Cylone

HIV science

2009-12-03T04:52:00.000-08:00

HIV stands for Human Immunodeficiency Virus. Like all viruses, HIV cannot grow or reproduce on its own. In order to make new copies of itself it must infect the cells of a living organism.
What does HIV look like?
HIV and CD4+ cell

In this computer generated image, the large object is a

human CD4+ white blood cell, and the spots on its surface

and the spiky blue objects in the foreground

represent HIV particles.

Outside of a human cell, HIV exists as roughly spherical particles (sometimes called virions). The surface of each particle is studded with lots of little spikes.

An HIV particle is around 100-150 billionths of a metre in diameter. That's about the same as:

* 0.1 microns
* 4 millionths of an inch
* one twentieth of the length of an E. coli bacterium
* one seventieth of the diameter of a human CD4+ white blood cell.

Unlike most bacteria, HIV particles are much too small to be seen through an ordinary microscope. However they can be seen clearly with an electron microscope.

HIV particles surround themselves with a coat of fatty material known as the viral envelope (or membrane). Projecting from this are around 72 little spikes, which are formed from the proteins gp120 and gp41. Just below the viral envelope is a layer called the matrix, which is made from the protein p17.
HIV structure

The proteins gp120 and gp41 together make up the spikes

that project from HIV particles, while p17 forms the matrix

and p24 forms the core.

The viral core (or capsid) is usually bullet-shaped and is made from the protein p24. Inside the core are three enzymes required for HIV replication called reverse transcriptase, integrase and protease. Also held within the core is HIV's genetic material, which consists of two identical strands of RNA.
What is RNA?

HIV belongs to a special class of viruses called retroviruses. Within this class, HIV is placed in the subgroup of lentiviruses. Other lentiviruses include SIV, FIV, Visna and CAEV, which cause diseases in monkeys, cats, sheep and goats. Almost all organisms, including most viruses, store their genetic material on long strands of DNA. Retroviruses are the exception because their genes are composed of RNA (Ribonucleic Acid).

RNA has a very similar structure to DNA. However, small differences between the two molecules mean that HIV's replication process is a bit more complicated than that of most other viruses.
How many genes does HIV have?

HIV has just nine genes (compared to more than 500 genes in a bacterium, and around 20,000-25,000 in a human). Three of the HIV genes, called gag, pol and env, contain information needed to make structural proteins for new virus particles. The other six genes, known as tat, rev, nef, vif, vpr and vpu, code for proteins that control the ability of HIV to infect a cell, produce new copies of virus, or cause disease.

At either end of each strand of RNA is a sequence called the long terminal repeat, which helps to control HIV replication.
HIV life cycle
Entry

A scientific video about the process of HIV cell entry.

HIV can only replicate (make new copies of itself) inside human cells. The process typically begins when a virus particle bumps into a cell that carries on its surface a special protein called CD4. The spikes on the surface of the virus particle stick to the CD4 and allow the viral envelope to fuse with the cell membrane. The contents of the HIV particle are then released into the cell, leaving the envelope behind.
Reverse Transcription and Integration

Once inside the cell, the HIV enzyme reverse transcriptase converts the viral RNA into DNA, which is compatible with human genetic material. This DNA is transported to the cell's nucleus, where it is spliced into the human DNA by the HIV enzyme integrase. Once integrated, the HIV DNA is known as provirus.
Transcription and Translation

HIV provirus may lie dormant within a cell for a long time. But when the cell becomes activated, it treats HIV genes in much the same way as human genes. First it converts them into messenger RNA (using human enzymes). Then the messenger RNA is transported outside the nucleus, and is used as a blueprint for producing new HIV proteins and enzymes.
Assembly, Budding and Maturation
HIV budding from a cell

This electron microscope photo shows newly formed HIV particles budding from a human cell.

Among the strands of messenger RNA produced by the cell are complete copies of HIV genetic material. These gather together with newly made HIV proteins and enzymes to form new viral particles, which are then released from the cell. The enzyme protease plays a vital role at this stage of the HIV life cycle by chopping up long strands of protein into smaller pieces, which are used to construct mature viral cores.

The newly matured HIV particles are ready to infect another cell and begin the replication process all over again. In this way the virus quickly spreads through the human body. And once a person is infected, they can pass HIV on to others in their bodily fluids.
HIV types, subtypes groups and strains
Introduction to HIV types, groups and subtypes

HIV is a highly variable virus which mutates very readily. This means there are many different strains of HIV, even within the body of a single infected person.

Based on genetic similarities, the numerous virus strains may be classified into types, groups and subtypes.
What is the difference between HIV-1 and HIV-2?

There are two types of HIV: HIV-1 and HIV-2. Both types are transmitted by sexual contact, through blood, and from mother to child, and they appear to cause clinically indistinguishable AIDS. However, it seems that HIV-2 is less easily transmitted, and the period between initial infection and illness is longer in the case of HIV-2.

Worldwide, the predominant virus is HIV-1, and generally when people refer to HIV without specifying the type of virus they will be referring to HIV-1. The relatively uncommon HIV-2 type is concentrated in West Africa and is rarely found elsewhere.
How many subtypes of HIV-1 are there?

The strains of HIV-1 can be classified into four groups: the "major" group M, the "outlier" group O and two new groups, N and P. These four groups may represent four separate introductions of simian immunodeficiency virus into humans.
HIV types, groups and subtypes

The different levels of HIV classification.

Group O appears to be restricted to west-central Africa and group N - a strain discovered in 1998 in Cameroon - is extremely rare. In 2009 a new strain closely relating to gorilla simian immunodeficiency virus was discovered in a Cameroonian woman. It was designated HIV-1 group P.1 More than 90% of HIV-1 infections belong to HIV-1 group M and, unless specified, the rest of this page will relate to HIV-1 group M only.

Within group M there are known to be at least nine genetically distinct subtypes (or clades) of HIV-1. These are subtypes A, B, C, D, F, G, H, J and K.

Occasionally, two viruses of different subtypes can meet in the cell of an infected person and mix together their genetic material to create a new hybrid virus (a process similar to sexual reproduction, and sometimes called "viral sex").2 Many of these new strains do not survive for long, but those that infect more than one person are known as "circulating recombinant forms" or CRFs. For example, the CRF A/B is a mixture of subtypes A and B.

The classification of HIV strains into subtypes and CRFs is a complex issue and the definitions are subject to change as new discoveries are made. Some scientists talk about subtypes A1, A2, A3, F1 and F2 instead of A and F, though others regard the former as sub-subtypes.
What about subtypes E and I?

One of the CRFs is called A/E because it is thought to have resulted from hybridization between subtype A and some other "parent" subtype E. However, no one has ever found a pure form of subtype E. Confusingly, many people still refer to the CRF A/E as "subtype E" (in fact it is most correctly called CRF01_AE).3

A virus isolated in Cyprus was originally placed in a new subtype I, before being reclassified as a recombinant form A/G/I. It is now thought that this virus represents an even more complex CRF comprised of subtypes A, G, H, K and unclassified regions. The designation "I" is no longer used.4
Where are the different subtypes and CRFs found?

The HIV-1 subtypes and CRFs are very unevenly distributed throughout the world, with the most widespread being subtypes A and C.

* Subtype A and CRF A/G predominate in West and Central Africa, with subtype A possibly also causing much of the Russian epidemic.5
* Historically, subtype B has been the most common subtype/CRF in Europe, the Americas, Japan and Australia. Although this remains the case, other subtypes are becoming more frequent and now account for at least 25% of new HIV infections in Europe.
* Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused the world's worst HIV epidemics and is responsible for around half of all infections.
* Subtype D is generally limited to East and Central Africa. CRF A/E is prevalent in South-East Asia, but originated in Central Africa. Subtype F has been found in Central Africa, South America and Eastern Europe. Subtype G and CRF A/G have been observed in West and East Africa and Central Europe.
* Subtype H has only been found in Central Africa; J only in Central America; and K only in the Democratic Republic of Congo and Cameroon.

Are more subtypes likely to "appear"?

It is almost certain that new HIV genetic subtypes and CRFs will be discovered in the future, and indeed that new ones will develop as virus recombination and mutation continue to occur. The current subtypes and CRFs will also continue to spread to new areas as the global epidemic continues.
The implications of variability
Does subtype affect disease progression?

A study presented in 2006 found that Ugandans infected with subtype D or recombinant strains incorporating subtype D developed AIDS sooner than those infected with subtype A, and also died sooner, if they did not receive antiretroviral treatment. The study's authors suggested that subtype D is more virulent because it is more effective at binding to immune cells.6 This result was supported by another study presented in 2007, which found that Kenyan women infected with subtype D had more than twice the risk of death over six years compared with those infected with subtype A.7 An earlier study of sex workers in Senegal, published in 1999, found that women infected with subtype C, D or G were more likely to develop AIDS within five years of infection than those infected with subtype A.8

Several studies conducted in Thailand suggest that people infected with CRF A/E progress faster to AIDS and death than those infected with subtype B, if they do not receive antiretroviral treatment.9
Are there differences in transmission?

It has been observed that certain subtypes/CRFs are predominantly associated with specific modes of transmission. In particular, subtype B is spread mostly by homosexual contact and intravenous drug use (essentially via blood), while subtype C and CRF A/E tend to fuel heterosexual epidemics (via a mucosal route).

Whether there are biological causes for the observed differences in transmission routes remains the subject of debate. Some scientists, such as Dr Max Essex of Harvard, believe such causes do exist. Among their claims are that subtype C and CRF A/E are transmitted much more efficiently during heterosexual sex than subtype B.10 11 However, this theory has not been conclusively proven.12 13

More recent studies have looked for variation between subtypes in rates of mother-to-child transmission. One of these found that such transmission is more common with subtype D than subtype A.14 Another reached the opposite conclusion (A worse than D), and also found that subtype C was more often transmitted that subtype D.15 A third study concluded that subtype C is more transmissible than either D or A.16 Other researchers have found no association between subtype and rates of mother-to-child transmission.17 18 19 20
Is it possible to be infected more than once?

Until about 1994, it was generally thought that individuals do not become infected with multiple distinct HIV-1 strains. Since then, many cases of people coinfected with two or more strains have been documented.

All cases of coinfection were once assumed to be the result of people being exposed to the different strains more or less simultaneously, before their immune systems had had a chance to react. However, it is now thought that "superinfection" is also occurring. In these cases, the second infection occurred several months after the first. It would appear that the body's immune response to the first virus is sometimes not enough to prevent infection with a second strain, especially with a virus belonging to a different subtype. It is not yet known how commonly superinfection occurs, or whether it can take place only in special circumstances.21 22
Do HIV antibody tests detect all types, groups and subtypes?

Initial tests for HIV are usually conducted using the EIA (or ELISA) antibody test or a rapid antibody test.

EIA tests which can detect either one or both types of HIV have been available for a number of years. According to the US Centers for Disease Control and Prevention, current HIV-1 EIAs "can accurately identify infections with nearly all non-B subtypes and many infections with group O HIV subtypes."23 However, because HIV-2 and group O infections are extremely rare in most countries, routine screening programs might not be designed to test for them. Anyone who believes they may have contracted HIV-2, HIV-1 group O or one of the rarer subtypes of group M should seek expert advice.

Rapid tests - which can produce a result in less than an hour - are becoming increasingly popular. Most modern rapid HIV-1 tests are capable of detecting all the major subtypes of group M.24 Rapid tests which can detect HIV-2 are also now available.25
What are the treatment implications?

Although most current HIV-1 antiretroviral drugs were designed for use against subtype B, there is no compelling evidence that they are any less effective against other subtypes. Nevertheless, some subtypes may be more likely to develop resistance to certain drugs, and the types of mutations associated with resistance may vary. This is an important subject for future research.

The effectiveness of HIV-1 treatment is monitored using viral load tests. It has been demonstrated that some such tests are sensitive only to subtype B and can produce a significant underestimate of viral load if used to process other strains. The latest tests do claim to produce accurate results for most Group M subtypes, though not necessarily for Group O. It is important that health workers and patients are aware of the subtype/CRF they are testing for and of the limitations of the test they are applying.

Not all of the drugs used to treat HIV-1 infection are as effective against HIV-2. In particular, HIV-2 has a natural resistance to NNRTI antiretroviral drugs and they are therefore not recommended. As yet there is no FDA-licensed viral load test for HIV-2 and those designed for HIV-1 are not reliable for monitoring the other type. Instead, response to treatment may be monitored by following CD4+ T-cell counts and indicators of immune system deterioration. More research and clinical experience is needed to determine the most effective treatment for HIV-2.26
What are the implications for an AIDS vaccine?

The development of an AIDS vaccine is affected by the range of virus subtypes as well as by the wide variety of human populations who need protection and who differ, for example, in their genetic make-up and their routes of exposure to HIV. In particular, the occurrence of superinfection indicates that an immune response triggered by a vaccine to prevent infection by one strain of HIV may not protect against all other strains. The effectiveness of a vaccine is likely to vary in different populations unless some innovative method is developed which guards against many virus strains.

Inevitably, different types of candidate vaccines will have to be tested against various viral strains in multiple vaccine trials, conducted in both high-income and developing countries.

Animal testing (also known as vivisection) elicits strong opinions from both those for and those against the practice. Its role in developing HIV treatments and AIDS vaccines is no less controversial.

Developing therapeutic and diagnostic products for use in humans is a long and complex process. With HIV infection, the search for effective drugs and vaccines has proven particularly difficult, as HIV is exceptionally good at changing its structure and evading destruction. In an ideal world, scientists would be able to test thousands of different compounds on human participants to see if any cured, treated or vaccinated them against HIV. However, to do this would be both highly time consuming and dangerous, as most compounds would not be effective, and some might cause illness or even death.

Researchers therefore often use animals to help them test the efficacy of drugs and vaccines, and to make sure that these products are safe. There are of course many ethical implications to animal experimentation, and many people are strongly opposed to the use of animals in any sort of experiment or study that may cause them distress or harm. So is it really necessary to use animals in the production of HIV drugs and vaccines? And are there any alternatives to animal testing?
Why are tests performed on animals?

There are three reasons why animals may be used in scientific experimentation. The first is to ensure the safety of new drugs and other pharmaceutical products. The second is to see whether such products might be effective in humans. The third is for general research into the biology of an animal, or the function and action of certain diseases within its body.
Safety trials

In many countries it is a legal requirement that all drugs and vaccines (not just for HIV) are tested on animals to ensure safety. In the United Kingdom for example, the Medicines Act of 1968 1 states that all new pharmaceutical products must be tested on at least two different species of live mammal, one of which must be a large non-rodent. This legislation was introduced shortly after the discovery that the drug Thalidomide could cause serious physical deformities in babies born to mothers who had taken it during pregnancy. Thalidomide was not thoroughly tested on animals (particularly pregnant animals) before it was prescribed to women, and this case is the root of many countries’ animal testing safety laws today.
Thousands of mice and other small rodents are used in animal experiments every year

Thousands of mice and other small rodents are used in animal experiments
every year

Animal safety tests usually come at the end of a long process of safety data collection that may include testing the product ‘in vitro’ (i.e. in a test-tube) and using a computer program to simulate what might happen to the drug inside the body. The regulations on what safety data is required for a new product vary from country to country (and also from drug to drug), but most drug authorities require all three types of data - animal, in vitro and computer- generated - for trials to be allowed to continue.

All this means that at some point, all ‘antiretroviral’ (anti-AIDS) drugs will have been tested on animals for safety.

There is an argument however that animals are actually fairly poor substitutes for humans and that some compounds that may well cause no harm to a mouse, could kill a human being. This is particularly the case for drugs that interact with the complex human immune system, such as the anti-inflammatory drug that caused major organ failure in six men involved in a trial at Northwick Park Hospital in London, England in 2006. However, such occurrences are rare.
Efficacy trials

While all drugs and vaccines have to be tested on animals to establish their safety, testing them to establish their effectiveness is a different matter.

HIV is a retrovirus specific to humans (hence the name ‘Human Immunodeficiency Virus’), which means it is not naturally found in any other animal. Some African primates, such as chimpanzees and a few species of monkey, are naturally infected with SIV (Simian Immunodeficiency Virus), which is believed to be the virus from which HIV originated. Chimpanzees can also be artificially infected with HIV in a laboratory. However most monkeys and chimpanzees have very efficient immune responses to SIV (and HIV), and do not develop AIDS, even after many years of infection. This can make it very difficult to assess whether a drug or vaccine actually works, so primates are not used as widely as human substitutes as they once were.

This said, there is one primate still commonly used to conduct efficacy testing: the Rhesus macaque monkey. Because Rhesus macaques originate from Asia, rather than Africa, they have never been exposed to SIV, and thus have no natural immune responses to it. A Rhesus macaque that is infected with SIV will therefore develop AIDS type illnesses in a relatively short time 2.

For this reason (and because they are not an endangered species like some other Asian primates), macaques are often used in HIV research. A few HIV drugs, such as AZT and tenofovir (see our Introduction to Antiretroviral Treatment page for more information about these), have been tested on macaques for efficacy, though stricter rules on the use of primates in animal testing, and greater knowledge of HIV, mean that more modern antiretrovirals are generally only tested on animals for safety reasons.

Vaccine development on the other hand makes extensive use of primates. Because it could be seen as unethical to give a healthy human a vaccine, and then expose them to HIV to see if the vaccine works (if it doesn’t, they’ll end up with HIV), animals can be used as substitutes to establish whether a vaccine is effective or not. This method can also be used to test the usefulness of current AIDS drugs (such as tenofovir) in preventing HIV infection. Such work of course raises significant questions over whether it is any more ethical to give a monkey HIV than a human, when it too may become sick with AIDS and die.

A fundamental problem with using macaques in vaccine research has been that they have different immune systems to humans. This means they cannot be infected with HIV-1 (although they are susceptible to certain strains of HIV-2), however they can be infected with SIV, or an SIV-HIV combination (‘chimeric’ virus) known as SHIV. A drug or vaccine that is effective in Rhesus monkeys infected with SIV or SHIV may not therefore be effective in humans with HIV. Conversely, a drug or vaccine that may be effective in an HIV positive human may be dropped because it appears ineffective in animals. Scientists have now constructed a simian strain of HIV-1 that differs from the human virus by only one gene and mimics early HIV infection, however the infected macaques did not develop AIDS3. Further research on this genetically engineered virus is necessary, however if successful this may make testing vaccines in primates potentially more reliable.

Monkey research has yielded significant discoveries about HIV in recent years4, including major findings that have strengthened understanding of early SIV and HIV infection5.
General research

As well as the testing of new drugs and other products, animals may also be used for more general research that aims to gain a greater understanding of a disease. Rhesus macaques, chimpanzees and even cats (who can get Feline Immunodeficiency Virus) may be used as human substitutes to see how HIV-like viruses operate within the body.
Rhesus Macaques are commonly used in HIV research

Rhesus Macaques are commonly used in HIV research

They can also be used to study natural phenomena such as transmission or disease progression, and the effects of non-therapeutic substances on HIV.

One example would be a study carried out in Rhesus macaques in 2006 6. Scientists looking at the effects of alcohol on SIV found that feeding the monkeys large quantities of alcoholic beverages over a short space of time (effectively making them ‘binge’ drink) could significantly speed up the rate at which HIV progressed to AIDS. This may well lead to a greater emphasis on moderate drinking amongst HIV positive people, and a reassessment of safe levels of alcohol. However, whether the results of this experiment could have been recreated using methods that didn’t involve animals is open to debate.
Can animal testing be justified?

Animal testing is an extremely controversial and hotly debated area, and there are many groups around the world that are strongly opposed to animals being involved in any form of experiment, even if it involves simply keeping them in captivity. Equally, there are groups who say that there is no alternative to animal testing, and that animals have saved many human lives. Some of the scientific and moral arguments for and against animal testing include:

* FOR: Animal testing is justified because of the many human lives that it can save
* AGAINST: There is no firm evidence that animal testing has saved anyone’s life directly, particularly in the case of HIV – most drugs could probably have been developed without the use of animals.

* FOR: Humans are clearly unique amongst animals in our abilities and intellect. Animals do not experience pain and emotion in the same way that we do because they lack language and the power of abstract thought
* AGAINST: An animal’s life is equal to a human’s and we have no right to assume otherwise simply because animals cannot express their pain and suffering in words

* FOR: Animals are the best way to test vaccines, because it would be unethical to give a human a vaccine, and then to try to give them HIV to see if it works.
* AGAINST: It is no more ethical to give an animal a life-threatening illness than it is to give one to a human.

* FOR: SIV-infected chimps and Rhesus macaques are good substitutes for humans, and make drug and vaccine development far more simple
* AGAINST: Monkeys and chimpanzees do not have identical immune systems to humans, and may not respond to drugs or vaccines in the same way. Rhesus macaques also cannot be directly infected with HIV. No HIV vaccine has yet been developed, despite many years of animal involvement.

* FOR: Any differences between animal and human biology are generally known, and can be factored in to experiments
* AGAINST: This overlooks the effect that stress may have on the normal functioning of an animal’s body, which may in turn affect the results of the experiment

* FOR: Not testing new pharmaceutical products on animals is highly dangerous
* AGAINST: Animals are often poor substitutes for humans, and some compounds that may well cause no harm to an animal, could seriously harm a human being. Likewise, a drug that is toxic to the animal it is tested on, may have no toxicity, and even therapeutic benefits in humans.

* FOR: There are no viable alternatives to testing pharmaceutical products for safety on animals. Scientists already use in-vitro studies and computer models, and animal testing comes only after these tests have been performed. If a drug fails either test, it will not be given to animals anyway.
* AGAINST: Studies have suggested that ‘micro-dosing’ (where only a tiny amount of a product is given to a human through the skin) could be a new and very effective alternative to animal experiments 7. The recent news that scientists have grown a small piece of human liver tissue from stem cells could also mean that it may one day be possible to perform initial 'human' safety trials in a lab8.

* FOR: There are very strong laws in place to ensure that distress and pain in animals is kept to an absolute minimum
* AGAINST: Pain and suffering still occur, and simply being in captivity can cause great distress to an animal, just as it would to a human. Plus, animal testing facilities cannot be monitored at all times, so the sort of treatment animals receive on a daily basis can never truly be known.

