

next. For it has an immeasurable capacity to change its outer

appearance -- millions of times over the course of the illness in

each cell it infects in each person -- and thereby to elude conquest.

Despite brilliant approaches to a vaccine, none is in sight, nor is

any expected in the foreseeable future, HIV/AIDS researchers agree.

For scientists -- and a few lay journalists such as myself -- who

have pursued in our respective ways the labyrinthine course of the

international AIDS pandemic, these years have been an extraordinarily

humbling journey. From a time when we wondered if we would ever see a

hundred, a thousand, a million people infected with HIV/AIDS, we now

are near the 70 million mark of officially infected people,

worldwide. More than 25 million of them have died, and 14 million

others have been orphaned.

To my mind, in a devilish manner, HIV/AIDS never disappoints: With

this virus, as with life itself, for every plus, every gain, there

has always been a consequent minus.

HIV/AIDS was born -- the virus mutated into a form that infects

humans -- at the right and the wrong time. The makeup of retroviruses

was becoming clear to scientists such as Baltimore, then of the

Whitehead Laboratory at MIT, who won a Nobel Prize for unraveling the

genetic code of these peculiar single-stranded RNA viruses.

They procreate by first making a single copy of themselves. They are

called retroviruses because they ``write " these mirror images of

their genetic code upside down and backward. In this way the new and

old copies of their individual genes fit together perfectly so they

convert temporarily into active, double-stranded viruses, which can

go into action as disease-inflicting invaders.

This much was known as the Age of AIDS dawned. But no one was

prepared for the holocaust of illness that was to come. Nor can

anyone foresee what 25 more years of this disease will entail, beyond

knowing that the plight will be far worse, not better, as the nations

with the largest populations, China and India, become hot HIV/AIDS

zones.

Virologist Max Essex of the Harvard AIDS Initiative, who has been a

major player in HIV/AIDS research from the beginning and who has

worked to understand and combat the pandemic in Africa and Asia, says

one thing is certain: ``Just as the retrovirus that causes AIDS

differs considerably today from the samples first studied 25 years

ago, the virus will continue to change so much that 25 years from now

it will bear virtually no resemblance to the HIV/AIDS virus types

seen now. " Its impact will change, too.

Not only can this virus evolve slowly in lesser ways within its own

type (or clade, as each strain is called), it can change rapidly in

major ways, combining clades into whole new specimens of HIV/AIDS

viruses. Usually these recombinant strains are stronger and easier to

transmit and are able to unleash secondary epidemics atop a

prevailing one. This seems to be happening as a more virulent,

recombinant strain (able to spread and kill faster, according to

Essex) is moving northwest from South Africa via coastal nations.

Initially, the arrival in the United States of this new killer

disease was ill timed, politically. Republican President

Reagan, an old-line conservative, took office as AIDS was emerging in

1981. He never uttered the word AIDS publicly until late in his

presidency. The political problem wasn't the disease, but rather the

group in which it appeared -- sexually active, gay men. A common

comment at the time was that ``had AIDS first turned up in members of

the Holy Cross college football team, no expense would have been

spared to discover the cause and find a treatment for the disease. "

Instead, of course, it was long underfunded and overlooked.

Nearly everywhere, AIDS is now the leading killer of young people in

their most sexually active years. Sex, after all, remains the

recreation of the poor. At the first international conference on AIDS

in Africa, held in Brussels before it was clear that AIDS was

definitely caused by HIV, a scientist warned that ``if AIDS turns out

to be a sexually transmitted disease [as it is], it would spread

across the world like a prairie fire. " And it has.

At this point, amazingly effective new anti-HIV/AIDS drugs,

especially the three-drug ``cocktail " formulated by Dr. Ho,

director of the Diamond Research Center in New York City, work

well, though side effects can be difficult. In states such as

Massachusetts noted for sophisticated medical regimens (treatment

plus monitoring for signs of resistance, necessitating changes in

medications), many HIV/AIDS patients survive 15 to 20 years. But,

sadly, about a third of patients do not tolerate the drugs well.

It's a far cry from the early years when life after diagnosis largely

amounted to a year or so of increasingly severe illness: frightful

pneumonias, brain and eye infections, liverish-looking skin cancers,

stark weight loss, and thrush, a fungal infection frequently so

flagrant it oozed out of a person's mouth. New drugs now thwart these

infections in modernized nations, but the vast majority of people

across the world with HIV/AIDS continue to suffer these awful

physical conditions.

Dr. Farmer of Harvard University and founder of Partners in

Health, a battery of health and economic programs that serve the

world's poorest, is convinced that poverty is the primary factor

underlying the spread of HIV/AIDS, along with tuberculosis and

malaria. Other authorities, including Essex, would add mobility as a

key factor, as workers travel to outlying jobs, pick up and carry the

infection with them, and then bring it home to wives and other sex

partners along the way.

Tragically, as many as three out of four individuals in countries

that are economically disadvantaged do not have access to -- and are

not yet receiving -- modern anti-HIV/AIDS medicines. Although

international health organizations worked hard to get up-to-date anti-

HIV/AIDS treatments to 3 million impoverished patients by 2005, the

efforts reached fewer than a million. Much more help is on the way.

However, in the modern world, too often the success of potent new

drugs has led to laxness among some sexually active gay men and

illicit drug users, who are choosing to disregard safe-sex practices.

In impoverished countries, the choice often is between HIV treatment

and enough food, so AIDS-stricken individuals sometimes dilute their

doses of medicine and sell the remainder, thus promoting drug-

resistant HIV strains.

Yet the Catholic Church dithers about lifting bans on condoms

(artificial contraception), even between marriage partners when one

is known to be HIV/AIDS infected, and even though condoms prevent

transmission of the virus. Some segments of the religious right

ludicrously oppose all safe-sex practices for HIV/AIDS prevention

except abstinence.

In much of the Muslim world, the disease has been slower to make

inroads but is gaining a foothold. There, special problems arise. In

such societies, polygamy is the cultural norm, so wives are expected

to bear numerous children. How will they be able to do so and still

be protected against AIDS by condom use, or by the vaunted vaginal-

gel microbicides now under development that will kill sperm along

with the HIV virus?

Although massive efforts are ongoing to produce and distribute modern

drugs against HIV/AIDS to millions more worldwide, the disease still

races ahead of efforts to prevent or even contain it. Further, each

new class of vital anti-HIV/AIDS drugs requires additional monitoring

of resistance or toxic reactions.

Each medical advance comes at a higher price and calls for more

trained health-care workers, while in most intensely infected areas

both money and manpower are scarce.

To bring HIV/AIDS under control in the quarter-century ahead,

government leaders are going to have to see the pandemic for what it

is and will continue to be -- the most confounding public health

problem in the world -- and at long last give it the priority it so

desperately deserves.

Loretta McLaughlin is a former Boston Globe editorial page editor and

a senior fellow at the Harvard AIDS Initiative.

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