* FOR: It is a legal requirement that drugs are tested on animals for safety in the majority of countries. Scientists have no choice in this matter.
* AGAINST: Perhaps if laws on the necessity for animal testing were relaxed, or animal safety-testing were banned, it would encourage scientists to develop other methods of testing toxicity that were equally effective. At the moment, they have no incentive to do so, so only a small handful of alternatives are being tested.

* FOR: No scientist wants to cause any more injury to an animal than is strictly necessary. Most scientists build up strong attachments to the animals they use in their experiments.
* AGAINST: This may be the case, but it is also very easy to become blasé about something that you do every day, and forget the pain and suffering your work is inflicting. Animals may well become little more than useful objects of study, rather than live creatures, and this can mean they are treated as disposable rather than indispensable.

What do HIV+ people think of animal testing?

Many HIV positive people condone, or remain neutral on animal testing because they are aware that the drugs they take to keep them alive have very likely been tested on animals at some point in the past.
Could human 'guinea pigs' be viable alternatives to real ones when testing new drugs?

Could human 'guinea pigs' be viable alternatives to real ones when testing new drugs?

In September 2005, six well-known AIDS organisations in the USA got together to form ‘Patient Advocates Against PETA’ (PAAP), a group that opposed the strong anti-animal testing stance of People for the Ethical Treatment of Animals (PETA) 9. Formed of ACT UP DC, ACT UP Southern California, AIDS Healthcare Foundation, AIDS/HIV Health Alternatives, AmASSI and the HIV Incarcerated Task Force, PAAP argued that PETA’s constant high-profile protests were hindering scientists in their search for effective HIV vaccines.

Their work was however opposed by a number of HIV positive individuals, who declared they were strongly opposed to animal testing, and did not condone PAAP’s actions. A consensus amongst HIV positive people themselves on the benefits of animal testing is obviously not very forthcoming.
What is the future for HIV and animal testing?

In recent years, scientists have begun to investigate the possibility of genetically altering the genes of some animals (particularly mice) to give them immune systems that more closely resemble a human’s, and are thus susceptible to HIV infection. Such small animal models could be useful, both for those developing new vaccines, and for those testing drugs for safety, but such work is strongly opposed by those who do not believe that genetically modifying animals is morally right or safe, as well as by those who oppose animal testing altogether.

Another alternative recently proposed is infecting ordinary mice with a chimeric form of HIV, similar to the 'SHIV' used to infect primates. This would allow efficacy trials of drugs and vaccines to be performed on small mammals, which could perhaps be combined with safety trials to reduce the time taken to reach regulatory approval. However, this would potentially increase rather than reduce the number of animals involved in clinical testing.10

Regulations on animal testing have been tightened considerably in recent years, and animals, particularly primates, are used in far fewer experiments than they once were. In most countries (particularly the UK, which has the tightest regulations on the use of animals for science) facilities where animals are held are inspected regularly to ensure that animals are being kept in hygienic, safe and comfortable conditions.

Nonetheless, animal testing is still very strongly opposed by many groups who believe that any form of animal exploitation is wrong. The majority of anti-vivisection groups stage peaceful protests that aim to raise awareness of the harm and pain that animal testing can inflict, and raise support amongst the public for a ban on the practice. However a small minority of animal rights activists have resorted to more extreme tactics, which have included intimidation of those directly involved in experimentation, intimidation of their families, suppliers and business partners, and criminal acts, ranging from harassment and vandalism to blackmail and arson 11, 12, 13.

Unfortunately, while such groups receive substantial media coverage, their extreme actions tend to drown out the messages of more moderate groups, who are simply calling for a reassessment of the law, or greater research and assessment of alternative methods. Their behaviour creates a counter-productive situation, whereby those who conduct experiments on animals become more determined to continue with their work because of the opposition they face, and the government refuses to launch a proper investigation into the current laws in case they are seen as ‘giving in’ to extremists. It also risks portraying all animal rights campaigners as extreme activists and all scientists as cruel animal abusers.

In reality, views on animal testing are not nearly as polarised as this. There are many moderate anti-vivisection groups, just as there are many scientists who would prefer not to test on animals if they had a choice. A meaningful debate between the two may well help to further progress into ending the reliance on animals for safety and efficacy testing, but while the issue remains connected to such controversy and extremism, discussions of this kind seem to be few and far between.

It may be that one day animal research produces a vaccine or a cure for HIV that saves millions of human lives. If this is the case, then some justification can perhaps be found in using animals for our own purposes. Until this time however, anti-vivisectionists need to remain focused on finding alternatives, informing and changing legislation and keeping testing on animals to an absolute minimum. It is only through such positive action that true progress can be made.

Evidence that HIV causes AIDS
Introduction

"AIDS is caused by infection with a virus called human immunodeficiency virus (HIV). This virus is passed from one person to another through blood-to-blood and sexual contact."1

That's the standard explanation of what causes AIDS. But what evidence do scientists have to support this theory? And why do some websites say that the world has got it terribly wrong – that HIV does not cause AIDS at all?

As an independent AIDS organisation founded in 1986, AVERT has taken a keen interest in the ongoing debate about what causes AIDS. As well as investigating the consensus position, we have followed and carefully considered the arguments of the dissident minority who claim that HIV is harmless or even that it might not exist. This topic is vitally relevant to how our organisation works to prevent people developing AIDS and to help those who are suffering.

It is AVERT's considered opinion that the evidence that HIV causes AIDS is abundant and conclusive. This page outlines some of that evidence, while also mentioning how some dissidents have interpreted things differently. In particular, we'll look for proofs of the following:

* AIDS is a new epidemic disease
* AIDS does not occur without HIV
* HIV infection is the only factor that predicts who will develop AIDS
* Surveillance statistics support the HIV theory
* Modern antiretroviral treatment is highly beneficial.

Who doubts that HIV causes AIDS?

By far the most significant scientist to question the HIV/AIDS theory is Professor Peter Duesberg, a virologist at the University of California at Berkeley, who first wrote about this topic in 1987. Throughout the 1990s and into the new millennium, as HIV/AIDS researchers announced many new discoveries and amassed huge volumes of data, Dr Duesberg remained unconvinced. He admits that HIV exists, but he maintains that it is harmless, and that AIDS is caused by non-contagious factors including drug abuse, malnutrition, and even the very drugs used to combat HIV.2

Other dissidents (often called "denialists" by their opponents) include the Perth Group of medical scientists and physicians from Australia. The Perth Group (led by Eleni Papadopulos) claims that nobody has conclusively proven the existence of HIV, so any proof that HIV causes AIDS has no foundation.3

Dissident arguments have received attention from the popular media, as well as from scientific journals. And with the rise of the Internet, alternative views have found a much wider audience, so that scarcely anyone interested in AIDS can have failed to hear of them.

Some of their followers are intrigued by conspiracy theories involving sinister drug companies or government persecution of minority groups. But alternative explanations can also appeal to those diagnosed with HIV or AIDS, who read that their condition might not be fatal, that they shouldn't take toxic drugs, and that unprotected sex poses no risks. Even a few AIDS service organisations have adopted non-HIV viewpoints.4

However, the proportion of scientists who doubt that HIV causes AIDS is tiny, and shows no sign of increasing. Interest in dissident views appears to have dwindled after the excitement surrounding Thabo Mbeki's AIDS panel and the Durban Declaration in 2000. It seems likely that new and better evidence, including the obvious benefits of modern drug treatments, has caused many former-dissidents to change their minds.
What is AIDS?

Before we can begin to look for a cause, we must first work out exactly what type of illness we are talking about.

In early 1981, doctors in New York and California began to report some bizarre new disease outbreaks. In both places, previously healthy young men were showing up with rare illnesses including Kaposi's sarcoma (a kind of tumour) and PCP (a type of pneumonia), which until then had been virtually unheard of among such people. Within months, dozens of similar cases had been reported in 23 American states and in the UK, representing the start of a massive and unprecedented epidemic.5

Doctors soon discovered a distinctive feature of these cases. More than anything else, the men were lacking a specific type of white blood cell, which is essential to a healthy immune system. Normally, people have between 600 and 1,500 "CD4+ cells" (also called T helper cells) in each cubic millimetre of their blood. But the men with the strange new disease typically had very much lower levels. This immune deficiency explained why they were so vulnerable to disease.

The cases were clearly related in time and by population group (initially gay men and injecting drug users). No cause of immune deficiency could be found, but it was clearly not inherited. Scientists therefore grouped together all of these strange new cases under the heading "Acquired Immune Deficiency Syndrome" – or AIDS for short.

In 1982, no-one claimed to know the cause of AIDS, so the first definition was based on the diagnosis of one of 13 rare diseases known to be linked to immune deficiency (including Kaposi's sarcoma and PCP) "occurring in a person with no known cause for diminished resistance to that disease".6 Over the years, the US definition has been refined as hundreds of thousands of similar cases have been documented, sometimes involving other diseases, but always associated with the same distinctive immune deficiency.7 Other definitions have also been developed to suit different situations elsewhere in the world.8

The latest US AIDS definition was created in 1993. Under this definition, someone has AIDS if they have one of 26 specific diseases (28 in children) but no known cause of immune deficiency other than HIV (with some diseases, a positive HIV test is required); or if they have a CD4+ cell count below 200 cells per cubic millimetre of blood, or less than 14% of all lymphocytes, plus a positive HIV test.9

Europe and Canada have similar AIDS definitions to the US, but do not include low CD4+ cell counts.
Problems with the definition?

The definition of AIDS usually requires a positive HIV test. This means that any connection between HIV and AIDS is artificially strengthened because any cases of "HIV-free AIDS" are discounted. In other words, the definition already assumes that HIV causes AIDS, so it can't be used to prove that theory. However, it is possible to redefine AIDS without reference to HIV or even to any other diseases.

The alternative definition of AIDS requires a CD4+ cell count consistently below 200 cells per cubic millimetre of blood, which cannot be explained by any factor other than HIV (such as cancer, malnutrition, radiation or chemotherapy). No HIV test is required.

It turns out that the vast majority of people diagnosed with AIDS fit these criteria. They form a population that barely existed before 1980, but which now numbers hundreds of thousands in the USA and Europe alone. People with such severe immune deficiency are at very high risk of developing serious illnesses and usually die within months (unless they take antiretroviral drugs).10 11 12 We can use this simple, unambiguous definition to test the association between HIV and AIDS.13 14
How can we prove that HIV causes AIDS?
Koch's Postulates

In the nineteenth century, the German scientist Robert Koch developed a set of four "postulates" to guide people trying to prove that a germ causes a disease. Scientists agree that if HIV satisfies all of these conditions with regard to AIDS then it must be the cause of AIDS:15

* Koch 1: The germ must be found in every person with the disease
* Koch 2: The germ must be isolated from someone who has the disease and grown in pure culture
* Koch 3: The germ must cause the disease when introduced into a healthy person
* Koch 4: The germ must be re-isolated from the infected person

Other evidence

Even Koch recognized that in some cases not all of his conditions could be met, so other evidence should also be considered. This is particularly true when the germ is a virus rather than a bacterium.16 Modern scientists are willing to consider a wide range of evidence. In particular, we can ask five key questions:

* Do surveillance statistics show a relationship between HIV and AIDS?
* How well does HIV infection predict illness and death?
* Do drugs designed to combat HIV benefit people with AIDS?
* Are there any credible causes besides HIV?
* What can we learn from Africa?

We'll address these questions after looking at Koch's Postulates.
Koch 1: The germ must be found in every person with the disease

The US Centers for Disease Control and Prevention (CDC) defines a condition called idiopathic CD4+ T-lymphocytopenia, or ICL for short. Someone is diagnosed with ICL if they have a CD4+ cell count below 300 cells per cubic millimeter, or 20% of all T lymphocytes, on at least two occasions, but have no detectable HIV infection, nor any other known cause of immune deficiency (such as cancer therapy). As many dissidents have pointed out, this is essentially a definition of HIV-free AIDS. So just how common is this condition?

In 1993, a CDC task force published the results of an exhaustive survey of ICL in the USA. They had reviewed 230,179 AIDS-like cases reported since 1983 and identified 47 patients with ICL (plus 127 uncertain cases). All of the other people with AIDS who had received an HIV test produced a positive result. What's more, the team closely investigated the ICL cases and discovered that they didn't fit the usual AIDS profile. There were 29 male and 18 female patients, and 39 of them were white (4 others were of Asian descent). In 29 cases, the researchers couldn't fit the people into conventional risk groups for AIDS (homosexual men, haemophiliacs, injecting drug users, and the sexual partners of such groups). Whatever these 47 cases represent, they don't seem to be typical of the massive epidemic that we're interested in.17

The findings of the ICL survey are backed up by large-scale monitoring studies, including the Multicenter AIDS Cohort Study (MACS). During the MACS, scientists monitored the health of 2,713 gay and bisexual men who tested negative for HIV antibodies. Over several years, only one of these men had persistently low CD4+ cell counts, and he was undergoing cancer therapy designed to weaken his immune system. Similar results have been found among blood donors, recipients of blood and blood products, injecting drug users and other groups: severe immune deficiency is virtually non-existent among those who test HIV-negative.18

As Dr Duesberg has pointed out, quite a lot of people (mostly in the early 1980s) have been diagnosed with AIDS in the USA despite never taking an HIV test, and nobody knows whether these people were HIV-positive or not. However, based on the much larger sample of people who have been tested, Koch's first postulate has certainly been satisfied. The only way by which dissidents have been able to come up with significant numbers of HIV-free "AIDS" cases is by using much looser definitions of AIDS. Such definitions include many people with milder immune deficiency, which is generally not fatal.19 20
What about false positive test results?

Diagnosis of infection using antibody testing is one of the best-established concepts in medicine. The World Health Organisation and the US National Institutes of Health agree that modern HIV tests are extremely reliable, and are even more accurate than most other infectious disease tests.21 22

Nevertheless, some dissidents have tried to dismiss the association between AIDS and HIV by claiming that many of those who test positive are not really infected with HIV. In particular, Christine Johnson has listed dozens of conditions reported to have produced false positive reactions on at least one occasion (under particular circumstances, using particular test kits).23

It is true that no test is perfect. However, what the dissidents usually don't mention is how rare the reports of false positive results have been, especially in recent years. Nor do they mention that every person who uses a test kit is trained to spot the telltale signs of a suspicious result, and to keep testing by various methods until no doubt remains. The conditions that cause false positive results are not only very uncommon, but are also typically short-lived, whereas HIV infection does not go away.24 25

The dissident theory cannot satisfactorily explain why scientists have been able to use various techniques to detect the virus itself in virtually everyone with AIDS, as well as in most people with positive antibody test results, as explained in the next section. These methods (including DNA PCR, RNA PCR and viral culture) are not affected by any of the factors said to produce false positive results in antibody testing.

Nor can the alternative theory fully explain why the association between AIDS and antibody test results is so exceptionally strong: virtually everyone with AIDS tests positive, while more than 99% of the US public tests negative. And it cannot explain why the proportion of people testing HIV positive should have increased so dramatically over time. For example, the proportion of South African women testing HIV positive in annual antenatal surveys rose from 0.8% in 1990 to 10.4% in 1995, 24.5% in 2000 and 29.5% in 2004. The age distribution of these data is similar to that of other sexually transmitted infections.26
Koch 2: The germ must be isolated from someone who has the disease and grown in pure culture

Koch required that the germ be isolated from all other material that could possibly cause disease, so that his third and fourth postulates could be properly tested.

In May 1983, Luc Montagnier and his colleagues in France reported the isolation of a virus they named LAV, which infected and killed CD4+ cells. A year later, the American Robert Gallo announced he had isolated a virus called HTLV-III and found a way to grow it in culture. It was later discovered that the two viruses were genetically indistinguishable, and they were renamed HIV.27

Researchers have been able to isolate and culture HIV from most AIDS patients whom they have examined (as well as from many other people with HIV antibodies).28 They have isolated the virus from blood cells, blood plasma, lymph nodes, semen, vaginal fluids, amniotic fluids, bone marrow, brain, cerebrospinal fluid, intestines, breast milk, saliva and urine, and cultured it in various cell types.29 Images taken using electron microscopy and other techniques have shown virus-like particles that have the size, shape, structure, density, proteins and behaviour expected of retroviruses.30 31 32

Techniques developed in the mid-1990s have made it much easier to extract and sequence the complete genetic material (genome) of an isolated virus.33 34 The Los Alamos database now contains hundreds of full-length HIV genomes from around the world, each containing the same nine genes.35 Based on genetic similarities and differences, these sequences have been used to define family trees of HIV types, groups and subtypes as well as hybrids called recombinant forms.36

Whole or partial HIV genomes have been detected in numerous AIDS patients, using a technique called PCR (the same technology is used to find DNA evidence with which to convict murderers or to settle paternity suits, as well as to detect the germs that cause hepatitis, tuberculosis and other diseases). Almost everyone who tests positive for HIV genetic material also tests positive for HIV antibodies, and vice versa, while those who test negative for one thing also lack the other.37 People who have been exposed to the same source of infection contain genetically very similar HIV strains – similar enough for court convictions.38

Scientists have used a standard technique of genetic science called molecular cloning to obtain highly purified HIV. Genetic material extracted using PCR or other techniques has been introduced into bacteria or other cells (usually using phages or plasmids), which then produce many exact copies (clones) of the viral genes. If cloned viral genomes are inserted (transfected) into human cells then they produce a new generation of infectious HIV particles, which are free from contamination.39

Virtually all experts agree that HIV has been isolated according to the most rigorous standards of modern virology, meaning that Koch's second postulate has without doubt been satisfied.
What about the Perth Group?

A small band of Australian scientists and physicians claims that HIV has never been properly isolated. The Perth Group has never said that HIV doesn't exist; rather they say that HIV has never been conclusively proven to exist. They don't trust any HIV tests, because they have not been verified using their "gold standard" of isolated virus. The Group uses the isolation argument to dismiss just about every type of evidence that HIV causes AIDS.40

Virtually all virologists believe that the Perth Group's conditions are unnecessary. They say nobody has ever used such rules to isolate any type of virus, and that other techniques are much more effective. According to the Perth Group's rules, nobody has isolated or proven the existence of the viruses said to cause small pox, influenza, measles, mumps and yellow fever.

Experts argue that the Group's rules are unreasonably demanding and impossible to satisfy fully, even though their main requirements have already been met.41 42 Dr Duesberg is among those who have tried in vain to persuade the Perth Group that HIV definitely exists and has been isolated using the most rigorous methods available.43 44 45

The Perth Group appears to have only two active members: a medical physicist called Eleni Papadopulos-Eleopulos and an emergency physician called Valendar Turner. In late 2006, Papadopulos-Eleopulos and Turner testified in the appeal trial of Andre Chad Parenzee, an HIV-positive man convicted of endangering life by having sex with three women without informing them of his infection. The two witnesses intended to demonstrate that HIV had not been proven to exist; that HIV tests were unreliable; and that there was no evidence of HIV transmission through sex.

The presiding judge concluded that the Perth Group members had no qualifications or practical experience in virology, immunology or epidemiology, and were not qualified to express opinions about the existence of HIV, or whether it had been shown to cause AIDS. The judge found that the pair relied entirely on the work of others, which they often took out of context and misrepresented. Their arguments were found to lack plausibility and cogency, and to have "minimal" probative value. "I am satisfied that no jury would conclude that there is any doubt that the virus HIV exists," said Justice Sulan. "I consider no jury would be left in any doubt that HIV is the cause of AIDS or that it is sexually transmissible."46
Koch 3 and 4: The germ must cause the disease when introduced into a healthy person, and the germ must be re-isolated from the infected person

The third and fourth postulates are much harder to prove. It's considered unethical to deliberately infect someone with pure HIV, so such an experiment has never taken place. However, there is no reason why the transmission has to be deliberate.

There have been three reports of lab workers developing immune deficiency after accidentally exposing themselves to purified, cloned HIV. As mentioned above, such cloned virus is free of all contamination from the original source. None of these people fitted conventional risk groups for the disease. In each case, HIV was isolated from the individual and, by genetic sequencing, was found to be the strain to which they'd been exposed. One of these workers developed PCP and had a CD4+ cell count below 50 cells before starting antiretroviral treatment.47

Still, three examples don't make a totally conclusive proof, so it's worth looking for more evidence.

One line of argument can be based on animal experiments.48 In some studies, chimpanzees deliberately infected with HIV-1 have gone on to develop AIDS-like conditions (though this appears to be rare),49 while HIV-2 has had the same effect on baboons.50 Macaque monkeys have developed AIDS after being infected with a hybrid virus called SHIV, which contains genes taken from HIV.51 And in mice engineered to have a human immune system, HIV produces the same patterns of disease as in humans.52

If we're prepared to bend the rules a bit further, we can look at people who've been infected with non-purified HIV. Such cases at least suggest that AIDS is infectious, though they don't rule out the possibility that more than one germ is involved.

Scientists have documented numerous cases of people developing AIDS after becoming infected with HIV as a result of blood transfusions, drug use, mother-to-child transmission, occupational exposure and sexual transmission. In such cases, they have recorded the development of HIV antibodies (seroconversion) using a series of blood tests, before progression to AIDS. Seroconversion is often accompanied by a mild flu-like illness or swollen glands.53

Until the mid-1990s, nobody claimed that HIV had fulfilled Koch's last two postulates. Even today, the proof is not quite perfect. But most scientists believe the evidence is now strong enough to put the case beyond all reasonable doubt.54
Surveillance statistics

Most countries with high rates of HIV have conducted regular national HIV surveillance studies since the early 1990s. AIDS case reporting began much earlier, in the early 1980s. All of the data are available to the public online.
HIV and AIDS in Thailand, 1984-2000

HIV and AIDS in Thailand, 1984-2000

AIDS case statistics are generally expected to underestimate the scale of AIDS epidemics, especially in African countries, because many cases go unreported. However, it is reasonable to assume that trends in the number of reports should roughly correspond to trends in the overall epidemic.

Of all countries, Thailand has one of the best records of HIV surveillance, with around 70 sites included each year since 1990. Thailand also has relatively good infrastructure for the reporting of AIDS cases. On the right is a graph showing trends in Thai statistics between 1984 and 2000.55

The graph shows that during the 1990s there was a dramatic increase in AIDS case reports. This increase came after a sharp rise in HIV prevalence, with a time lag of a few years (nearly 200,000 HIV tests conducted between 1985 and 1987 produced fewer than 100 positive results).56 Such a time lag is exactly what the HIV theory predicts, because most people are expected to live with HIV for some time before developing AIDS.

Thailand is not unique. Exactly the same pattern can be seen in statistics worldwide, from Albania (where HIV and AIDS are both very rare) to Zimbabwe (where AIDS case reports soared during 1987-95, following the trend in HIV prevalence).57 58

This trend can also be seen within individual countries as regions, cities or population groups with higher HIV prevalence report a higher rate of AIDS.59
How well does HIV infection predict illness and death?

A mountain of evidence shows that much can be predicted from a positive test result. For example:

* Around half of people develop AIDS-defining conditions within 10 years of HIV infection, if they don't take antiretroviral drugs. Only a few do not develop AIDS within 20 years.60 61

* HIV-positive Americans and Canadians are over 1,000 times more likely to develop AIDS-defining diseases (such as PCP and Kaposi's sarcoma) than those who test negative.62 63

* A study in Uganda found that HIV-positive people were 16 times more likely to die over five years than those who tested negative. For those aged 25-34 years old, HIV infection raised the death rate by a factor of 27.64 Numerous other studies have found similar results in Tanzania, Malawi, Rwanda and other parts of Africa.65 66 67 68

* A study of female sex workers in Thailand found the death rate to be over 50 times greater among those who tested positive. All of the positive women died of conditions associated with immune deficiency, compared with none of the negative women.69

* During a 16-year, large-scale monitoring study of homosexual and bisexual men in the US, 60% of HIV-positives died compared with 2.3% of HIV-negatives.70

* In the UK between 1979 and 1992, death rates increased massively among HIV-positive haemophiliacs, but remained unchanged among the rest.71 Similar research in the USA found that HIV-positive haemophiliacs were 11 times more likely to die over a ten-year period, compared with those who tested negative.72

* In a European study of babies born to HIV-positive women, none of those who tested negative developed AIDS, compared to 30% of those who tested positive. By their first birthday, 17% of the HIV-positive babies had died.73 A similar study in Uganda found that more than half of HIV-positive babies died before their second birthdays, compared to one sixth of those who were HIV-negative.74

Alternative theories cannot explain why HIV tests should be so effective at predicting illness and death in so many diverse groups of people from all parts of the world.

It is even possible to predict the likelihood that someone will soon develop AIDS by measuring the amount of HIV in their blood, which is known as "viral load". Such measurements can be made using PCR, branched-DNA signal-amplification (bDNA) or quantitative microculture techniques. For example, the table below - based on a long term study of 1,604 patients - illustrates just how useful bDNA forecasts can be:75
Viral load (RNA copies per millilitre of blood plasma) Proportion of patients developing AIDS within six years
less than 500 5.4%
501-3,000 16.6%
3,001-10,000 31.7%
10,001-30,000 55.2%
more than 30,000 80.0%

Dr Kary Mullis, who invented the PCR process, has questioned its ability to measure viral load. However, his arguments have been theoretical, and are not backed up by large-scale surveys, which have repeatedly shown a clear association between viral load and progression to AIDS (in all parts of the world).76 77 Dr Mullis' objections do not apply to the unrelated bDNA and quantitative microculture techniques. Modern bDNA tests produce very similar viral load counts to modern PCR tests (though this was less true of some earlier models).78 79 As with antibody tests, there is no convincing alternative explanation for why viral load counts should be such useful indicators.
Effective drug treatments

The first drug licensed for fighting HIV was zidovudine, better known as AZT, which gained approval in 1987. Multiple studies found that AZT reduced opportunistic infections and increased CD4+ cell counts and survival among people with AIDS. However, the positive effects of AZT did not last very long, and a major investigation known as the Concorde Study found that people who started taking the drug at an early stage of HIV infection, before the onset of symptoms, received little or no long-term benefit (though neither did they fare any worse).80 81 82

Since the mid-1990s, other types of anti-HIV drugs have also been available, including protease inhibitors, which were designed specifically to target HIV proteins.83 It has been found that when different drugs are taken together, they bring much longer-lasting benefits than AZT alone.

Numerous large-scale, controlled studies have consistently shown that the right combination of drugs can dramatically reduce incidence of AIDS and death. One drug is better than none, and two is better than one, but a combination of three drugs (from two different classes) is much better still. Virologists explain that this is because HIV finds it a lot harder to evolve resistance to several drugs at the same time. Modern three-drug combinations reduce the risk of AIDS and death by over 80%.84 85 86 87

Many recent studies in Africa have found that treatment is just as effective there as it is in Europe and America.88

In most people, the drugs cause a sharp fall in viral load. However, some patients do not experience such an effect, and these people are far more likely to develop AIDS or to die. This fact in itself very strongly suggests that HIV causes AIDS.89
HIV and AIDS in the United Kingdom, 1988-2002HIV and AIDS in the United Kingdom, 1988-2002

The benefits of more effective drug treatments can be seen in national statistics from rich countries in which most people have had access to them. On the right is a graph of HIV diagnoses, AIDS diagnoses and AIDS deaths in the UK between 1988 and 2002. This graph shows that the numbers of AIDS diagnoses and deaths fell by more than half between the end of 1995 and the end of 1998. This trend followed the widespread introduction of combination therapy.90

Similar patterns can be seen in statistics from other European countries, Canada, Australia and the USA.91 However, it should be noted that American statistics were distorted during the period 1990-1996 because of a major expansion in the AIDS surveillance case definition in 1993. For the first time, people could be diagnosed with AIDS on the basis of a low CD4+ cell count. The majority of these people would have gone on to develop AIDS-defining diseases before death, so would have been included in the statistics anyway, but the change in definition meant they were diagnosed earlier, and this skewed the statistics.

The distortion caused by the change in definition was temporary, and cannot account for the major declines in AIDS diagnoses and deaths that occurred in the USA during the late 1990s. Nor can the declines be explained by trends in HIV incidence.92 93 94 95 Incidence of AIDS-defining infections like PCP rose during the early 1990s and then decreased significantly between 1995 and 1998.96 97

The ability of antiretroviral drugs to prevent mother-to-child HIV transmission has been demonstrated around the world.98 Following the widespread introduction of these drugs during pregnancy, the number of reported AIDS cases among American children has fallen to around 100 per year, compared to nearly 1,000 per year in the early 1990s.99

Antiretroviral therapy, alongside treatment for opportunistic infections, is thought to have saved at least three million years of life in the USA alone.100
Drug abuse and other factors

Dissidents who claim that HIV does not cause AIDS have felt compelled to come up with alternative causes. These generally include recreational drugs (including heroin, cocaine, amphetamines and nitrite inhalants known as "poppers"), malnutrition, lack of clean drinking water, clotting factors used in blood transfusions, and anti-HIV drugs such as AZT. Some groups also suggest semen, "immune overload", antibiotics, benzene, stress, or lack of sleep.

In the early 1980s, when only a small number of AIDS cases had been reported, the medical establishment gave some of these possible causes very serious consideration. But such theories quickly lost favour as more cases emerged among men, women and children who did not fit the established risk groups, and it was established that affected people had been exposed to the bodily fluids of other affected people.101 Epidemiological data pointed to an infectious cause before HIV was ever isolated.102

Today, most scientists agree that controlled studies of drug users, heterosexuals, homosexuals, haemophiliacs and twin babies have consistently shown that HIV is the only factor that predicts who will develop AIDS. Associations in time and place between trends in drug use or promiscuity and trends in AIDS diagnoses are considered much too weak to prove causation.103 104

Dr Duesberg has claimed that some HIV-negative drug users have developed AIDS-like immune abnormalities and diseases. But his definition of "AIDS-like" is very vague, and none of these cases would merit an AIDS diagnosis.105 106 107

Antiretroviral drugs can have toxic side effects. However, there is no evidence that anti-HIV drugs cause the severe immune deficiency typical of AIDS, and there is abundant evidence that currently recommended courses of antiretroviral therapy can improve the length and quality of life of HIV-positive people.108 109 110 111

Certain AIDS-related diseases are more common among some population groups than among others. This is not surprising, and it does not mean that they cannot all have the same underlying cause.112 113

Severe malnutrition is a known cause of immune deficiency (though not the specific type of immune deficiency that is characteristic of AIDS). That is why all definitions of AIDS specify that there must be no evidence of severe malnutrition. Poor nutrition is also thought to make people with HIV more vulnerable to illness, so improving diet is an essential component of programmes to help HIV-infected people around the world. Still, such actions are not by themselves sufficient, because thousands of Africans who are well fed and cared for continue to die from AIDS. As the next section explains, there is no evidence that deterioration in diet or living standards can explain AIDS in Africa, which appears to be a totally new epidemic disease.
AIDS in Africa

Some dissidents claim there is no great new AIDS epidemic in Africa, just the same old diseases caused by poverty, hunger and poor sanitation. They say that official statistics are misleading because AIDS in Africa may be diagnosed on the basis of various clinical symptoms without an HIV test if none is available.114 We'll challenge these claims using four lines of argument.

Firstly, medical records from a number of African countries show marked increases in a number of AIDS-related diseases during the late 1970s and early 1980s. These records suggest that AIDS was probably rare or non-existent before that time.115

Secondly, as discussed above, numerous studies have found that people who test positive for HIV face a much higher risk of illness and death. Surveillance studies show that HIV prevalence rates have soared across sub-Saharan Africa since the early 1980s, and are now extremely high. It is therefore reasonable to estimate that millions are ill and dying.116

Thirdly, since the early 1980s, African countries with high HIV prevalence have suffered increased burdens of disease and death, as measured by censuses and surveys. For example:

* Between the 1980s and mid 1990s, adult death rates rose significantly in countries where HIV had been widespread for many years (such as Uganda, Zambia and Zimbabwe), but not in countries where rates had been lower.117 118

* Increases in death and disease have disproportionately affected young and middle-aged adults, especially those living in urban areas. Relatively well-paid professionals including teachers and doctors have been among the worst hit. This pattern is not typical of diseases caused by malnutrition or dirty water, which generally target the poor and the elderly.119 120 121

* In several countries, the number of orphans has risen so dramatically that communities can no longer cope, and child-headed households are now commonplace. Such changes indicate that sexually active adults are dying while children (and the elderly) are surviving. Household surveys have revealed a strong correlation between rates of orphanhood and adult HIV prevalence.122 123 124

* Patterns of disease have changed. For example, rates of Kaposi's sarcoma have soared,125 and tuberculosis - which was once confined to the poor, the weak and the elderly - today kills numerous well-fed Africans in the prime of life.126 127

Not all of sub-Saharan Africa has been equally affected by the recent changes. For example, Southern Africa has suffered much more than Western Africa, even though the regions have experienced similarly high levels of extreme poverty, malaria, food shortages and conflict. The only factor associated with the changes is HIV prevalence.128 129

Fourthly, the number of reported AIDS cases has risen across sub-Saharan Africa. Experts believe these statistics vastly underestimate the scale of the epidemics because the reporting systems are inadequate. This inadequacy is partly due to frequent misdiagnosis (compounded by AIDS-related stigma), but is mostly due to poor infrastructure and lack of access to healthcare. In addition, the quality of the reporting systems varies from one country to another. Nevertheless, it is possible to spot two clear patterns in the data.

The first obvious trend is that the number of reported AIDS cases increased everywhere during the 1980s. As in all other parts of the world, this increase followed a rise in HIV prevalence. The second trend concerns the number of AIDS cases reported per million of population. In general, the highest rates have been recorded by Southern African countries where HIV has been widespread for many years, while the lowest rates tend to come from Western African countries with historically much lower HIV prevalence. The lowest AIDS rate of all is reported by the island nation of Madagascar, where until recently HIV was extremely rare.130

The only major exception to the pattern in AIDS case rates is South Africa, which has reported relatively low figures. However, HIV prevalence did not reach very high levels in South Africa until the mid-1990s, several years later than in nearby countries such as Zambia and Zimbabwe. In addition, South Africa stopped reporting AIDS cases to the World Health Organisation in 1996, before most other African countries, and before the rise in HIV had had a chance to take effect.131

Compelling evidence of the impact of AIDS in South Africa since that time comes from studies of death certificates. These show that the annual number of reported deaths (from all causes) rose by 79% between 1997 and 2004. Among those aged 25-49 years old, the increase was 161%.132 Rates of death from AIDS-related conditions increased according to a distinctive age distribution, which peaked among the age groups 0-4 and 25-49 years. Other conditions showed no such pattern. The estimated number of AIDS deaths based on these data is similar to estimates based on HIV prevalence.133
What we don't know

There are still a few things we don't know about HIV and AIDS.

For example, we don't really know why both HIV and AIDS have become generally common in some African countries but not in Europe or the US – though we do have some theories. Contributing factors include the much higher prevalence of untreated sexually transmitted diseases in Africa (which greatly increase the chances of HIV transmission) and, quite possibly, differences between HIV subtypes.134 135 In addition, people who have poorer general health (including those who have malaria or tuberculosis) tend to have more HIV in their bodily fluids, which makes them more likely to transmit the virus.

Different patterns of sexual networking also have an effect. Viral loads are especially high during the first few weeks after infection, so the risk of transmission is then much higher. This means that people who have several concurrent sexual partners are able to spread the virus very efficiently before they test positive or fall ill. Studies suggest that, even though Africans do not report more sexual partners over a lifetime than other populations, concurrent partnerships are more common in Africa and most common in Southern Africa.136 137

Due to lack of access to HIV testing and treatment, as well as educational and cultural factors, the vast majority of Africans do not know their HIV status, and many people, especially women, find it very difficult to adopt strategies that would lower their risk of becoming infected or of infecting others. High levels of mobility, particularly of migrant workers, can also help to spread HIV.138

The concentration of an infectious disease among particular groups is not unusual. Hepatitis B is transmitted via much the same routes as HIV, and in Western countries it has similar risk groups. Hepatitis C (which is primarily spread via blood) is largely confined to injecting drug users, and recent increases in syphilis (usually sexually transmitted) have been fuelled by outbreaks among men who have sex with men. Surveillance statistics from throughout the Western world show that AIDS is becoming increasingly common outside the traditional risk groups, following a similar trend in HIV cases. In 2003, around a third of new American AIDS diagnoses, and two-thirds of those among women, occurred among non-drug using heterosexuals.139 Epidemiological evidence of male-to-female, male-to-male and female-to-male sexual transmission of HIV is abundant.140

Something else we don't fully understand is how HIV causes AIDS. Again, however, we do have some theories, which explain how the virus might be able to stop the immune system working properly in a number of ways, not just by directly killing cells.141 Ignorance about precisely how something happens is not proof that it does not happen.
Conclusion

There is no single scientific paper that proves HIV causes AIDS. Instead there are tens of thousands of papers containing a wide range of evidence that, taken together, make the case overwhelming.

People should be encouraged to question scientific orthodoxy. However, the views of AIDS dissidents, which have been well known for many years and thoroughly debated in scientific journals, have failed to win support. The core arguments of the Perth Group (that HIV has not been isolated according to their own particular rules) and Dr Duesberg (that no one fully understands how HIV causes AIDS) do not invalidate the wide range of evidence outlined on this page. The HIV theory is compelling because it provides a simple, unique cause that consistently accounts for all of the observed phenomena.

As an independent AIDS organisation, AVERT is primarily interested in what works. Studies have repeatedly shown that antibody testing is a highly effective way of predicting risk for AIDS; that modern antiretroviral treatment brings dramatic benefits; and that people who avoid exposure to HIV do not get AIDS. We will therefore continue wholeheartedly to recommend these things.

A cure for AIDS

There is no cure for AIDS. Although antiretroviral treatment can suppress HIV – the virus that causes AIDS – and can delay illness for many years, it cannot clear the virus completely. There is no confirmed case of a person getting rid of HIV infection. Sadly, this doesn’t stop countless quacks and con artists touting unproven, often dangerous “AIDS cures” to desperate people.

It is easy to see why an HIV positive person might want to believe in an AIDS cure. Access to antiretroviral treatment is scarce in much of the world. When someone has a life-threatening illness they may clutch at anything to stay alive. And even when antiretroviral treatment is available, it is far from an easy solution. Drugs must be taken every day for the rest of a person’s life, often causing unpleasant side effects. A one-off cure to eradicate the virus once and for all is much more appealing.

Distrust of Western medicine is not uncommon, especially in developing countries. The Internet abounds with rumours of the pharmaceutical industry or the U.S. government suppressing AIDS cures to protect the market for patented drugs. Many people would prefer a remedy that is “natural” or “traditional”.
Where’s the harm in fake AIDS cures?
Group of men looking at unproven AIDS cure

A man selling an unproven AIDS cure in Papua New Guinea

Unproven AIDS cures have been around since the syndrome emerged in the early 1980s. In most cases, they have only served to worsen suffering.

First of all, fake cures are a swindle. Someone who invests their savings in a worthless potion or an electrical zapper has less money to spend on real medicines and healthy food.

Many peddlers of bogus cures insist their clients avoid all other treatments, including antiretroviral medicines. By the time a patient realises the “cure” hasn’t worked, their prospects for successful antiretroviral treatment may well have diminished.

Fake cures may also cause direct harm to health. Inventors often refuse to reveal their recipes. Some so-called cures have been found to contain industrial solvents, disinfectants and other poisons. The dangers posed by the virgin cleansing myth – which advocates sex with children as a cure for AIDS – are only too clear.

Finally, the promotion of fake AIDS cures undermines HIV prevention. People who believe in a cure are less likely to fear becoming infected with HIV, and hence less likely to take precautions.
Why is it so difficult to cure AIDS?

Curing AIDS is generally taken to mean clearing the body of HIV, the virus that causes AIDS. The virus replicates (makes new copies of itself) by inserting its genetic code into human cells, particularly a type known as CD4 cells. Usually the infected cells produce numerous HIV particles and die soon afterwards. Antiretroviral drugs interfere with this replication process, which is why the drugs are so effective at reducing the amount of HIV in a person’s body to extremely low levels. During treatment, the concentration of HIV in the blood often falls so low that it cannot be detected by the standard test, known as a viral load test.

Unfortunately, not all infected cells behave the same way. Probably the most important problem is posed by “resting” CD4 cells. Once infected with HIV, these cells, instead of producing new copies of the virus, lie dormant for many years or even decades. Current therapies cannot remove HIV’s genetic material from these cells. Even if someone takes antiretroviral drugs for many years they will still have some HIV hiding in various parts of their body. Studies have found that if treatment is removed then HIV can re-establish itself by leaking out of these “viral reservoirs”.

A cure for AIDS must somehow remove every single one of the infected cells.
Reputable research on curing AIDS
Activating resting immune cells

Many researchers believe the best hope for eradicating HIV infection lies in combining antiretroviral treatment with drugs that flush HIV from its hiding places. The idea is to force resting CD4 cells to become active, whereupon they will start producing new HIV particles. The activated cells should soon die or be destroyed by the immune system, and the antiretroviral medication should mop up the released HIV.

Early attempts to employ this technique used interleukin-2 (also known as IL-2 or by the brand name Proleukin). This chemical messenger tells the body to create more CD4 cells and to activate resting cells. Researchers who gave interleukin-2 together with antiretroviral treatment discovered they could no longer find any infected resting CD4 cells. But interleukin-2 failed to clear all of the HIV; as soon as the patients stopped taking antiretroviral drugs the virus came back again.1 2

There is a problem with creating a massive number of active CD4 cells: despite the antiretroviral drugs, HIV may manage to infect a few of these cells and replicate, thus keeping the infection alive. Scientists are now investigating chemicals that don’t activate all resting CD4 cells, but only the tiny minority that are infected with HIV.

One such chemical is valproic acid, a drug already used to treat epilepsy and other conditions. In 2005 a group of researchers led by David Margolis caused a sensation when they reported that valproic acid, combined with antiretroviral treatment, had greatly reduced the number of HIV-infected resting CD4 cells in three of four patients. They concluded that:

“This finding, though not definitive, suggests that new approaches will allow the cure of HIV in the future.”3

Sadly, it seems such optimism was premature; more recent studies suggest that valproic acid has no long term benefits.4 5 In fact it’s quite possible that all related approaches are flawed because the virus has other hiding places besides resting CD4 cells. There is a lot about HIV that remains unknown.
Bone marrow transplants and gene therapy

In November 2008, a pair of German doctors made headlines by announcing they had cured a man of HIV infection by giving him a bone marrow transplant.6 The transplant - given as a treatment for leukemia - used cells from a donor with a rare genetic mutation known as Delta 32 that confers resistance to HIV infection. Twenty months after the procedure researchers reported they could find no trace of HIV in the recipient's bone marrow, blood and other organ tissues.

Other experts have said that more tests are required to verify this cure claim,7 though it is not the first of its kind. Of more than thirty HIV positive patients given bone marrow transplantation prior to 1996, two appeared to have been cured of their infection based on molecular testing and post-mortem biopsy samples.8 9

Even assuming it can be effective, bone marrow transplantation is too dangerous and costly for widespread use as a cure. Many patients die as a result of chemotherapy or reactions to the transplant, which is usually a last resort in treating life-threatening diseases. As Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, put it:

“It’s very nice, and it’s not even surprising. But it’s just off the table of practicality.”10

Nevertheless the German transplant does raise hope for related approaches. If scientists can find another way - such as gene therapy - to confer the same sort of protection against HIV as Delta 32 provides, then they may be able to stop the virus replicating. Research in this area is in its very early stages; it may be many years before a useful treatment is found, if at all.
Hope for the future

Some of the world’s top research institutions are today engaged in studies to learn more about the behaviour of HIV, resting CD4 cells and other hiding places. But the truth is that this field does not receive a lot of funding. Some people think the search for a cure is not worth much investment because the task may well be impossible.

Yet there are still those who remain hopeful, including the research charity amfAR, which in 2006 awarded nearly $1.5 million to AIDS cure researchers. Activist Martin Delaney is among those calling for an end to defeatism:

“Far too many people with HIV, as well as their doctors, have accepted the notion that a cure is not likely. No one can be certain that a cure will be found. No one can predict the future. But one thing is certain: if we allow pessimism about a cure to dominate our thinking, we surely won’t get one… We must restore our belief in a cure and make it one of the central demands of our activism.”11

How to spot fake AIDS cures and treatments

As already stated, there is no proven cure for AIDS. The best advice is to steer clear of anyone claiming otherwise. For those who find themselves tempted, here are a few pointers for spotting quack therapies.
Who makes the claims?

Try to find some information about the person or people promoting the product. What are their credentials? If someone claims to be a doctor then they should say what type of doctor, and where they got their qualifications.
What claims do they make?

Look at how the product is presented. Reputable scientists and doctors don’t use sensational terms such as “miracle breakthrough”. Also watch for evidence of poor scientific understanding; for example, no expert would refer to HIV as “the HIV virus” or “the AIDS virus”.

It is very rare for a medicine to be 100% effective for all patients. It is highly implausible that a single product could cure a wide range of unrelated diseases such as cancer, asthma, AIDS and diabetes. A real scientist would be extremely wary of making such claims.
What’s in the cure?

Many inventors won’t reveal what goes into their so-called cures. Ask yourself why this might be. Could it be that their methods wouldn’t stand up to scientific scrutiny?

It is important to remember that words like “natural” and “herbal” are no guarantee of safety. After all, hemlock and ricin (derived from castor beans) are both entirely natural and extremely toxic. As the U.S. Food and Drug Administration points out,

“Any product – synthetic or natural – potent enough to work like a drug is going to be potent enough to cause side effects.”12

What evidence do they offer?

To gain the approval of medical authorities, any new treatment must undergo very extensive testing. Countless products destroy HIV in the laboratory but are ineffective or dangerous when used by people. A proper trial involves a large group of volunteers divided randomly into two sets. One half uses the test product and the other receives a placebo (a harmless pretend medicine that looks like the real thing). During the trial, neither the scientists nor the volunteers should know who is getting which treatment. Afterwards, the results for the two groups are compared to see if the test product performed better than the placebo.

Virtually all promoters of “AIDS cures” cannot provide any data from large-scale, randomised human trials. Instead they rely on anecdotes, personal testimonies, laboratory experiments or small-scale trials with no placebo comparison. This type of evidence is always unreliable.

Personal testimonies are notoriously untrustworthy. Usually there is no way of knowing whether the people in question ever existed, let alone whether they were helped by the therapy. There have been cases of people being paid to pretend they’ve been cured. And even if a handful of people really did get better after they took the treatment, this doesn’t necessarily mean that it works; the improvements may just have been a coincidence. Many negative reports may have been left out of the promotional material.

Proving that HIV has been eradicated isn’t easy. Changes in symptoms or weight gain are not sufficient, and neither is a viral load test. Even if the test can’t detect HIV in the bloodstream (perhaps because the person has been on antiretroviral therapy), this doesn’t mean the virus has been cleared from all parts of the body. Much more thorough investigation is needed.
Beware of conspiracy theorists

Many sellers of fake medicines fall back on conspiracy theories to explain why their products haven’t undergone proper testing. They say that government agencies and the medical profession seek to suppress alternative treatments to safeguard the profits of the pharmaceutical industry.

This kind of allegation is a sure sign of a charlatan. In reality, leading scientists investigate all kinds of therapies that can’t be patented. For example, the U.S. government has funded research into using generic drugs (such as valproic acid) and human hormones (such as interleukin-2) as aids to ridding the body of HIV infection.
Do some research

Any important medical breakthrough will be reported in peer-reviewed journals such as Nature, Science or The Lancet. The mainstream media will pick up the story and leading experts will express their opinions.

Simply typing the name of a supposed cure into an Internet search engine and reading some of the resulting web pages will quickly establish whether it has widespread support. It is also worth searching an online medical database such as PubMed for scientific studies and reviews.
Consult an expert

Always talk to a doctor or other health professional before trying any medical treatment. If you need more information or a second opinion, try contacting a reputable health organisation or telephone helpline. Several American states have AIDS Fraud Task Forces dedicated to combating quackery, and local Food and Drug Administration offices can provide details of any action taken against a product or its manufacturer. Similar agencies operate in most other parts of the world.
Examples of false or unproven cures

What follows is a list of some products and methods that have attracted attention in recent years. It is safe to say that none of these is a cure for AIDS. Many of these so-called remedies are likely to do more harm than good.
President Jammeh’s AIDS cure

President Jammeh of The Gambia, a small country in West Africa, made a dramatic announcement in January 2007:

“I can treat asthma and HIV/AIDS and the cure is a day’s treatment. Within three days the person should be tested again and I can tell you that he/she will be negative... The mandate I have is that HIV/AIDS cases can be treated on Thursdays. That is the good news and the bad news is that I cannot treat more than ten patients every Thursday.”13

Three weeks later the president’s office released the results of viral load tests conducted on the first batch of patients. According to the official statement, “the herbal medicine and therapy administered by President Jammeh have yielded results beyond all reasonable doubts, that they are effective and can cure AIDS.”14 On closer inspection, however, the findings were far from convincing.

Of the four patients with HIV-1, one had a very high viral load, one high, one moderate, and one undetectable. Of the four patients with HIV-2, one had a low viral load and three had less than the detectable level.15

The fact that half of the patients still had detectable virus in their blood shows that the president’s cure cannot be 100% effective. More importantly, as already noted, an undetectable viral load does not prove that HIV has been eradicated. Some of the patients had previously been taking antiretroviral therapy, which often renders the virus undetectable. Apparently no evaluation was done before the president’s treatment began.

The viral load tests were conducted at a university in Dakar, Senegal, using samples of the patients’ blood. It has since emerged that the scientists who ran the tests were unaware of the samples’ origin. The Senegalese experts rebutted the president’s interpretation of their findings:

“There is no baseline ... you can’t prove that someone has been cured of AIDS from just one data point. It’s dishonest of the Gambian government to use our results in this way” Dr. Coumba Toure Kane16

“The interpretation by the Gambian authorities of the results of HIV antibody and viral load testing on blood samples sent to my laboratory is incorrect... Of those samples that were HIV-positive (66.66%), none could be described as cured.” Professor Souleymane Mboup17

The results of a second set of viral load tests, conducted by the National Institute of Hygiene in Morocco, were released in March 2007. For the first set of patients the numbers were similar to those found in Senegal. Among 31 other patients only six had undetectable viral loads.18

Clinical data for the third and fourth batch were released in October 2007. On this occasion the State House chose to withhold the name of the country in which the samples were tested. Twenty-seven of the seventy patients were found to have undetectable viral loads. Another twenty-seven had viral load counts above half a million, which is considered to be very high. The CD4 counts for twenty-seven of the seventy patients were below 200, which means they had progressed from HIV infection to AIDS. Curious repetitions within the viral load count data cast doubt on their accuracy.19

At least two of the president’s patients are known to have died.20

These unpromising outcomes have not shaken the president’s belief in his treatment, which is endorsed by the Gambian health ministry and is administered at state hospitals. President Jammeh, who has no medical qualifications, refuses to disclose exactly what goes into his cure. All he has revealed is that it involves seven herbs, “three of which are not from Gambia.”21 The treatment involves a green paste and a grey liquid each applied to the patient’s skin, and a yellowish tea-like drink. Even more important, according to President Jammeh, is the power of prayer:

“For everything that we do 90% we have to invoke the name of almighty Allah, and then 10% is what the herbs take care of.”22

Leading AIDS experts have expressed great concern about President Jammeh’s exploits. According to Dr. Pedro Cahn, President of the International AIDS Society:

“It is premature and unethical to label this product a cure if it has not been thoroughly tested and proven. Furthermore, to take patients off potent combination antiretroviral therapy, which has saved millions of lives since its introduction in 1996, is shocking and irresponsible.”23

A fifth batch of patients began treatment in February 2008.24 As of August 2008, the president was treating 122 people.25
Other herbal cures

Herbal mixtures comprise the most popular form of alternative AIDS therapy. Although it is possible that some of these treatments may benefit people with HIV, none is a proven cure.

* Comforter’s Healing Gift, a South African company, produces an extract of a plant called sonneblom (not sunflower). According to Freddie Isaacs, the inventor of the treatment and a co-director of the company, this product is a cure for AIDS.26 Other spokespersons have said such claims go against company policy, and the product should be described as a nutritional supplement until it has undergone proper testing. According to some reports one of South Africa’s leading attorneys, Christine Qunta, is closely connected with Comforter’s Healing Gift. South Africa’s opposition party has laid a charge against Qunta of authorising the sale of an unlicensed medicine.27
* Dr. Sebi (born Alfredo Bowman) says his “electric foods” can cure AIDS, cancer and many other illnesses. Sebi, who has offices in Honduras and the USA, has no medical qualifications and many of his views are totally at odds with basic principles of mainstream science. In Sebi’s opinion, AIDS (like all other diseases) occurs when “the mucous membrane has been compromised”.28 He says his plant extracts cure the illness by removing the mucous. Sebi was arrested in 1987 and again in 1997 for publishing false health claims and practising medicine without a licence.29 30 He has published no verifiable evidence to support his “AIDS cure”.
* IMOD was developed by scientists from Russia and Iran. When the Iranian government unveiled the drug in February 2007, many media sources, including Iran’s Fars News Agency, described IMOD as an “AIDS cure”.31 The official IMOD website makes no such claim, but does say that human trials of the drug found it increased CD4 counts in HIV positive people.32 No study reports have been published in medical journals. The research team did not respond to emails from the author of this article.
* Khomeini (or Khomein or Comein) was invented by Professor Sheik Allagholi Elahi of Iran, who set up a clinic in Uganda to sell this so-called AIDS cure for more than $1,500 per patient. The Ugandan Ministry of Health appointed a team of experts to monitor some of the few hundred people taking the treatment. After their study showed Elahi’s claims to be false, the government banned the use and distribution of Khomeini in April 2006, and Ehahi was arrested.33
* MAB Formula One and MAB Formula Two were developed by Ghanaian doctors and ethno-botanists led by Dr. Jacob Akumoah-Boateng. According to the researchers MAB Formula One kills HIV while MAB Formula Two boosts the immune system. Dr. Akumoah-Boateng says tests in the U.S. demonstrated the disappearance of HIV and HIV antibodies after the treatment was given, though none of the findings have been published in the medical literature.34
*
Ubhejane bottles on a shelf

The fake AIDS cure Ubhejane on sale in a South African pharmacy
Ubhejane, a brown liquid said to be made from 89 herbs, has been taken by many hundreds of HIV positive South Africans. Its creator, Zeblon Gwala, says Ubhejane reduces viral load and increases CD4 counts in HIV positive people. He advises that it should not be taken at the same time as antiretroviral treatment.

Ubhejane has often been referred to as a “cure for AIDS” and Gwala’s employees have reportedly promoted it as such, despite having no evidence from rigorous human trials.35 36 Scientists who have tested Ubhejane in the laboratory have stressed that they haven’t demonstrated any benefits to patients.37 South Africa’s opposition party has attempted to have Gwala prosecuted for fraud.38 In 2008, the Advertising Standards Authority of South Africa demanded the withdrawal of an advertisement stating that Ubhejane boosted immunity and reduced viral load, having found these claims to be unsubstantiated.39

Chemicals

Many people mistakenly believe that what destroys HIV in the test tube must also work in the human body. This is one reason why a number of disinfectants and other chemicals have been wrongly promoted as cures for AIDS.

* Armenicum (also known as iodine-lithium-alpha-dextrin or ILalphaD) is a type of iodophor, a chemical that slowly releases iodine when mixed with water. According to Armenian scientists Armenicum, injected into the bloodstream, acts as an antiretroviral drug by blocking the replication of HIV. They claim to have evidence that the substance reduces viral load and increases CD4 counts in HIV positive people. The inventor of Armenicum, Alexander Ilyen, once said he was convinced it would lead to an AIDS cure.40 No studies of HIV positive people treated with Armenicum have been published in peer-reviewed journals. In a report on an animal experiment published in June 2007 the Armenicum research team admits that, “The systemic therapeutic application of iodophores has not yet been accepted”.41 A BBC investigation of Armenicum in 1999 found that the health of two American men got worse after they took the drug.42 Nevertheless the Armenian government has invested most of its HIV treatment resources in Armenicum, which costs more than three times as much as antiretroviral therapy. By late 2008, ten years after the drug was introduced, around 800 people had taken Armenicum.43
* Colloidal silver is a suspension of extremely tiny silver particles in water. Many websites say this clear, colourless liquid effectively treats a wide range of bacterial and viral infections, including HIV infection. While it is true that colloidal silver kills germs in laboratory conditions, there is no reliable evidence of any benefit in people. Contrary to the claims of many retailers, colloidal silver is not harmless. Regular use can cause an irreversible bluish-grey discolouration of the skin, known as argyria.44 Consuming very large amounts of colloidal silver may lead to neurologic problems, kidney damage, stomach distress, headaches, fatigue, and skin irritation.45 There has been at least one reported case of a man falling into a coma after ingesting colloidal silver.46 In America it is illegal for retailers to make any health claims for this product.47
* Tetrasil (or Imusil) is a substance containing tetrasilver tetroxide. A patent held by Dr. Marvin S. Antelman claims that this simple chemical compound cures AIDS by “electrocuting” HIV.48 Dr. Antelman admits his approach to AIDS is “non-conventional” and he does not trust viral load tests: “Accordingly we have patients who display viral load reduction and those that do not who are nevertheless cured of AIDS”, he has said.49 Tetrasilver tetroxide is more commonly used for disinfecting swimming pools.50 After it was promoted as an AIDS cure in Zambia the government banned Tetrasil because it has no proven benefits for people living with HIV.51 In America it is illegal to promote Tetrasil for the treatment or prevention of any disease.52
* Virodene is based on the industrial solvent dimethylformamide (DMF). In the late 1990s this chemical was touted as a possible cure for AIDS. For several years senior members of the South African government, including Thabo Mbeki, vehemently supported research into Virodene as an AIDS treatment, against the advice of medical experts. South Africa’s drug regulators have long prohibited use of Virodene as it has no proven benefits. Laboratory studies have found that DMF does not destroy HIV or inhibit its replication. The only trial of its effectiveness in humans, conducted in Tanzania, found that Virodene did not reduce viral load and had only marginal effects on the immune system.53 DMF is considered a toxic substance; workers are advised to avoid skin contact with the chemical because it may cause serious liver damage.54 55 Imunoxx, which a Namibian company markets as an immune booster, is essentially identical to Virodene.

Oxygen therapy

* Hydrogen peroxide, diluted in water, is commonly used as a bleach and a disinfectant. Some alternative health practitioners advocate drinking, injecting or bathing in weak solutions of this chemical as a cure for AIDS, flu, cancer and other illnesses. There is no evidence to support these claims. Several people have died as a result of swallowing or injecting hydrogen peroxide.56 57
* Ozone is an unstable form of oxygen gas. Ozone therapy has been proposed as a treatment or cure for many illnesses, including HIV infection. One delivery method is autohemotherapy, which involves removing some of a patient’s blood, exposing it to ozone, and then putting it back into the patient. Alternatives include pumping the gas into the rectum, drinking water containing ozone bubbles (ozonized water, which contains hydrogen peroxide), or injecting the gas into the bloodstream. Studies of ozone autohemotherapy in HIV positive people have found it has no significant effect on CD4 counts and other outcomes.58 59 According to the U.S. Food and Drug Administration, “Ozone is a toxic gas with no known useful medical application in specific, adjunctive, or preventive therapy. In order for ozone to be effective as a germicide, it must be present in a concentration far greater than that which can be safely tolerated by man and animals.”60 It is illegal for retailers in America to make any health claims for ozone generators.

Electrical zappers

* Dr. Hulda Clark (who is not a licensed medical doctor) promotes a range of products said to cure AIDS including an electrical “zapper” which, by generating low voltage electricity, is supposed to kill parasites, bacteria and viruses in the body. No proper studies of the zapper have been conducted. Dr. Clark’s methods of diagnosing HIV are highly unconventional; she believes that HIV comes from intestinal worms in the presence of benzene, and that HIV can be found in snails.61 It is therefore doubtful whether the people she claims to have cured of HIV infection were ever really infected.62 Dr. Clark left America after being taken to court for practising medicine without a licence.63 She now runs a clinic in Tijuana, Mexico, where she has also run into trouble with the authorities.64
* The Bob Beck Protocol involves a set of therapies devised by the late Dr. Bob Beck (who was not a medical doctor) that are supposed to cure AIDS, cancer and all other diseases. The four components are electric currents, magnetic pulses, colloidal silver and ozonized water. There is no good evidence that electricity can cure any infection. Claims about the healing powers of Bob Beck’s devices are based entirely on test tube studies and unverifiable anecdotes.

Immune boosters

Some so-called AIDS cures are meant to stimulate the human immune system. Since HIV makes new copies of itself by infecting active immune cells, there is a real danger that such therapies will hasten the spread of the virus rather than contain it.

* Dr. Gary R. Davis got his idea for an AIDS cure from a goat that appeared in his dreams. The late Dr. Davis never prescribed his goat serum treatment (known as BB7075) to HIV positive Americans due to legal restrictions. In 1998 one young girl, Precious Thomas, was given the serum by her mother, who stole it from Davis’ office. Some websites say the girl was cured of HIV infection, based on a viral load test conducted soon afterwards.65 In a 2006 interview, however, Precious Thomas made clear that she was still infected with HIV.66 After being denied approval in America, Dr. Davis and his associates tried to conduct goat serum trials in Ghana. Again he was stopped because “the supporting evidence for asking for registration and use of the serum was totally inadequate”.67 In late 2006, a few months before Dr. Davis’ death, the BBC exposed an attempt by a British company to test the substance on dozens of people in Swaziland, despite the lack of toxicity tests and other necessary preliminary studies.68
* The Antidote – a drug derived from a crocodile protein – has been promoted via spam email and websites with the promise that “It kills all known deadly viruses and bacteria in the body”.69 Absolutely no scientific evidence has been offered to support this claim.
* V-1 Immunitor (or V-AIM or Immureboost) is a pink pill containing antigens taken from the pooled blood of HIV positive people. A clinic in Thailand began distributing V-1 in 2001. Demand soared when the pill’s inventor, Vichai Jirathitikal, said it had eliminated HIV in two patients.70 The Thai Ministry of Public Health responded by conducting a study of those receiving V-1; the findings were not encouraging. According to a government minister, “the pill does not have any effect on the body’s immune system, white blood cell count and amount of the virus in the blood”.71 Other studies of the so-called vaccine – all carried out by employees of its manufacturer – do not provide convincing evidence of benefit. AIDS patients treated with V-1 typically survive for a matter of weeks, as opposed to the years achieved through antiretroviral treatment.72 Although the company has said that people treated with V-1 have “serodeconverted” from HIV-positive to HIV-negative,73 this claim is based on unreliable evidence and is not taken seriously by the scientific community.74 The manufacturing and sales licences for V-1 in Thailand were revoked in April 2003.75 76 Apparently undaunted, Vichai Jirathitikal and a company called Immureboost have continued to promote the product under the new name V-AIM, describing it as a therapeutic vaccine rather than a cure for AIDS.77

Faith-based cures

Religious bodies have done much to help the response to AIDS, especially by caring for the sick. Sadly a small minority of religious leaders have abused the trust placed in them by promising to cure AIDS through faith, sometimes in exchange for money or gifts. Most reports come from sub-Saharan Africa, where evangelical Americans are among those implicated.78

One of the most startling examples of recent times concerns an Ethiopian church where thousands of HIV positive people have sought a cure in showers of holy water. At one time, pilgrims were told to trust in faith alone and to refuse medication.79 Church patriarch Abune Paulos has since endorsed the use of antiretroviral treatment:

“What we are saying is taking the drugs is neither a sin nor a crime. Both the Holy Water and the medicine are gifts of God. They neither contradict nor resist each other.”80

The virgin cleansing myth

The myth that sex with a virgin can cure sexually transmitted diseases has a long history in Europe and elsewhere. Since the emergence of the AIDS epidemic, there has been much concern that this belief might encourage the rape of children, especially in Africa where HIV is widespread. A number of horrific reports in the popular press have fuelled such anxiety.
road sign

A road sign in Zambia confronting the "virgin AIDS cure myth"

Belief in the virgin cleansing myth has been reported from Africa, Asia, Europe and the Americas. There is no doubt that it has led to abuse of not only children but also the disabled (who are often assumed to be virgins).81 Nevertheless, the scale of the myth’s impact is disputed because it is not the only motivation behind child rape.82 83 In many cases the goal is more likely to be prevention than cure: men are seeking partners who are less likely to have HIV.

Thankfully efforts are being made to dispel the virgin cleansing myth around the world. But to effectively clamp down on child rape, such campaigns must be accompanied by changes to the cultural and legal environment that enables abuse to take place.
Spontaneous cures: Andrew Stimpson

Occasionally there are reports of HIV seeming to vanish for no obvious reason. One especially sensational story broke on 13th November 2005, when two British newspapers reported that a 25-year old Scot, Andrew Stimpson, had become the first person to be cured of HIV infection.84 85

In interviews with the two papers, Stimpson said he first suspected he might have HIV in 2002, after several weeks of feeling tired and feverish. Knowing his partner had been HIV positive for a number of years, Stimpson visited the Victoria Sexual Health Clinic in London for an HIV antibody test in May. The result was negative, but he was encouraged to return for further tests, as HIV antibodies often do not appear in the blood until several weeks or even months after initial infection.

In August 2002, Stimpson returned for three more HIV antibody tests. His first, taken on the 15th, was “indeterminate” (i.e. neither definitely positive nor negative), but the following two (taken on 20th and 23rd August) both found him to be HIV antibody positive. However, a viral load test showed the amount of virus in his blood was low, so he was not prescribed antiretroviral therapy. He made a personal choice to start taking multivitamin and mineral tablets and other dietary supplements.

For fourteen months Stimpson remained surprisingly healthy, so much so that, in October 2003, his doctor offered him a repeat test for HIV antibodies. Remarkably, the test came back negative. Two more, carried out in December 2003 and March 2004, also gave negative results.

Andrew Stimpson tried to launch a legal case against the Chelsea and Westminster NHS Trust (CWT) which had tested him, assuming his results had been mixed up with those of another client. The blood samples associated with his original positive diagnosis and his subsequent negative results were retested, and the DNA from the samples compared to his. All the samples were found to belong to Stimpson, and retesting produced the same “positive then negative” antibody results. According to Stimpson:

“After the repeat tests my doctor came into the room saying, ‘You’ve cured yourself! This is unbelievable.’”86

Andrew Stimpson’s story became an overnight media sensation. But a statement from the CWT cast doubt on the cure claims:

“It is probable that there was never any evidence of Mr Stimpson having the HIV virus but rather that there was transient evidence of an antibody response to the virus present in his bloodstream when he had the initial tests... The antibody testing is exquisitely sensitive and the smallest measure can be recorded which is probably what happened in this case.”87

A spokesperson for the CWT later said they had not categorically stated that Andrew Stimpson’s case was an example of a false positive test result, but that it was one of a number of scenarios that needed to be considered.88 The media quickly accepted the “false positive” explanation, and by the end of the month the story had ceased to be of interest to them.

The only news since then dates from June 2006, when the Guardian newspaper reported that Stimpson was still working with doctors, but that because of medical confidentiality, very little more was known about the case. However, Anna Maria Geretti, a clinical virologist at the Royal Free Hospital, was willing to speculate:

“These follow-up tests are very complicated. They could take over six months. But personally, I’m sceptical that they will find a cure from this case.”89

The most likely explanation remains the occurrence of a highly unusual false positive antibody test result. This may happen if the test detects a non-HIV antibody (i.e. a similar antibody produced against a different virus) or, theoretically, because there are somehow HIV antibodies present without an actual HIV infection. Occasionally a false positive may be the result of a faulty test, though a second backup test would normally eliminate this possibility.

Although receiving three false positive results would be exceedingly unusual, some scientists believe it is more plausible than a spontaneous cure. In any case it’s extremely unlikely that, as some newspapers suggested, the multivitamins and dietary supplements that Andrew Stimpson took would have had any effect on his “seroreversion” (the process of going from HIV antibody positive to HIV antibody negative). Millions of people living with HIV take multivitamins and minerals; while such supplements may help to maintain good general health, there is no evidence that they can eliminate HIV infection.

AIDS vaccine

An AIDS vaccine does not yet exist, but the idea is undergoing research and development.
Why do we need an AIDS vaccine?

Even a partially effective AIDS vaccine could save millions of lives. Experts have calculated that a vaccine that is 50% effective, given to just 30% of the population could reduce the number of HIV infections in the developing world by more than half over 15 years. More effective AIDS vaccines could cut the infection rate by more than 80%.1

Efforts to develop a vaccine against HIV and AIDS have been underway for many years. In 1996, Dr Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Diseases said:

“Developing a safe and effective vaccine against HIV is critical to our efforts to control the devastating pandemic of HIV and AIDS” 2

This statement is still true today.
So what is a vaccine?

A vaccine is something that teaches the body to recognise and defend itself against viruses or bacteria that cause disease. Vaccines either help to prevent infection, or help to prevent or delay illness in people who are already infected. A vaccine is not the same thing as a cure for AIDS.

Effective vaccines have already been developed for some diseases, such as smallpox, polio and tetanus, and these have saved millions of lives. But there is still no vaccine against HIV, the virus that causes AIDS.
What would be the advantage of an AIDS vaccine?

An AIDS vaccine would have a number of key advantages over today’s HIV prevention options. In particular, the protection offered by a vaccine during sex would not depend on the consent of both partners (unlike condom use), and would not require behaviour change (unlike abstinence). A vaccine would also be invaluable for couples wishing to conceive a child while minimising the risk of HIV transmission.

Children could be given a vaccine before ever being exposed to the virus, and ideally this would protect them from all routes of HIV transmission. Vaccinating large numbers of people would probably require relatively little equipment and expertise, and would be much simpler and cheaper than providing antiretroviral treatment for those already infected.
How might an AIDS vaccine work?
an antibody in contact with an HIV protein

This image shows an antibody (green) in contact with an HIV protein (yellow & red), which is a possible target for AIDS vaccine developers.

An AIDS vaccine could be effective in either of two ways. A “preventive” vaccine would stop HIV infection occurring altogether, whereas a “therapeutic” vaccine would not stop infection, but would prevent or delay illness in people who do become infected, and might also reduce the risk of them transmitting the virus to other people. Although a preventive vaccine would be ideal, a therapeutic vaccine would also be highly beneficial.

The basic idea behind all AIDS vaccines is to encourage the human immune system to fight HIV. The immune system works using a combination of cells and chemicals called antibodies. Early vaccine research focused on teaching the immune system to produce antibodies that would block HIV entering human cells. However, products designed to work this way failed in clinical trials because the antibodies worked only against lab-cultured HIV, not against the wild strains of the virus.

Recent research has focused on encouraging the immune system to produce cells to fight HIV. Nevertheless, many scientists believe such “cell-mediated” approaches will not be very effective on their own, even as therapeutic vaccines. It seems likely that a really effective vaccine will have to take a two-pronged approach involving both cells and antibodies.
Why is it difficult to develop an AIDS vaccine?

Developing an AIDS vaccine is a very difficult challenge for scientists. There are many reasons for this, including:

* Nobody has ever recovered from HIV infection, so there is no natural mechanism to imitate
* HIV destroys the immune system cells that are meant to fight against it
* Soon after infection, HIV inserts its genetic material into human cells, where it remains hidden from the immune system
* HIV occurs in several subtypes, each of which is very different from the others
* Even within each subtype, HIV is highly variable and constantly changing
* There are no good animal models to use in experiments

Can these difficulties be overcome?

There are reasons to be optimistic about the search for an AIDS vaccine, despite the slow progress so far. Vaccines against other diseases took many decades to develop, whereas HIV was only discovered in the mid 1980s. It is therefore much too early to give up hope, especially given the current speed of scientific progress. In the past, some experts doubted the possibility of an effective polio vaccine, yet today polio is close to being eradicated thanks to successful vaccination programmes.

One particular reason for remaining hopeful is that most people remain healthy for several years after becoming infected with HIV, and a small minority have survived as long as 20 years without developing AIDS, even though they never entirely rid themselves of the virus. Also it appears that a few people have some kind of natural resistance to HIV infection, meaning they never become infected despite repeated exposure to the virus. These facts suggest that the immune system can be quite effective at controlling HIV.
Who is supporting research and development?

In 2008, the public, philanthropic and private sectors invested around $868 million in preventive AIDS vaccine research and development.3 The public sector provided around 84 percent, the philanthropic sector accounted for 12 percent, and the commercial sector accounted for the remaining 4 percent. Although funding for vaccine research has increased substantially since 2000, the 2008 contributions were a 10 percent decrease from 2007.4

The quest for an AIDS vaccine is aided by the not-for-profit International AIDS Vaccine Initiative (IAVI), which helps to support and coordinate vaccine research, development, policy and advocacy around the world. In addition an alliance of organisations called the Global HIV/AIDS Vaccine Enterprise exists to coordinate research and promote scientific cooperation and collaboration.
How are the possible AIDS vaccines tested?

Any potential AIDS vaccine must pass through three phases of clinical trials before being judged safe and effective. The first phase usually lasts from twelve to eighteen months, whereas the last phase can take three or four years to complete. In most cases volunteers taking part in the trial must be HIV-negative at the start of the trial, though it is important also to test safety in those who are already infected. Some therapeutic vaccine candidates may be tested on HIV-positive people to see if they can delay disease progression.

* Phase I involves a small number of volunteers to test the safety of various doses
* Phase II involves hundreds of volunteers to further assess safety and, in some cases, positive responses
* Phase III involves thousands of volunteers to test safety and effectiveness

A recent innovation is the Phase IIb trial, a larger form of the Phase II trial that provides some indication of effectiveness.

Trials of AIDS vaccines are made more difficult by the ethical obligation to provide condoms and prevention counselling to all those who take part. Providing such services lowers the overall rate of HIV transmission, which increases the number of volunteers required to produce a significant result.
What vaccine trials have already taken place?
AIDSVAX

The first AIDS vaccine candidate to undergo Phase III trials was called AIDSVAX. Two separate studies were conducted. One had around 5,400 participants - mostly gay American men - while the other involved around 2,500 injecting drug users in Thailand. The vaccine was made from a single HIV protein and was meant to stimulate a protective antibody response. The trials began in 1998 and 1999 respectively, and ended in 2003. No beneficial effect was found in either population group.5
STEP and Phambili

Two Phase IIb trials of a vaccine candidate created by the pharmaceutical company Merck were halted in September 2007. The studies - known as STEP and Phambili - had been expected to produce their first results by 2010. They were stopped when researchers found people receiving the vaccine were no less likely to become infected with HIV than those given the placebo - the version that had no medicinal properties. The STEP trial had started in 2004 in the USA, Canada, Australia, Peru and the Caribbean; the Phambili trial had begun in January 2007 in South Africa.6 7

There is some concern that slightly more HIV infections occurred among people who received the Merck vaccine than among those who took a placebo. The vaccine was delivered using adenovirus type 5, which causes the common cold. It has been suggested that the vaccine may have provoked a different immune response among people who already had some immunity to the adenovirus strain, and that this may have made them more susceptible to HIV infection. This hypothesis - which is supported by laboratory evidence8 - raises questions about the use of adenovirus in future vaccines.9 It has also been noticed that uncircumcised men were four times more likely to become infected with HIV if they received the vaccine than if they received the placebo.10

Following the failure of the trial several other trials were delayed to ensure the design of the trail took into account what had been learnt from the Merck vaccine study.

Leading vaccine researcher Dr. Gary Nabel described the results of the Merck vaccine trial as “a big blow to the field”.11 Nevertheless, Dr. Seth Berkley, President and CEO of the International AIDS Vaccine Initiative, has stressed that the outcomes are not all negative:

“Though the Merck candidate failed, the trial did not. The contribution of the volunteers was not in vain. As a result of their dedication, the field will have new data that will inform future vaccine design, help with the prioritization of candidates in the pipeline and guide decisions on how to best proceed with ongoing and upcoming trials.”12

ALVAC / AIDSVAX trial

In 2006 AIDSVAX was used in another Phase III trial in combination with ALVAC.13 It was hoped that a trial combining AIDSVAX, which promotes the production of antibodies to HIV, and ALVAC, which is designed to stimulate a cellular response to the virus, would prove more effective than the previous AIDSVAX trial.14 The trial recruited 16,402 young adults in Thailand.

The results, published in late 2009, showed that 74 trial candidates who received a placebo became infected with HIV, compared to 51 who had received the vaccine candidate.15 Although further examination produced mixed results, the analysis which the authors claimed was most relevant showed the vaccine prevented HIV infection by 31.2%. Drawing on this statistically significant result, the authors concluded that the trial showed a "modest protective effect of vaccine".16

Opinion differed over the significance of the study. Seth Berkley, of the International AIDS Vaccine Initiative was optimistic:

“The outcome is very exciting news and a significant scientific achievement. It’s the first demonstration that a candidate AIDS vaccine provides benefit in humans. Until now, we’ve had evidence of feasibility for an AIDS vaccine in animal models. Now, we’ve got a vaccine candidate that appears to show a protective effect in humans, albeit partially.” - 17

However, Dr. Otto Yang, an immunologist at University of California, LA, said:

"the results are weak enough that we need to be very careful about assigning too much optimism to them... It seems not so likely that the vaccine really did what it was intended to do". - 18

What vaccine trials are now underway?

By 2009, twenty-nine human trials of preventive HIV/AIDS vaccines were taking place worldwide.19 This number included one Phase II trial; three Phase I/II trials and twenty-five Phase I trials.
How soon could we have an effective vaccine?

“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed.”

- Professor John Mellors

In 1984, at the press conference arranged to announce the discovery of HIV, the US Health and Human Services Secretary Margaret Heckler said she hoped a vaccine against AIDS would be ready for testing in about two years.20

Unfortunately, the problem has turned out to be much more challenging than Secretary Heckler expected. Today’s researchers agree that the quest for an AIDS vaccine still has a long way to go. It is possible that the search could last decades.

“HIV infection has never provided scientists with a proof of concept of predictable protection, which historically has been the guiding principle for successful vaccine development.” – Dr Anthony S. Fauci, Director of NIAID21

The failure of the STEP trial in 2007 in particular has led some scientists to question whether the current approach to AIDS vaccine development has much chance of success, given that it favours products that work in a similar way to the failed Merck candidate.

“The path forward is not clear. I think there is agreement on that. Anybody who talks about a timeline for a vaccine is being silly and uninformed. It will require an incremental process of knowledge, and experimentation, and testing of ideas.” - Professor John Mellors22

The news media regularly announce a new “breakthrough” in AIDS vaccine research. However, most of these stories refer to products in Phase I or Phase II trials, where there has been no evidence of the product actually working in humans. Such stories are realistically talking only about potential breakthroughs.

Few if any vaccines are 100% effective. Most probably the first AIDS vaccines to succeed in trials will offer only partial protection, and these may need to be improved or combined with other products before being suitable for widespread use. Vaccine development is likely to proceed by small, incremental steps; we are unlikely to see an immediate “miracle breakthrough”.
Reaching people in need

If trials conclusively find a particular vaccine to be safe and effective then the next challenge is to distribute it and help people access it. In addition both governments and individuals will need to be convinced that the product is worth investing in. The process of getting a vaccine to all the hundreds of millions of people in need could take many years.

An important consideration is whether a vaccine could undermine the popularity of existing HIV prevention methods, such as condoms. If a product is only partially effective (as is almost inevitable) then experts will have to weigh up the potential risks and benefits very carefully before considering distribution. Upon release of any product, awareness-raising and prevention efforts will need to be redoubled to counter the risk of complacency.
Conclusion

It is very unlikely that HIV and AIDS will ever be eradicated without new scientific developments. Eventually, unless great progress is made in prevention, the number of people living with HIV will outstrip the resources available for treatment. The search for an effective vaccine must therefore be one of the very highest priorities for scientific research.

However, it is not realistic to expect such research to produce a major breakthrough for some time yet, and we should be wary of news stories suggesting otherwise. Any new discovery needs to undergo trials lasting years, and must then be distributed around the world before we will see its full benefits.

There is also a danger that focus will be diverted from existing successful initiatives that require continued funding, such as prevention and antiretroviral treatment programmes.

“The world is jumping into a flurry of excitement about a possible solution many years down the line – nobody seems to be in a similar flurry about the fact that, right now, two out of three people who need ART to stay alive aren’t receiving it.” – Paula Akugizibwe, AIDS and Rights Alliance for Southern Africa23

Millions of lives can be saved using the knowledge and tools already at our disposal, provided the world commits itself wholeheartedly to the cause.

Microbicides

A microbicide for HIV does not yet exist, but the idea is currently being researched and developed.
What is a microbicide?

A microbicide is something designed to destroy microbes (bacteria and viruses) or to reduce their ability to establish an infection. A microbicide for preventing HIV infection would be applied to the vagina or rectum to prevent the virus being passed on during sex.
What are the advantages of HIV microbicides?

A microbicide would share many of the advantages of an AIDS vaccine. It would be especially useful for women unable to insist on their partner using condoms, who might be able to use a microbicide without their partners knowing. However, a microbicide would not be able to prevent all forms of HIV transmission, and would require regular reapplication. Unlike vaccines, an effective microbicide must be made into a commodity that people will want to use regularly, such as a cream, gel or vaginal ring.
How might an HIV microbicide work?

A microbicide could work in at least four different ways:

* Kill or inactivate HIV
* Stop the virus entering human cells
* Enhance the body’s normal defence mechanisms against HIV
* Inhibit HIV replication

It is possible that a microbicide could work in much the same way as a vaccine, so research in one area could benefit the other. Alternatively, a microbicide could work in a similar way to today’s antiretroviral drugs, or it could act like a detergent by disrupting the outer coating of the virus.
What are the challenges in developing HIV microbicides?

There are many chemicals that kill HIV, including undiluted household bleach. But what is needed for a microbicide is something that works against HIV without causing discomfort or irritation. For example, when researchers investigated using the spermicide Nonoxynol-9 as an HIV microbicide they were surprised to find it actually increased the rate of transmission, probably because it caused vaginal lesions and inflammation, which made it easier for HIV to establish an infection, even though Nonoxynol-9 killed the virus in lab tests.1

For a microbicide to become popular, researchers must develop not only the active ingredient but also a microbicide that is socially acceptable, affordable and easy to apply. Ideally it would provide protection for several days or even weeks at a time.

Another major issue is how a microbicide affects sperm. To reach all those in need, scientists will have to develop both contraceptive and non-contraceptive microbicides.
Who is supporting research and development?

In 2008 around $244 million was invested in microbicide research and development - up by 8% on the previous year. About 85% of this money came from the public sector, 14% came from the philanthropic sector and 1% was accounted for by commercial companies (only $2.5 million).2

At present no major pharmaceutical firm is investing significant amounts of its own money in microbicide research because it is complex and the market is uncertain.3 As Professor Jonathon Weber has stated:

"[Microbicides] are perceived as drugs for Africa, and no one makes money from Africa" - 4

How are the possible microbicides tested?

There are three phases of clinical trials that a potential mircobicide must pass through before it is judged effective and safe. Phase I tends to last between twelve and eighteen months, whereas the final phase can take up to three or four years.

* Phase I involves a small number of volunteers to test the safety of various doses
* Phase II involves hundreds of volunteers to further assess safety and, in some cases, positive responses
* Phase III involves thousands of volunteers to test safety and effectiveness

The Phase IIb trial, a recent innovation, is a larger variant of the Phase II trial.

All microbicide trials provide condoms and prevention counselling to all participants, as an ethical obligation. As a result, the overall rate of HIV transmission is lowered, which means more volunteers are needed to produce a significant result. Most volunteers must be HIV-negative at the beginning of the trial, though it is also important to test safety in those who are already infected.
How many microbicides trials are under way?

By 2009, ten HIV microbicide candidates were undergoing trials.5 This included Phase III trials of PRO 2000 and Buffergel and a Phase IIb trial of Tenofovir gel.

* PRO 2000 is a type of entry inhibitor
* Buffergel maintains acidity in the vagina
* Tenofovir gel is based on an antiretroviral drug

There are more than 60 organisations involved in the development of microbicides. This includes sponsors, funders and research groups.6
Which microbicide trials have recently ended?

In August 2006, Family Health International decided to halt a Phase III trial of a surfactant called SAVVY after preliminary results showed no evidence of a protective effect. The organisation has no plans to further investigate this product.7
A computer-generated image of HIV exiting a cell

A computer-generated image of HIV exiting a cell

Two Phase III trials of an entry inhibitor called cellulose sulphate (also known as Ushercell) were halted in January 2007 after some sites recorded a higher HIV infection rate among women who used the gel, compared to those who were given a version that had no medicinal properties (a placebo). This result led to speculation that the gel may have increased the risk of HIV transmission. Later analysis indicated that the higher infection rate may have been due to chance.8

In February 2008, researchers announced the results of a Phase III trial of Carraguard, an entry inhibitor based on carrageenan, which is derived from seaweed. The product - the first ever to complete Phase III testing - was shown to be safe, but had no significant effect on HIV transmission.9

Also in February 2008, it was decided that the largest PRO 2000 trial should stop testing a higher strength version of the product because it was unlikely to be beneficial. A weaker version was investigated, but in 2009 the results did not reach a level of statistical significance.10 11 Results from a much larger study of PRO 2000, sponsored by the Medical Research Council and the Department for International Development in the United Kingdom, are expected in late 2009.
Conclusion

If one of the microbicide candidates were successful in preventing HIV infection, it would be a while before it would become widely available. Any successful product would have to undergo review and licensing by regulatory agencies before becoming available to the public. It would take time to work out the best formulation and dosage; find a suitable delivery method; and distribute the product. Also, if an effective product is produced it may be difficult finding investors, as the microbicide will have to be available to women in low- and middle- income countries and therefore profit margins will be low.12 In addition, any successful microbicide will only be partially protective and so would have to be complemented with other prevention methods.13

Whilst it is important to ensure continued funding and support for microbicide development, it would not be helpful to be overly optimistic about the effectiveness and potential availability of such a product. A microbicide will not be a ‘silver bullet’ for ending the epidemic, but rather another tool to add to existing prevention efforts.

History of AIDS

2009-12-03T04:40:00.003-08:00

These are some of the most important events that occurred in the history of AIDS over the period 1987-1992.
1987 History

At the beginning of January the UK Secretary of State for Social Services, Norman Fowler, visited San Francisco, and in a widely publicised visit shook hands with an AIDS patient. It was suggested that Princess Diana should follow his example, which she did later in the year.1 2

A leaflet about AIDS was delivered to every household in the UK, and the British Government also launched a major advertising campaign with the slogan "AIDS: Don't Die of Ignorance", and with the secondary advice:3 4

The ‘tombstone’ AIDS advert that was aired in 1987 in the UK. ©

"Anyone can get it, gay or straight, male or female. Already 30,000 people are infected." 5

In February there was a general media "AIDS week", when there were numerous TV and radio programs on AIDS in the UK.6 Many other countries also had education campaigns.

By this time, the World Health Organisation had been notified of 43,880 cases of AIDS in 91 countries.7

The first HIV case was officially recorded in the Soviet Union, and a massive HIV testing programme was conducted.8

Meanwhile in San Francisco, gay rights activist Cleve Jones made the first panel for the AIDS Memorial Quilt in memory of his friend Marvin Feldman.9

"The Names project is a campaign to provide memorials to those lives by creating a huge quilt made up of individual panels, each 3 by 6 feet, that have been made by families friends and co-workers of those who died. Each of the nearly 3000 panels, which have come from all over the country, bears the name of a victim of acquired immune deficiency."10

In March the U.S. Food and Drug Administration (FDA) approved AZT as the first antiretroviral drug to be used as a treatment for AIDS.11

Around the same time the organisation ACT UP (the AIDS Coalition to Unleash Power) was founded. ACT UP was committed to direct action to end the AIDS crisis, and their demands included better access to drugs as well as cheaper prices, public education about AIDS and the prohibition of AIDS-related discrimination. On 24th March they held their first mass demonstration on Wall Street.12
Silence=Death, gay protest

'Silence=mort' is the French language version of 'Silence=Death'.

Many of the placards used in ACT-UP's demonstrations carried the graphic emblem "SILENCE=DEATH". Created in 1987 by a group of gay men calling themselves the Silence=Death project, the emblem was leant to ACT-UP and for many Americans it became the symbol of AIDS activism.13

One ACT-UP committee used the emblem in a window display called "Let the Record Show" at the New Museum of Contemporary Art in New York; afterwards they regrouped as Gran Fury:14

"a band of individuals united in anger and dedicated to exploiting the power of art to end the AIDS crisis"15

Over the next few years Gran Fury produced many high profile public projects including the art banner announcing "Kissing doesn't kill: Greed and indifference do" and the poster "AIDS: 1 in 61" about babies born HIV positive in New York City.16

On the other side of the world, in Australia, the Grim Reaper education campaign was launched, with television images of death mowing down a range of victims in a bowling alley. Although widely criticised at the time, the advertisements did succeed in ensuring widespread discussion of AIDS.17

The Australian AIDS commercial from 1987.

"A bowling alley of death, haunted by decomposing grim reaper bowling over men, pregnant women, babies and crying children was featured on national television last night as the part of a $3 million AIDS education campaign, The 60-second commercial featuring the grim reaper, a macabre and dramatic rotten corpse with scythe in one hand and bowling ball in the other, is spearheading efforts by the National Advisory Committee on AIDS to educate Australians about the incurable disease."18

On 31st March, at a ceremony at the White House attended by President Reagan, it was announced that an agreement had been reached regarding ownership of the HIV antibody test patent. The Pasteur Institute agreed that it would end its legal challenge, and would share the profits from the test with the U.S. Department of Health and Human Services.19 Although the agreement officially resolved the question of who had invented the HIV antibody test, it did not address the question of who had discovered HIV and identified it as the cause of AIDS. It was generally agreed that:

"historians can decide who found the AIDS virus first."20

But to many people it appears clear that HIV was isolated in Paris a year before it was isolated in the USA.21

The following day President Reagan made his first major speech on AIDS, when he addressed the Philadelphia College of Physicians. Reagan advocated a modest federal role in AIDS education, having told reporters the previous day that he favoured teaching pupils about AIDS,
Kissing doesn't kill advert

Poster "Kissing doesn't Kill: Greed and indifference do" Gran Fury collection

"as long as they teach that one of the answers to it is abstinence - if you say it's not how you do it, but that you don't do it."22

In England the first specialist AIDS hospital ward was opened by Princess Diana. The fact that she did not wear gloves when shaking hands with people with AIDS was widely reported in the press.

"she shook my hand without her gloves on. That proves you can't get AIDS from normal social contact."23

The WHO Global Programme on AIDS had developed a Global AIDS Strategy, which was approved by the World Health Assembly in May. The Global AIDS Strategy established the objectives and principles of local, national and international action to prevent and control HIV/AIDS, and it included the need for every country to have a "supportive and non-discriminatory social environment".24

But on 31st May President Reagan gave a speech about AIDS at a dinner of the American Foundation for AIDS Research and particularly focused on increasing routine and compulsory AIDS testing.25
Australian Grim Reaper advert

Grim Reaper (Australian AIDS campaign) circa 1987

The following day Vice President George Bush opened the 3rd International Conference on AIDS in Washington and was booed by the audience when he defended President Reagan's HIV testing proposals. Demonstrators against the administration's policies were arrested outside the White House by police wearing long yellow rubber gloves.26

"On the nightly news broadcasts, the world saw pictures of demonstrators being arrested by police wearing bright yellow, arm-length gloves. Although research had by now proved that the AIDS virus could not be passed through casual contact, the sight of the gloves served to reinforce the public's general overestimation of the risk of HIV transmission."27

In June the U.S. Public Health Service added AIDS to its list of diseases for which people on public health grounds could be excluded from the USA.28 Subsequently in July the "Helms amendment" created by Senator Jesse Helms added HIV infection to the exclusion list.29 Few foresaw the implications of the addition and it went virtually unnoticed.30

In July the WHO reviewed the evidence and confirmed that HIV could be passed from mother to child through breastfeeding. Nevertheless they recommended that HIV positive mothers in developing countries should be encouraged to breastfeed, as in many circumstances safe and effective use of alternatives was impossible.31

In light of more widespread HIV testing, the CDC revised their definition of AIDS to place a greater emphasis on HIV infection status.32

Prejudice against people with HIV continued in America. The Ray family lived in Arcadia, Florida, and they had three sons, each of whom was a haemophiliac and was HIV positive. During 1986 the family was told their sons could not attend school. In 1987 the family moved to Alabama, and once again they were refused entry to school. Threats against the family grew louder and more frequent, and on August 28th the Rays' small single-storey house was doused with gasoline and torched.33

In England, the UK Government expanded syringe exchange schemes to prevent transmission of HIV through drug use, and also launched an advertising campaign with the message 'Don't inject AIDS'.34

In the autumn, a book by Randy Shilts called 'And the Band Played On' was published, which chronicled the early years of the AIDS epidemic.35 Shilts' book made an important contribution to documenting the history of AIDS, but his view of "the facts about AIDS", as well as his opinions, differ greatly from others on a number of occasions.36

Shilts was the first to identify a French-Canadian flight attendant called Gaetan Dugas as 'Patient Zero'. Shilts claimed that Gaetan Dugas played a key role in the early spread of AIDS in America, and the story of 'Patient Zero' was widely publicised by the media.37 But there never was a Patient Zero.
1 in 61 advert

Poster "AIDS: 1 IN 61" Gran Fury collection

"There's no Patient Zero. It's lots and lots people moving around from New York to San Francisco, and the rest of the world. If there ever was an original Patient Zero, it would have been back in the mid-Seventies. But there isn't an original Patient Zero." - Andrew Moss38

In Africa, President Kaunda of Zambia announced that his son had died of AIDS, and appealed to the international community to treat AIDS as a worldwide problem.39 In Uganda, 16 volunteers who had been personally affected by HIV/AIDS came together to found the community organisation TASO.40

In October, AIDS became the first disease ever debated on the floor of the United Nations (UN) General Assembly. The General Assembly resolved to mobilize the entire UN system in the worldwide struggle against AIDS, under the leadership of the WHO.41

The American scientist Dr. Peter Duesberg published a scientific paper in a cancer journal that questioned the then dominant theory that viruses were involved in cancer causation, and also queried the link between HIV and AIDS.42 In November, Channel 4 broadcast the documentary 'AIDS: the Unheard Voices' to its British audience. In the documentary Duesberg and others argued that HIV could not be the cause of AIDS.43

By December, 71,751 cases of AIDS had been reported to the World Health Organisation, with the greatest number reported by the USA (47,022). Countries reporting over 2,000 cases included France (2,523), Uganda (2,369) and Brazil (2,102). Five other countries reported more than 1,000 cases: Tanzania (1,608), Germany (1,486), Canada (1,334), UK (1,170) and Italy (1,104).

The WHO also reported that an estimated 5 to 10 million people were infected with HIV worldwide, with 150,000 cases of AIDS expected to develop in the following 12 months and up to 3 million within the next 5 years.44
1988 History
1988 World AIDS day logo

As the global mobilisation against AIDS continued, a world summit of ministers of health was held in London to discuss a common AIDS strategy. The summit focused on programmes for AIDS prevention, and there were delegates from 148 countries.

One outcome of the meeting was the London Declaration on AIDS Prevention, which emphasised education, the free exchange of information and experience, and the need to protect human rights and dignity.45 The Director-General of the World Health Organization chose this occasion to announce that the WHO intended to promote an annual World AIDS Day, and the first such day would be on 1st December 1988.46

The meeting was opened by the UK's Princess Royal, who upset many people involved in AIDS education, as well as many people with AIDS, when she stated that:
All people with AIDS are innocent

Poster "All people with AIDS are innocent" Gran Fury collection

"the real tragedy concerns the innocent victims, people who have been infected unknowingly, perhaps as a result of a blood transfusion … but possibly, worst of all, those babies who are infected in the womb and are born with the virus."47

If there are "innocent victims", then by implication there are also "guilty victims". This was an unfortunate suggestion to be making at a world meeting on AIDS prevention.

In May the United States finally launched a coordinated HIV/AIDS education campaign.48 The distribution took place of 107 million copies of "Understanding AIDS", a booklet by Surgeon General C. Everett Koop.49 'Understanding AIDS' was the single most widely read publication in the United States in June 1988, with 86.9 million readers.50

The following month the American Medical Association urged doctors to break confidentiality in order to warn the sexual partners of people being treated for AIDS.51

"We are saying for the first time that, because of the danger to the public health and danger to unknowing partners who may be contaminated with this lethal disease, the physician may be required to violate patient confidentiality. The physician has a responsibility to inform the spouse or known partners. This is more than an option. This is an professional responsibility."

AIDS activists conveying the message that every half an hour someone dies from AIDS; Washington DC, 1988

AIDS Activists, Washington DC, 1988

In the USA frustration continued to grow over the slowness of progress in improving access to drugs. When the Presidential Commission on the HIV Epidemic issued its final report in June 1988, it declared that the FDA arrangements were "not meeting the needs of people with AIDS". On October 11th more than 1,000 ACT-UP demonstrators virtually shut down operations at the FDA headquarters.52

Eight days after the ACT-UP demonstration the FDA announced new regulations to speed drug approval.53

The first official needle exchange was started in the US to prevent transmission of HIV through drug use.54 A limited experiment started in November in New York City and, at about the same time, the Prevention Point opened in San Francisco.55 56 But Congress prohibited the use of federal funds to support needle exchange programs.57

On December 1st, the first World AIDS Day took place, with the WHO asking everyone to "Join the Worldwide Effort."58
1989 History

On February 7th, the FDA announced that it was going to approve an aerosol form of the drug Pentamidine for the treatment of PCP (a type of pneumonia) in people with AIDS.59 Much of the data that led to this approval was collected by CCC, the County Community Consortium of San Francisco, with further data collected by another community research organisation called CRI, the Community Research Initiative of New York.60

By March 1st, 145 countries had reported 142,000 cases of AIDS to the World Health Organisation (WHO). The WHO regarded this as under-reporting, and estimated the actual number of people with AIDS around the world to be over 400,000. It was predicted that this figure would rise to 1.1 million by 1991. It was also estimated that 5-10 million people were already infected with HIV.61

On April 2nd, Hans Verhoef, a Dutch man with AIDS, was jailed in Minnesota under the federal law banning travellers with HIV from entering the USA.62 In June a protest against the law took place at the opening ceremony of the Fifth International Conference on AIDS in Montreal, when 250 protestors with placards stormed the stage.63
AZT bottles

Zidovudine, better known as AZT

In August, there were more developments with respect to treatment, when the results were announced of a major drug trial known as ACTG019. ACTG019 was a trial of the drug AZT, and it showed that AZT could slow progression to AIDS in HIV positive individuals with no symptoms at all. The findings were considered extremely exciting, and on August 17th a press conference was held, at which the Health Secretary, Louis Sullivan said:

"Today we are witnessing a turning point in the battle to change AIDS from a fatal disease to a treatable one."

The result had enormous financial implications for the makers of the drug, Burroughs Wellcome. The day after the press conference, the value of the company's stock rose by 32 per cent.64 The high price of AZT angered many people; with a year's supply for one person costing about $7,000, Burroughs Welcome were accused of "price gouging and profiteering".65 66

In September, the cost of the drug was cut by 20%.67

In October the second drug for the treatment of AIDS, dideoxyinosine (ddI), started to be made available to people with AIDS, even though only preliminary tests had been completed.

"It become clear that ddl was not just another drug in terms of need: it was a life-and-death matter, said Richard L. Gelb, chairman of Bristol Myers."68

1990 History

At the beginning of the year, it was reported that a large number of children in Romanian hospitals and orphanages had become infected with HIV as a result of multiple blood transfusions and the reuse of needles. Jonathan Mann, the head of the WHO's Global programme on AIDS, noted that 'Eastern Europe is the new frontier for the AIDS epidemic'.69

In China, 146 people in Yunnan Province near the Burmese border were found to have HIV infection due to sharing needles. This shocked public health officials in China. It was not known whether this was the first sign of an epidemic or an isolated outbreak.70

"AIDS and drug addiction are still seen as consequences of contact with the West, AIDS being known as aizibing, the 'loving capitalism disease'."71

In New York city the needle exchange scheme was closed down.72
Jonathan Mann

Johnathan Mann

Jonathan Mann resigned as the head of the WHO AIDS programme, to protest against the failure of the UN and governments worldwide to respond adequately to the exploding pandemic, and to protest against the actions of the then WHO director-general Dr. Hiroshi Nakajima.73 During Jonathan Mann's leadership, the AIDS programme became the largest single programme in the organisation's history.74 But more importantly:

"Jonathan's persistence and passion helped wake up the world."75

and,

"Had it not been for Jonathan's unique contributions, the world's approach to AIDS might very well have gone towards mandatory testing and quarantine."76

Ryan White

Ryan White, 1971-1990

On April 8th Ryan White died in the United States. He was a haemophiliac infected with HIV through the use of infected blood products. He had become well known a few years earlier as a result of his fight to be allowed to attend public school.77 Just a few months later the Ryan White CARE Act was passed by Congress. The aim of the act was to provide grants to improve the quality and availability of care for individuals and families with HIV disease.78

In the UK and the US, there started to be more discussion about whether there would ever be a heterosexual epidemic because of the difficulty of female-to-male transmission of HIV.79 80 81

In June, a TV programme called 'The AIDS Catch' was screened in the UK, again questioning whether HIV caused AIDS and whether AIDS was infectious or not. The programme provoked a hostile response among the AIDS community and organisations.82 Some people felt that the programme was sensationalist and contained factual inaccuracies. It was also felt that the programme caused significant distress among people with HIV and undermined the efforts carried out in the field of HIV/AIDS prevention.83

Protests against the ban on HIV positive people entering America had continued. Although there had been minor changes to the law, at the time of the 6th International Conference on AIDS in San Francisco in June it was still considered by many to be "discriminatory and medically unsupportable".84 Consequently there was a widespread boycott of the conference, and many people who did speak at the conference took the opportunity to voice their views. One such person was June Osborn, the Chair of the National Commission on AIDS, who said:

"How sorry I am, and how embarrassed as an American, that our country whose tradition serves as a proud beacon for emerging democracies, should persist in such misguided and irrational current policy."85

Many demonstrations took place during the conference week, the most significant being the "United Call to Action", in which activists, scientists, and many others marched together to emphasise the importance of unified action to end AIDS.86
ACTUP protestors at the AIDS conference

ACT-UP protests at AIDS Conference, San Francisco

The International AIDS Society (IAS) announced that no further IAS sponsored conference would be held in a country that restricted the entry of HIV infected travellers.87 As a result of the US travel policy, no major international AIDS conference was to be held in the USA after 1990.

In July the CDC reported the possible transmission of HIV to a patient during a dental procedure. The dentist had been diagnosed with AIDS three months before performing the procedure. The CDC investigation did not identify any other risk factors or behaviours that could have put the patient at risk of HIV infection.88 A couple of months later the patient was named as 22-year old Kimberly Bergalis and the dentist was named as David Acer.89

"When she was diagnosed with AIDS we were in disbelief. All we could wonder was whether something went wrong at the dentists. Health officials said no way, it just can't happen. But Kimberly stuck by her guns and kept telling them to look at the dentist. Eventually the CDC supported her conclusion." - George Bergalis -90

In the UK, Prime Minister John Major announced that the Government would pay £42 million compensation to haemophiliacs infected with HIV and their dependants.91

By the end of the year, over 307,000 AIDS cases had been officially reported to the WHO, but the actual number was estimated to be closer to a million. It was estimated that 8-10 million people were living with HIV worldwide, of whom about 5 million were men and 3 million were women.92
Area Estimated HIV Reported AIDS Estimated AIDS
Africa >5,500,000 77,043 >650,000
N America 1,000,000 156,658 200,000
S America 1,000,000 28,937 90,000
Asia 500,000 843 2,000
Europe 500,000 41,564 50,000
Oceania 30,000 2,334 2,700
Total <9,000,000 307,379 <1,000,000

The 3 million HIV-infected women were estimated to have given birth to around 3 million infants, of whom over 700,000 were likely to have become infected with HIV.
1991 History

At the beginning of 1991 the CDC published a report confirming that, in addition to Kimberly Bergalis, two other patients had probably been infected by the same dentist.93 Such was the public concern about this that America's leading medical and dental associations announced that HIV positive doctors and dentists should warn their patients about their infection status or give up surgery.94 During the summer, in the midst of continuing public hysteria, the CDC also recommended that infected health care workers should be barred from certain procedures.95 96

The largest peak in requests for HIV testing in the UK was observed in January 1991 when the character Mark Fowler, in the BBC television series EastEnders, was diagnosed HIV-positive.97

In the autumn, in a dramatic move, Kimberly Bergalis testified to the US Congress. In what she called her "dying wish", she asked members of congress to enact legislation for mandatory HIV testing of health care workers, to ensure that:98

"others don't have to go through the hell that I have."

But, overwhelmed by opposition from the medical profession, the CDC chose not to recommend mandatory testing, and dropped its plans to list procedures that should not be carried out by HIV positive health workers. Kimberly Bergalis died a few days later.99 100

During the summer, a third antiretroviral drug dideoxycytidine (ddC) was authorised by the FDA for use by patients intolerant of AZT.101

Also during the summer, a study was published which showed that HIV was transmitted much more easily through breast milk than had previously been thought.102 But despite admitting that the news was discouraging, the WHO also said that women in developing countries should continue to breastfeed, as the threat to infant health from contaminated water was even greater than the threat from AIDS.103

The decision was taken to hold the 1992 international AIDS conference in Amsterdam, rather than its planned location in Boston, following the American administration's decision not to lift entry restrictions on HIV-infected travellers.104

A video of Magic Johnson announcing his retirement at a press conference on 7th November 1991

In the USA Earvin (Magic) Johnson announced that he had tested HIV positive and was therefore retiring from professional basketball, on the advice of his doctors. He said that he planned to use his celebrity status to help educate young people about the disease. He also said:

"I think sometimes we think, well, only gay people can get it - it is not going to happen to me. And here I am saying that it happen to anyone, even me Magic Johnson." - 105

A couple of weeks later in the UK, Freddie Mercury, lead singer of the rock group Queen, confirmed that he had AIDS. Just one day later it was announced that he had died.106

In France, haemophiliacs who became infected through infected blood products sued leading medical and government officials. They accused the blood transfusion centres of allowing the use of HIV-contaminated blood, even though tests to screen blood for HIV and techniques to destroy the virus in blood products were available.107 108
AIDS Ribbon

The red ribbon became an international symbol of AIDS awareness during 1991. The organisation Visual AIDS in New York, together with Broadway Cares, and Equity Fights AIDS, established the wearing of a red ribbon as a way of signifying support for people living with HIV/AIDS.109

As the end of 1991, about 450,000 AIDS cases had been reported to the Global Programme on AIDS (GPA) / World Health Organisation (WHO). It was estimated that 5-7 million men and 3-5 million women had been infected with HIV. Of these 9-11 million HIV-infected adults, nearly 1.5 million were estimated to have progressed to AIDS.110
1992 History

The WHO set as a priority target for prevention that, by the year 2000, the whole population at risk from HIV and AIDS in Africa and Asia should live in communities where condoms were both readily available and affordable.111

In the UK, the Department of Health made it an offence to sell, advertise or supply HIV antibody testing kits to the public.112

During 1992, a major UK newspaper ran a series of articles challenging the orthodox view that HIV alone causes AIDS.113

"But suppose the researchers are looking in the wrong place. Suppose HIV doesn't equal AIDS. Then we will have witnessed the biggest medical and scientific blunder this century." - The Sunday Times journalist Neville Hodgkinson114

Many other British newspapers joined the heated debate with journalists, researchers, activists and organisations expressing their opinions about the cause of AIDS.115

"'But what if HIV does cause AIDS? What effect will such articles have on attempts to inform the public on safe sex, or on the people who are suffering from AIDS and taking anti-HIV drugs?" - 116

Tennis star Arthur Ashe announced that he had been infected with HIV as a result of a blood transfusion in 1983.117

Fearful that it was discouraging tourists, a new government in Thailand threatened to scale down the country's extensive AIDS awareness campaign, which had begun in 1991 and won international acclaim. However, the government lost power within weeks and the campaign was restored.118

The FDA approved the use of ddC in combination with AZT for adult patients with advanced HIV infection who were continuing to show signs of clinical or immunological deterioration. This was the first successful use of combination drug therapy for the treatment of AIDS.119

"This new drug is not a cure, said James Mason, M.D., assistant secretary for health and head of the Public Health service, but it constitutes an important addition to the expanding group of antiviral drugs currently available, including AZT and DDI, for treating people with AIDS."

The CDC, under pressure from patients and doctors, decided to revise its definition of AIDS. The previous list of illnesses that defined AIDS had been criticised for some time because it did not include many of the conditions most often seen in HIV positive women and injecting drug users. The new definition would take effect from the start of 1993.120 121

The VIII International Conference was successfully held in Amsterdam rather than in its originally planned venue in Boston due to the U.S. travel policies on HIV positive people.122

In France four health care officials were brought to trial accused of allowing the distribution, between 1980 and 1985, of blood products known to be contaminated with HIV.123 124 The former director of the transfusion service, Michel Garretta, was sentenced to four years in prison, as was Jean-Pierre Allain, the former head of research at the transfusion centre. The third doctor, Jacques Roux, was given a four-year suspended sentence, whilst the fourth doctor was acquitted.125

In response to rising HIV prevalence, the Indian government decided to allocate $100 million to the National AIDS Control project over the next five years, which amounted to more than 15% of the national health budget. Most of this money would come from a World Bank loan.126 Experts predicted that within five years there might be more people affected by AIDS in India than in any other country

These are some of the most important events that have occurred in the history of AIDS over the period 1993-1997.
1993 History

In January it was reported that some people with AIDS already had resistance to the drug Zidovudine (AZT) even though they themselves had never taken the drug.

"Some of the patients may have gotten the virus from other patients who have been taking AZT and who are now transmitting the resistant virus."

Researchers said there was an urgent need to develop new drugs to combat the epidemic.1

On January 6th the Russian ballet star Rudolf Nureyev died. His doctor said that "he died from a cardiac complication following a cruel illness", but it was widely reported that he had died from AIDS.2 3 He was buried in his evening clothes with his medals and his favourite beret.4

During January, 116 new cases of AIDS were reported in the UK, bringing the cumulative total to 7,045. One in 6 of these new cases were acquired through heterosexual intercourse.5
HIV positive Romanian children

HIV-positive Romanian children

In Romania, despite the progress made since the overthrow of the Causescu regime, the number of children infected with HIV had increased. There were an estimated 98,000 infected orphans.6

China had reported one thousand cases of HIV infection, mostly in injecting drug users, but it was believed that this greatly understated the scale of the country's HIV epidemic.7 8 The Ministry of Health in China announced that soon only approved government blood donation centres would be able to collect and sell blood.9

In February the tennis player Arthur Ashe died, less than a year after announcing that he had been infected with HIV.10

In March, the House of Representatives in the USA voted overwhelmingly to retain the ban on the entry into the country of HIV positive people. 11

In South Africa, the National Health Department reported that the number of recorded HIV infections had grown by 60% in the previous two years and was expected to double in 1993. A survey of women attending health clinics indicated that nationally some 322,000 people were infected.12

A video of Princess Diana speaking at an AIDS conference in 1993.

Princess Diana continued her HIV/AIDS advocacy work and spoke at the opening address of the 2nd International Conference on HIV in Children and Mothers in Edinburgh.

"By the year two thousand, only seven years from now - even the most conservative estimates predict there will be more than thirty million people worldwide with HIV - equivalent to more than half the population of the United Kingdom". - Diana - Princess of Wales, 1993

In the UK in March, there were a large number of rather hysterical stories in the British press about the fact that a number of doctors in England had continued to practise medicine whilst knowing they were infected with HIV.13 The UK government responded by issuing new guidelines, according to which health care workers who believed that they had been exposed to HIV had to seek medical advice and testing. 14

Meanwhile scientists had found that HIV 'hides out' in lymph nodes and similar tissue early in the course of infection.15

“The virus lies concealed for a decade or so, quietly seeding the destruction of the immune system, the researchers found. The finding resoundingly solves a mystery of AIDS: where does the virus secrete itself during the decade or so after an initial infection when patients feel well and little virus can be detected in their blood?”16

In early April the ministers of health and finance from 39 countries met in Riga, Latvia, and launched an initiative to contain the spread of HIV in Central and Eastern European countries.17 During the Eighties, many countries of Central and Eastern Europe, the newly independent states, and the Russian Federation had introduced large-scale screening for HIV infection, with in excess of 20 million tests being carried out in the Russian Federation during 1993. One aspect of the Riga initiative was a refocusing of testing policies away from this mass screening and towards voluntary testing.18

A video of Dr R.P. Brettle talking in 1993 about AIDS treatment and the results of the Concorde trial.

The preliminary results were published of the large Anglo-French clinical trial of AZT known as Concorde.19 The results were interpreted as meaning that AZT was not after all a useful therapy for HIV positive people who had not developed symptoms.20

In the UK the radio DJ and comedian Kenny Everett announced that he was HIV positive, as did Holly Johnson, former lead singer with the group Frankie goes to Hollywood.21 22

The World Bank reviewed it activities against AIDS in Africa, and decided that AIDS should not dominate its agenda on population, health and nutrition issues. The World Bank believed that AIDS would have little demographic effect but recognised that it was a serious threat to health and economic development. With reference to blood screening, it was argued that this was costly and "might not be cost-effective under all circumstances".23

The ninth International AIDS meeting was held in Berlin, Germany. The general feeling of the meeting was one of disappointment. The message conveyed by the people who attended was once again to put more money and effort into effective prevention of HIV and AIDS.

“Dr. James W. Curran, who heads the AIDS Programme at the Centers for Disease Control and Prevention in Atlanta, said he left the meeting 'dispirited by the relentless assault of the virus'.”24

At the beginning of the year the CDC had expanded the US definition of AIDS to include people with other opportunistic infections, as well as HIV infected adults with a CD4 count of less than 200. The expert epidemiology group of the European Centre for the Epidemiological Monitoring of AIDS together with the WHO's Regional Office for Europe accepted the inclusion of the additional indicator diseases but not the CD4 cell count criteria. European data collection on this basis began on July 1st.25

In mid-1993 six United Nations organizations, including the WHO, began to seek agreement on forming a novel joint and cosponsored UN programme on HIV/AIDS.26

By this time it had been realised that HIV was also spreading rapidly in the Asia and Pacific regions, home to more than half the world's population, where more than 700,000 people were already believed to be infected.27

A video of Dr. Brettle talking in 1993 about combination therapy.

The drug 3TC was authorised by the FDA in the USA and the Federal Health Protection Branch in Canada, to be used in "compassionate" therapy in people who had not responded to other AIDS treatment or who are not eligible for clinical trials.28 Those patients who had developed a resistance to AZT were offered didanosine (ddI) and dideoxycytidine (ddC) - drugs that had been extensively studied. A number of trials were underway comparing the effectiveness of taking AZT on its own and in combination with ddI and ddC.29

Despite the years of litigation and number of newspaper accounts of the infection of haemophiliacs and transfusion recipients, no formal investigation of what had happened in Germany was undertaken until the 'scandal' of October 1993. In October, the failure of a small German blood supply company called UB Plasma to screen blood and plasma for HIV was made public. The company's misconduct was discovered by the Federal Health Office by chance, as a result of routine examination of positive HIV test results.30 The Federal Government also admitted that officials had covered up 373 cases of HIV-contaminated blood in the 1980s.31

On World AIDS Day, 1st December, Benetton in collaboration with ACT UP Paris placed a giant condom (22 metres high and 3.5 wide) on the obelisk in Place de la Concorde in Central Paris in an effort to waken the world to the reality of the disease. A symbolic monument to HIV prevention, it appeared on the covers of newspapers worldwide.32

At the end of 1993 the estimated number of AIDS cases worldwide was 2.5 million33
Region Estimated Adult HIV infection Estimated adult AIDS cases
Australasia >25000 5000
North America >1 million 400000
Western Europe 500000 125000
Latin America & Caribbean 1.7 million 300000
Sub-Saharan Africa >9 million 1.7 million
South and South-East Asia 2 million >75000
East Asia and Pacific >35000 >1000
Eastern Europe and Central Asia >50000 4500
North Africa & The Middle East 75000 12000
Total >14 million >2.5 million
1994 History

In the US the CDC launched a series of 13 bold and frank AIDS advertisements breaking away from their previous low-key approach. The advertisements focused on the use of condoms, which were rarely seen or even mentioned on American 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.'"34

Your pocket guide to sex

'Your Pocket Guide to Sex' Book

In the UK, the Department of Health vetoed an AIDS campaign promoting safer sex and condoms, developed at a cost of £2 million, on the grounds that it was too explicit.35 The campaign was developed by the Health Education Authority (a government funded body), who later in the year were banned by the Department of Health from distributing the book, "Your Pocket Guide to Sex".36

In February the film maker Derek Jarman died of AIDS. He wrote in the preface of his autobiography:

"On 22nd of December 1986, finding I was body positive, I set myself a target: I would disclose my secret and survive Margaret Thatcher. I did. Now I have my sights on the millennium and a world where we are equal before the law."37

Randy Shilts

Randy Shilts

Randy Shilts, author of the book 'And the band played on' also died in February.38

In March, the actor Tom Hanks won an Oscar for playing a gay man with AIDS in the film Philadelphia.39

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 20-35.40

In France, on 7th April all the television networks, public and private, broadcast 'Tous contre le Sida' ('All against AIDS'), a special 4-hour AIDS programme. The aim was to heighten awareness about HIV/AIDS and to raise money.41 The estimated audience for the program was 33 million. Some 32,000 cases of AIDS had been recorded in France, with 15 deaths each day, and an estimated 150,000 people were thought to be infected. 42
European safe sex campaign

'The Flying Condom' AIDS prevention campaign, Europe

During the summer, the AIDS Prevention Agency in Brussels, in collaboration with the European Union, launched a campaign whose central image was 'the flying condom'. This was intended to serve as a visual reminder to young travellers of the risks of HIV infection. The logo was displayed in airports, railway stations, popular holiday destinations and other places young people visited during the summer.43

A large European study on mother-to-child transmission showed that Caesarean section halved the rate of HIV transmission.44

Research indicated that Thailand had reduced its rate of HIV transmission. This was largely due to action by the government, which had distributed condoms to brothels and insisted that they were used consistently; establishments that failed to comply were threatened with closure. Condom use in commercial sex had risen from 14% in 1989 to 94% in 1993.45

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 1994.46 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.47

At the end of July, the UN Economic and Social Council approved the establishment of a new "joint and cosponsored UN programme on HIV/AIDS" to replace the WHO's Global Programme on AIDS. The separate AIDS programmes of the UNDP, World Bank, UN Population Fund, UNICEF and UNESCO would have headquarters with the WHO in Geneva, starting in 1996.48 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.49

A study, ACTG 076, showed that AZT reduced by two thirds the risk of HIV transmission from infected mothers to their babies.50 Somepeople believed that ACTG076 was:

“the most stunning and important result in clinical acquired immunodeficiency syndrome research to date.”51

And according to Dr Harold Jaffe of the CDC:

“It is 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.” - The New York Times -52

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.53
Pedro Zamora

Pedro Zamora

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.54

India by this time had around 1.6 million people living with HIV, up by 60% since 1993. Local and state governments were accused of underusing and misusing HIV prevention funds.55

On 11th November AIDS killed the 22-year old Pedro Zamora. He had become famous when he appeared on MTV's 'Real World' documentary about the real lives of a group of young room mates.56

In December, President Clinton asked Joycelyn Elders to resign from the post of US Surgeon General, following her suggestion during a World AIDS Day conference that school children should, amongst other things, be taught about masturbation. Gay activists defended the Surgeon General and criticised the president's record on AIDS. Fears were expressed that the president's action would discourage other government leaders from speaking frankly about AIDS.57
1995 History

By 1st January 1995, a cumulative total of a million cases of AIDS had been reported to the World Health Organisation Global Programme on AIDS. Eighteen million adults and 1.5 million children were estimated to have been infected with HIV since the beginning of the epidemic.58

Later in the month the CDC announced that in the US, AIDS had become the leading cause of death amongst all Americans aged 25 to 44.

“The dramatic rise is due to the accumulating toll from AIDS and is almost certain to continue because of AIDS deaths reflect infections from HIV, the AIDS virus that were acquired several years earlier.” - Dr. Harold W. Jaffe of the CDC -59

Two research reports provided important new information about how HIV replicates in the body and how it affects the immune system.60 61

Meanwhile in the USA, two reports by government scientists recommended that the Clinton administration lift the ban on federal funding for needle exchange programs, because the programmes had been shown to be effective in reducing the spread of disease.62 63

In March the VII International Conference for People Living with HIV and AIDS was held in Cape Town, South Africa - the first time that the annual conference was held in Africa.64 The conference was opened by the deputy President, Thabo Mbeki, who spoke about how:

"the impact has begun to cut deep. Those affected are from the young and able-bodied work-force as well as young intellectuals."65

The South African Ministry of Health announced that some 850,000 people - 2.1% of the 40 million population - were believed to be HIV positive. Among pregnant women the figure had reached 8% and was rising.66
Peter Piot

Peter Piot Director of UNAIDS

The conference was also addressed by Dr Piot, the Director of the new Joint United Nations Programme on AIDS (UNAIDS). Dr Piot confirmed his commitment to involve people living with HIV/AIDS in the planning, shaping and guiding of the global response to the epidemic.67

In July, the US Senate voted to extend the Ryan White Care Act.68 As a result of the first five years of the Act:

"in the place of activists there were now thousands of AIDS organisations throughout the country - the AIDS "industry" made possible by the Ryan White Care Act".69

By the autumn of 1995, 7-8 million women of childbearing age were believed to have been infected with HIV. The WHO spoke out about the 'inadequate international response':

"The impact of the HIV/AIDS epidemic on women … is not yet receiving sufficient political awareness, commitment or enough action of programmes responding to the specific needs of women."70

Also in August, researchers announced the results of a study in Tanzania, which found that treating people for sexually transmitted diseases such as gonorrhoea substantially reduced their risk of becoming infected with HIV.71

In September two clinical trials, the Delta trial and the ACTG175 trial, showed that combinations of AZT with ddI or ddC were more effective than AZT alone in delaying disease progression and prolonging life.72

On 1st December, World AIDS Day, Nelson Mandela called on all South Africans to

"speak out against the stigma, blame, shame and denial that has thus far been associated with this epidemic."73

Protease Inhibitors

Protease Inhibitors

The FDA approved the first of a potent new family of anti-AIDS medications. The drug saquinavir belonged to a class of drugs called protease inhibitors. Its approval in record time was said to be:

"some of the most hopeful news in years for people living with AIDS."74

By December 15th, the World Health Organisation had received reports of 1,291,810 cumulative cases of AIDS in adults and children from 193 countries or areas. The WHO estimated that the actual number of cases that had occurred was around 6 million. Eight countries in Africa had reported more than 20,000 cases.75

Other organisations estimated that by the end of 1995, 9.2 million people worldwide had died from AIDS.76

Worldwide during 1995, it was estimated that 4.7 million new HIV infections occurred. Of these, 2.5 million occurred in Southeast Asia and 1.9 million in sub-Saharan Africa. Approximately 500,000 children were born with HIV infection.77

The WHO's Global programme on AIDS closed as planned on 31st December 1995.78 They estimated that by the end of the century, 30 to 40 million people would have been affected by HIV.79
1996 History
United Nations Logo

The new Joint United Nations Programme on AIDS (UNAIDS), bringing together six agencies belonging to or affiliated with the UN system (WHO, UNDP, UNICEF, UNFPA, UNESCO and the World Bank), became operational on January 1st.80

In February the heavyweight boxer Tommy Morrison was identified as HIV positive after being tested prior to a fight.81

"'I thought AIDS was something that happened to gays and drug addicts. A macho guy like me who loves ladies and is superfit - he doesn't get AIDS.' - These words were spoken not in 1986 but in 1996 by Tommy Morrison."82

In March, a government appointed panel issued a report sharply criticising the US government's domestic response to AIDS:

"The Government's $1.4 billion AIDS research program is uncoordinated, lacks focus and needs a major overhaul to attract new scientific talent and spur novel and imaginative ideas."83

Meanwhile the effect of AIDS was continuing to be felt at a community level. In the USA there had been a cumulative total of 81,500 AIDS cases in New York, and:

"despite two world wars, the Depression and epidemics, nothing in this century has affected the life expectancy for New Yorkers as greatly as AIDS."84

In May the US Food and Drug Administration (FDA) approved the first 'home sampling' system of HIV testing. Until then the FDA had insisted that all tests for HIV (whether blood or oral fluid) had to be done under the supervision of health professionals. Under the new system, someone would buy a sampling kit from a shop or by mail order, collect a sample of their blood, send it to a laboratory for testing, and receive their results by phone.

"'Too many American do not know their HIV status. Knowledge is power, and power leads to prevention', said HHS Secretary Donna E. Shalala. 'The availability of a home test should empower more people to learn their HIV status and protect themselves and their loved ones.'"85

Meanwhile in China it was estimated that the actual number of AIDS cases could be as high as 100,000. Two thirds of the reported AIDS cases had occurred in the southern province of Yunnan, where the use of heroin and the sharing of dirty needles had helped the spread of HIV.86
Nevirapine

Nevirapine (Viramune)

In June the FDA approved the drug Viramune (nevirapine), the first in a new class of drugs known as non-nucleoside reverse transcriptase inhibitors.87 Another treatment development that took place was the introduction of the viral load test, which provided information about the risk of disease progression.88

Throughout 1996 there was excitement and optimism about the treatment of HIV infected people.89 The health of many improved enormously when they started taking combination therapy. For some people, particularly those had been ill in hospital and were then able to go home, the improvement in health was so dramatic that it was referred to as the "Lazarus Syndrome".90

At the start of the 11th International Conference on AIDS in Vancouver in July:

"the air was electric with excitement and anticipation about the findings on combination therapies to be reported during the meeting."91

Some scientists even declared that:

"aggressive treatment with multiple drugs can convert deadly AIDS into a chronic, manageable disorder like diabetes."92

One doctor suggested that giving combination therapy to patients in the first few weeks of infection might mean that the virus could be completely eliminated in two or three years.93

However, Nkosazana Zuma, the health minister of South Africa, reminded the conference delegates that:

"most people infected with HIV live in Africa, where therapies involving combinations of expensive antiviral drugs are out of the question."94

It was also reported that there were limitations on the use of the drugs, such as severe side effects and the difficulty of taking large numbers of pills each day.95

"If you think the cure is here, think again. The cure is not here. We are a long way from a cure, even for the rich who can afford the treatments." - Eric Sawyer96

The government of Brazil pledged to begin providing free combination antiretroviral treatment by the end of the year. It said it would spend up to $45 million on protease inhibitors over the following twelve months.97

In October, in Washington D.C., the AIDS Memorial Quilt was displayed in its entirety for the last time, but it was also the first time that a display of the quilt had been visited by an American president.98 99

"What it has done always in the past, and will continue to do, is to put a face on this epidemic. It makes this epidemic human." - Anthony Turney100

In December, the White House announced its first ever AIDS strategy. This called, amongst other things, for sustained research to find a cure and a vaccine; a reduction in new infections; guaranteed access to high quality care for AIDS patients; and fighting AIDS-related discrimination.

"None of us can afford to sit by and watch this epidemic continue to take our neighbors, friends and loved ones from us" - President Clinton in a letter accompanying the AIDS plan101

AIDS advocates said that much would depend on how the stategy was implemented.

"It doesn't require rocket science to figure out what to do, what it requires is the political will to back it up." - Paul Donato102

New outbreaks of HIV infection were erupting in Eastern Europe, the former Soviet Union, India, Vietnam, Cambodia, China and elsewhere.

"The epidemic is starting to skyrocket in Russia and the Ukraine where transmission is from everything - injecting drugs, poor hygiene, and heterosexual and homosexual intercourse."- Dr Peter Piot103

At the end of the year UNAIDS estimated that during 1996 some three million people, mostly under the age of 25, had become newly infected with HIV, bringing to nearly 23 million the total number of infected people. In addition an estimated 6.4 million people - 5 million adults and 1.4 million children - had already died.
1997 History

Early in 1997 it was reported that, for the first time since the AIDS epidemic became visible in 1981, the number of deaths from AIDS had dropped substantially across the USA.104 This was excellent news but:

"The decline in deaths leaves more people living with AIDS and HIV infection. We do not want to be a wet blanket here, but we still need programs that assure good access to treatment and care for infected people." - Dr John Ward105

In New York City the decline was even more dramatic, with the number of people dying from AIDS falling by about 50 per cent compared to the previous year.106 The number of babies being born HIV positive had also declined dramatically.107

By the spring it was clear that although excellent for many people, the antiretroviral drugs did have unpleasant and in some cases serious side effects. Resistance could also occur, even when three drugs were being taken, and adherence was an important issue with many pills needing to be taken each day.108

A number of treatment guidelines were published, and some doctors, particularly in the UK, disagreed with the more aggressive approach taken by the US guidelines.109 110 Some doctors were particularly concerned about the recommendations concerning the beginning of treatment when patients did not have symptoms.111 The US approach was sometimes referred to as the "hit early, hit hard"112 approach to treatment.

Later in the year a number of studies were published which showed that HIV could not after all be eradicated by two or three years of treatment, even if three drugs were taken and the treatment was strictly followed.113

In May 1997 President Clinton set a target for the USA to find an AIDS vaccine within ten years, so it could be the "first great triumph" of the 21st century. To help attain this goal Clinton announced that a dedicated HIV vaccine research and development centre would be established at the National Institutes of Health.

"With the strides of recent years, it is no longer a question of whether we can develop an AIDS vaccine - it is simply a question of when. And it cannot come a day too soon." - President Clinton114

In July the CDC reported that it was likely that there had been a case of transmission of HIV as a result of "deep kissing", although other routes of transmission could not definitely be excluded. The HIV positive man had sores in his mouth and gums that regularly bled, and his female partner also had gum disease with inflamed and sore areas in her mouth.115

In August, at a UNAIDS-organised meeting in Nepal, an appeal was made for urgent joint action by South Asian regional governments to check the spread of the pandemic. Estimates of HIV/AIDS cases in India, Myanmar (Burma), Bangladesh and Nepal were put at 3 million, 350,000, 20,000, and 15,000 respectively.116

At the end of the year, UNAIDS reported that worldwide the HIV epidemic was far worse than had previously been thought. More accurate estimates suggested that 30 million people were infected with HIV. The previous year's estimate had been 22 million infected people.117

"The older estimates were based on data that came from a small number of countries. It was assumed that one could extrapolate similar rates of transmission for all countries in a particular regional factors would be pretty much the same. It turns out that the assumption was wrong." - The New York Times118

South African Kids

South African Children

It was also estimated that 2.3 million people died of AIDS in 1997 - a 50% increase over 1996. Nearly half of those deaths were of women, and 460,000 were children under 15. UNAIDS said it was likely that, in terms of AIDS mortality, the full impact of the epidemic was only just beginning.

Worldwide, 1 in 100 adults in the 15-49 age group were thought to be infected with HIV, and only 1 in 10 infected people were aware of their infection. It was estimated that by the year 2000 the number of people living with HIV/AIDS would have grown to 40 million.119

In Latin America and the Caribbean the disease was already having a major impact. Earlier in the year a doctor in San Pedro Sula, Honduras had said:

"We will go from a city that is predominantly young to a city of old people and children. We are in over our heads with AIDS cases. It is devastating us. And all we can do here is watch people die, nothing more."120

The United States Agency for International Development (USAID) said it believed that 40 million children in developing nations would lose one or both parents to AIDS by the year 2010.

"It is a crisis of staggering proportion, that is going to affect not only the future of these countries, it is going to affect the entire global network of trade, diplomacy and development. What we are talking about here is something that has never been seen before, which is countries with one-sixth to one-quarter of all children without one or both parents."121

These are some of the most important events that occurred in the history of AIDS over the period 1998-2002.
1998 History

In Canada there was an outbreak of HIV infection amongst injecting drug users in Vancouver.1

Glaxo Wellcome cut the price of AZT by 75% after a trial in Thailand showed it was safe and effective at preventing mother-to-child transmission of HIV in developing countries.2 However, even with this price cut it was expected that the drug would still be far too expensive for use in many developing countries.3

The Clinton Administration refused to lift a ten-year ban on using federal funds for needle exchange programmes

In some countries HIV positive people were returning to work, having recovered their health as a result of combination antiretroviral drug treatment. However, some people began to be affected by quite severe side effects of the drugs. The emergence of negative reactions - which included a kind of fat redistribution called lipodystrophy - cast doubt on the long term safety of combination therapy. The reasons why lipodystrophy appeared in some people taking anti-HIV drugs were unknown. Some reports linked the syndrome to drug regimens that contained protease inhibitors.4

"While fat disappears from some areas, for unknown reasons it redistributes to build up in others. The back of the neck resembles a buffalo hump. Breasts enlarge. A woman may have to buy a bra that is two sizes larger that the last one. The abdomen swells producing a sometimes painful pot belly that is dubbed 'a protease paunch'. A woman may look pregnant when she is not. Exercise may not work it off."5

In April, the Clinton Administration refused to lift a ten-year ban on using federal funds for needle exchange programmes, despite concluding for the first time that such exchanges prevent the spread of HIV and do not encourage drug use. Leaders in the fight against AIDS condemned the unexpected decision, which was announced by Health and Human Services Secretary Donna Shalala. During her speech Shalala quoted NIH director Varmus as saying:

"An exhaustive review of the science indicates that needle exchange programmes can be an effective component of the global effort to end the AIDS epidemic. Recent findings have strengthened the scientific evidence that needle exchange programmes do not encourage the use of illegal drugs."

But, without explanation, Shalala said the administration had "decided that the best course at this time is to have local communities use their own dollars to fund needle exchange programmes".6

In the UK the London Lighthouse charity closed its residential unit.7

In June, the company AIDSvax started the first human trial of an AIDS vaccine using 5,000 volunteers from across the USA.

"It opened a new era in AIDS research, and led us toward the human trials. It was like being in a room that was partially lit and getting darker and darker, and suddenly the lights went on and you could see the pathway out."8

San Francisco started a pioneering Post Exposure Prophylaxis (PEP) program giving HIV drugs to people that might have been exposed to HIV through sexual contact or needle sharing during injecting drug use. The HIV drugs were given to people at the earliest possible time after the risk exposure.

"The treatment really is to try, in case they've been exposed to HIV, to stop the replication before it infects the cells and like a brush fire gets out of control."9

The company AIDSvax started the first human trial of an AIDS vaccine using 5,000 volunteers

A study found that the combination of caesarean delivery and AZT reduced the risk of HIV transmission from a mother to her baby to less than 1%. The study also found that women who took AZT but delivered their babies by natural childbirth had a higher risk (6.6%) of transmitting HIV to their babies.10

In July, the 12th International AIDS conference was held in Geneva. The challenge of this conference was not only to discuss the advantages available for the treatment of HIV, but also to conquer overwhelming pessimism. The mood of the meeting was in sharp contrast to the euphoria at the previous AIDS meeting in Vancouver two years before.

"A series of reports about new problems with anti-HIV drugs and setbacks in vaccine trials left many participants thinking that their best hope against the epidemic was the strategy they had since it began: prevention."11

A French court ordered the former French prime minister Laurent Fabius to stand trial on charges of involuntary homicide for allowing HIV-tainted blood to be used in transfusions.12

The first case of a patient being infected with a strain of HIV resistant to the most powerful new antiretroviral drugs was reported in San Francisco in July. The mutated strain of HIV, seemingly impervious to protease inhibitors and older drugs, was found in a newly infected patient at San Francisco General Hospital.

"We may be seeing an emerging and dangerous edge to the epidemic."Dr. Frederick Hecht of the University of California at San Francisco13

The United Nations issued new recommendations advising that HIV positive women in developing countries should be counselled to make their own decisions about how to feed their babies. This was interpreted as a major policy shift towards endorsing the use of infant formula. At the same time the United Nations decided to conduct pilot projects in eleven developing countries to expand access to services to prevent mother-to-child transmission of HIV.14

Jonathan Mann, the first director of the Global Program on AIDS, died in the crash of Swissair flight 111, along with his wife the AIDS researcher Mary-Lou Clements-Mann.

"It was always safe for scientists and institutions to think of AIDS as a virus, a transmissible infection… but Dr. Mann structured it as a human rights issue, and a global rights issue. He really was a spiritual leader as well as scientific leader."Dr. James Curran15

Red ribbon in South Africa dedicated to Gugu Dlamini

Red ribbon in South Africa dedicated to Gugu Dlamini

The FDA gave approval for various new drugs including Sustiva (efavirenz), another drug in the NNRTI group.16

In South Africa, Gugu Dlamini, an AIDS activist, was beaten to death by her neighbours after revealing her HIV positive status on Zulu television. This happened just a month after Deputy President Thabo Mbeki had called for people to "break the silence about AIDS" in order to defeat the epidemic.17

"It is a terrible story. We have to treat people who have HIV with care and support, and not as if they have an illness that is evil."- Thabo Mbeki18

The 1998 World AIDS Campaign 'Young People: Force for Change' was prompted in part by the epidemic's threat to those under 25 years old, for as HIV rates rose in the general population, new infections were increasingly concentrated in the younger age groups. The campaign also had a special representative, Brazilian footballer Ronaldo.19

UNAIDS estimated that during the year a further 5.8 million people became infected with HIV, half of them being under 25.20
Country Estimated new HIV infections 1998
North America 44,000
Caribbean 45,000
Latin America 160,000
Western Europe 30,000
North Africa/Middle East 19,000
Sub-Saharan Africa 4 million
Eastern Europe/Central Asia 80,000
East Asia/Pacific 200,000
South Asia/South-East Asia 1.2 million
Australia & New Zealand 600
Global total 5.8 million

Sub-Saharan Africa was home to 70% of people who became infected with HIV during the year. South Africa, which trailed behind some of its neighbouring countries in HIV infection levels at the start of the 1990s was catching up fast. It was estimated that one in seven new HIV infections in Africa were believed to be occurring in South Africa. In Botswana, Namibia, Swaziland and Zimbabwe, the estimates showed that between 20% and 26% of people were living with HIV or AIDS.21
1999 History

In the United States a doctor who injected his former lover with HIV infected blood was sentenced to 50 years in prison.22

A group of researchers at the University of Alabama claimed to have discovered that a particular type of chimpanzee, once common in West Central Africa, was the source of HIV. The researchers suggested that HIV-1 was introduced into the human population when hunters became exposed to infected blood.23

Reports started to emerge from South Africa of rape cases involving young girls. It was suggested that a popular myth that sex with a virgin could cure AIDS was the root cause of this increase in child rapes.24 Later on in the year, the South African President Thabo Mbeki claimed that the anti-HIV drug AZT was toxic and could be a danger to health.25

According to the annual World Health Report, AIDS had become the fourth biggest killer worldwide, only twenty years after the epidemic began.26

The Ugandan ministry of Health started a voluntary door-to-door HIV screening programme using rapid tests in an effort to reduce the spread of HIV. This effort was intended to make HIV screening services accessible to more people, especially in rural areas where there were neither modern laboratories nor electricity to run standard HIV tests.27 Since 1986 the Ugandan government had implemented a number of successful initiatives, and whereas in 1992 it was estimated that 30% of adults in Kampala were living with HIV, by 1999 the figure had fallen to 12%.28 However, HIV/AIDS was still a considerable health problem in Uganda. It was estimated that 820,000 adults and children were living with HIV/AIDS as at the end of 1999.29

In the UK a judge ordered that a five-month-old baby girl should be tested for HIV against her parents' wishes. The baby's parents refused to have their daughter tested, contending that she was perfectly healthy and that they should have the right to decide what was best for her.

"This case is not about the rights of the parents, and if, as the father has suggested, he regards the rights of a tiny baby to be subsumed within the rights of the parents, he is wrong, the judge said."30

South Africa won the first round in its battle with the United States and multinational pharmaceutical companies to force a cut in drugs prices. The dispute concentrated on South African legislation that enabled local companies to manufacture HIV/AIDS drugs that could be sold at a fraction of the price of similar imported products. The US argued that the South African laws undermined the patent rights of drug manufacturers.31

Initial findings from a joint Uganda-US study identified a new drug regimen, a single oral dose of the antiretroviral drug nevirapine, as being both affordable and effective in reducing mother to baby transmission of HIV. This research provided real hope that mother to child transmission could be effectively reduced in developing countries.32

"This extraordinary finding is the most recent in our efforts to bring an end to AIDS, not only in the United States but in countries around the world."Donna E. Karala, the Health and Human Services Secretary

The UK Government announced that all pregnant women in Britain would be offered an HIV test in an attempt to reduce the number of babies infected with HIV. The Labour Government set a target of reducing the number of infant infections by 80% by 2002.33

Health officials rejected attempts to reopen the bath houses in San Francisco, which were closed 15 years previously at the height of the epidemic in 1984.34 A survey published in August found that growing numbers of gay men in San Francisco were having unprotected sex.35 The survey results provoked concern and disappointment among public health authorities because, instead of declining, the rate of new HIV infections had remained at about 500 per year.36

Needle sharing among injecting drug users set off an explosive increase in HIV infections in Russia. In Moscow, three times as many cases were reported in the first nine months of 1999 as in all previous years combined.37
Injecting drug use in Russia

Drug use in Russia

"Russia is broke, and AIDS prevention programs are taking a back seat to problems that appear more pressing, such as mass poverty, crime and Russia's huge foreign debts."38

In November, China broadcast its first ever television advertisement for condoms in an effort to stop the spread of sexually transmitted diseases and HIV/AIDS.39 Shortly after the advertisement was seen by hundreds of millions of people, it was banned by the State Administration of Industry and Commerce.40

'The River', a book by Edward Hooper, was published. There was a lot of debate about the role of polio vaccines in the origin of the AIDS epidemic.41

T-20, a member of a new class of AIDS drugs called fusion inhibitors, went into clinical trials.42

The Kenyan President Daniel arap Moi declared AIDS a national disaster and ordered a National AIDS Control Council to be set up immediately.

"AIDS is not just a serious threat to our social and economic development, it is a real threat to our very existence, and every effort must be made to bring the problem under control."President Moi43

However the president also said that his government and Kenya's churches would not advocate the use of condoms as a method of prevention because this would encourage young people to have sex.

A research study published in November argued that male circumcision could help to reduce HIV infection rates in Africa and Asia.44

At the request of countries around the world eager to reach the age group at highest risk, the 1999 World AIDS Day campaign, "Listen, Learn and Live!", continued to focus on people under 25.45

By the end of 1999, UNAIDS estimated that 33 million people around the world were living with HIV/AIDS and that 2.6 million people worldwide had died of the disease in 1999, more than in any other year since the epidemic began.46 It was also reported that for the first time more women than men were infected with HIV in Africa.47

"In 1992, a team headed by the late Dr. Jonathan Mann at the Harvard School of Public Health, published estimates of HIV infections in sub-Saharan Africa ranging from 20.8 million to 33.6 million by 2000. The World Health Organisation criticized Dr. Mann's estimates as excessive. Now academic scientists are criticizing the figures of Dr. Piot's Team. 'When we look at the figures today, they are worse than the scenarios Jonathan had published,'Dr. Piot"48

The World Bank warned that the effect of AIDS in Asia could be to erase the region's economic gains over the last two decades unless governments maintained funding for social programs. The United Nations estimated that 7 million people in Asia were living with HIV/AIDS.49
2000 History
Jesse Jackson publicly taking an oral HIV test

Jesse Jackson publicly taking an oral HIV test

In January, the Centers for Disease Control and Prevention (CDC) reported that, for the first time, the rate of AIDS diagnoses among black and Hispanic gay men had overtaken that among white gay men in the U.S. Statistics showed that African Americans comprised 57% of all new HIV infections, even though they made up just 13% of the U.S. population.50 In order to publicise the importance of HIV testing for African Americans, reverend Jesse Jackson publicly took an oral HIV test.51

UK national statistics revealed that 1999 had been the first year in which the number of newly diagnosed HIV infections probably acquired through heterosexual sex was higher than the number probably acquired through sex between men.52

Preliminary studies presented at the 7th Conference on Retroviruses and Opportunistic Infections showed that, in some cases, temporarily stopping HIV drug therapy might not lead to increased levels of virus or the development of drug resistance.53 This later became known as the structured treatment interruption or drug holiday.

In February, the trial started of Bulgarian health workers charged in Libya with deliberately infecting children with HIV. The Bulgarian medics - five nurses and an anaesthetist - were detained in 1998 after almost 400 children were given infected blood at a hospital in Benghazi, Libya's second largest city. Eight Libyans and a Palestinian were also charged.54

A more definitive study was published about the risk of transmitting HIV through oral sex. Although earlier studies had identified oral sex as a means of transmitting HIV, the new study was designed to find out the extent of HIV transmission through oral sex among men who have sex with men. The research suggested that oral sex accounted for about 7% of cases.55

"I think it reinforces what we've said already - which is that condoms should be used for whatever type of sex you have."Dr. Robert Janssen, Director of the Division of HIV/AIDS prevention at the CDC56

Thabo Mbeki

Thabo Mbeki

Early in the year the South African government made a decision to invite a panel of experts to pursue debate on questions relating to HIV/AIDS.57 In March it was reported that South African President Thabo Mbeki had consulted two American 'dissident' researchers to discuss their claim that HIV was not the cause of AIDS.58

Israel lost one of its most successful singers, Ofra Haza, from what was believed to be an AIDS-related complication. Following her death there was a considerable increase in demand for helplines and anonymous HIV testing.

"Nevertheless, her death has brought the whole issue of AIDS out into the open in Israel. This can only be a good thing for a country which has seven openly HIV positive people - including myself - out of an estimated 10,000."Aviram Germanovitch, Director of the Israeli AIDS Task Force59

In April, President Mbeki sent a letter to world leaders explaining his views on HIV/AIDS. In this letter Mbeki argued, amongst other things, that since HIV is spread mostly through heterosexual contact in Africa, the continent's problems are unique.

"Accordingly, as Africans, we have to deal with this uniquely African catastrophe... It is obvious that whatever lessons we have to and may draw from the West about the grave issue of HIV-AIDS, a simple superimposition of Western experience on African reality would be absurd and illogical."60

In Botswana, as many as one in four adults and four of every ten pregnant women were estimated to be infected with HIV.61 The president of Botswana, Festus Mogae, announced that new contributions from donors including $50 million donated by the Bill and Melinda Gates Foundation would allow his country to provide antiretroviral therapy to all HIV-infected pregnant women and children born with the virus.62

The Clinton Administration formally declared HIV/AIDS to be a threat to U.S national security. The United States government believed that the global spread of AIDS was reaching catastrophic dimensions that could topple foreign governments, spark ethnic wars and undo decades of work building free-market democracies abroad. It was the first time the National Security Council was involved in fighting an infectious disease.63

"We shouldn't pretend that we can give injections and work our way out of this. We have to change behaviour, attitudes, and it has to be done in an organized, disciplined, systematic way."Bill Clinton64

Later in the year, the U.S. Institute of Medicine released a report that sharply criticised the Clinton Administration for failure to develop a comprehensive and effective plan to combat the disease in the United States.65

In May, at the opening of the first meeting of the presidential advisory panel on AIDS in South Africa, President Mbeki offered his first detailed explanation of why he had consulted the two American 'dissident' AIDS researchers. He also explained why the 33-member presidential AIDS advisory panel contained people who believed that HIV caused AIDS and others who did not.

"We were looking for answers because all the information that has been communicated points to the reality that we are faced with a catastrophe, and you can't respond to a catastrophe merely by saying I will do what is routine."66

Five pharmaceutical companies offered to negotiate steep reductions in the prices of AIDS drugs for Africa and other poor regions.67 A couple of months later the United States offered sub-Saharan African nations loans to finance the purchase of AIDS drugs and medical services.68 The offer was not seen as very helpful and was rejected by many African nations.69

"Making drugs affordable is the solution rather than offering loans that have interest."70

According to the latest UNAIDS report, there were 34.3 million people infected with HIV worldwide, of whom 1.3 million were children under the age of 15. It was predicted that AIDS would cause early death in as many as half of the teenagers living in the hardest hit countries of southern Africa, causing population imbalances. In particular, it was predicted that two thirds of 15 year-old children in Botswana would die of AIDS before they reached 50.71

Almost four million people were estimated to be living with HIV in India. This meant that the country had the second largest HIV population in the world: only South Africa had more people living with HIV.72
HIV positive woman marching during the AIDS conference

HIV positive woman marching during the Durban AIDS conference

In July, the 13th International AIDS Conference was held in Durban, South Africa. This was the first time that such a conference was held in a developing country or in Africa.73 Nkosi Johnson, an eleven year old HIV-positive boy, gave a speech in the opening ceremony of the conference and called for the government to give AZT to pregnant HIV-positive women.74

Mbeki used his opening address at the conference to stress the role of poverty in explaining the problems faced by Africa and compared the campaign against AIDS with the struggle against apartheid.75

"As I listened and heard the whole story told about our own country, it seemed to me you could not blame everything on a single virus."76

To counter the comments made by president Mbeki, over 5,000 scientists around the world signed the 'Durban Declaration' affirming that HIV is the cause of AIDS.77

Nelson Mandela, South Africa's former president, closed the AIDS conference with a call for action to combine efforts and save people.78

"History will judge us harshly if we fail to do so now, and right now."

At the conference, preliminary findings were reported from nonoxynol-9 studies in Africa and Thailand. Scientists had hoped that nonxynol-9 would prove to be the first effective 'microbicide' that could reduce the risk of HIV transmission during sex, but the findings were quite the opposite. Women at high risk of HIV infection were warned not to use the spermicide nonoxynol-9 because the studies suggested it might increase the risk of transmission.79

"If you use nonoxynol-9, you are either wasting your money or possibly wasting your life."Dr. Joseph Perriens80

For some people these were not surprising findings, since the toxic effects of nonoxynol-9 had been reported since 1989.81

There were few other noteworthy scientific findings reported at the conference.

In September, the first phase of a new vaccine trial was launched in Oxford. The trials were sponsored by the International AIDS Vaccine Initiative.82 The research into an AIDS vaccine was criticised by the World Bank for focusing on a vaccine that could be marketed in western countries, despite the fact that more than 90% of HIV infections were in the developing world.83

It was reported that the number of people living with HIV in Brazil was less than half that once predicted by health experts, and the number of AIDS deaths had plummeted by as much as fifty per cent since the introduction of combination antiretroviral therapy in 1996. The country's HIV prevention and treatment programmes were seen as a model for other resource-poor countries to emulate.

"It makes a lot of sense to look at what Brazil is doing... Something they're doing is working."Mbulelo Rakwena, South Africa's ambassador to Brazil -84

Treatment provision remained non-existent in South Africa, and President Mbeki stated in an interview with the Time Magazine that he did not think that HIV alone caused AIDS.

"Clearly there is such a thing as acquired immune deficiency. The question you have to ask is what produces this deficiency. A whole variety of things can cause the immune system to collapse… But the notion that immune deficiency is only acquired from a single virus cannot be sustained. Once you say immune deficiency is acquired from that virus your response will be antiviral drugs. But if you accept that there can be a variety of reasons, including poverty and the many diseases that afflict Africans, then you can have a more comprehensive treatment response."85

In October, President Mbeki announced his withdrawal from the scientific and public debate on the causes of AIDS after admitting that he had created confusion in South Africa.86

There has been a lot of confusion about what Mbeki said and did not say during the year.87 It is clear that over a period of some months, particularly in April and in September, Mbeki led many people to think that either 1) he does not believe that HIV causes AIDS or 2) he does not believe that HIV causes AIDS on its own.

It would seem that Mbeki may have believed that immune deficiency is caused by a collection of factors such as poverty, nutrition and contaminated water as well as HIV, rather than just HIV on its own:

"You cannot attribute immune deficiency solely and exclusively to a virus."88

It is true that poverty related factors such as malnutrition will hasten the onset of AIDS in people who are HIV-positive. Therefore, it is also true that provision of food will slow down the progression of HIV. However improved nutrition is not enough in itself to permanently keep people healthy. History provides evidence of this.89
2001 History
Chinese campaign poster for World AIDS day

Chinese campaign poster for World AIDS day, 2001

After years of denial, China finally admitted that HIV/AIDS threatened its public health and economic security. China's most senior AIDS researcher stated that China could soon have one of the world's largest populations of people living with HIV. Infections were predicted to grow from about 600,000 to 6 million by 2005.90 It was believed that nearly 75% of people living with HIV in China had acquired the virus through injecting drug use or transfusion with contaminated blood.91

The Indian drug company Cipla offered to make AIDS drugs available at reduced prices to the international aid organisation Medecins Sans Frontieres (MSF). Cipla's offer to produce drugs at a price less than $1 per day put further pressure on multinational drug companies.92

The U.S. Government threatened Brazil with legal action over its production of generic HIV drugs.93 The complaint was dropped later in the year and Brazil promised to give the USA advance warning before changing its patent law for drugs.94

Thirty-nine pharmaceutical companies withdrew their case against the South African government's efforts to lower drug prices. This victory was, however, overshadowed by a statement by the health minister Manto Tshabalala-Msimang, who said that the government already offered adequate treatment to AIDS patients and that proposals to buy antiretroviral drugs were still being considered.95 The South African government released its annual HIV/AIDS figures estimating that 4.7 million people were infected with HIV/AIDS and that 24.5% of pregnant women were HIV-positive in 2000.96

According to a CDC study of six large U.S. cities, 30% of young gay black men were infected with HIV.97

"When people think 'gay', they think 'white'. But the people still at the greatest risk are sexually active gay men, and that cuts across all races."Helene Gayle of the CDC98

The CDC also reported that the rate of new HIV infections was increasing twice as fast among people aged over 50 as among younger age groups.

"Officials have speculated that a more open society, people entering the dating scene after the monogamy of marriage and the absence of a fear of pregnancy is causing the alarming rise in sexually transmitted infections."99

Zimbabwe's government announced that it would dissolve the board of the National AIDS Council, after allegations of inappropriate political support and mismanagement of funds. Zimbabwe had one of the highest HIV infection rates in Africa. It was estimated in 2001 that AIDS had orphaned 1 million children and 25% of Zimbabwe's 12 million population were HIV positive.100

In April 2001, it was reported that the year 2000 saw by the far the largest number of new HIV cases yet recorded in the UK. The Public Health Laboratory Service (PHLS) recorded 3,435 new diagnoses in 2000.101

"Many of those being diagnosed are people infected some years ago, but who are now coming forward for testing. This is good news because once people are diagnosed they can seek treatment."Barry Evans102

Kofi Annan

Kofi Annan

In April, at the African Summit in Nigeria, United Nations Secretary-General Kofi Annan called for spending on AIDS to be increased tenfold in developing countries.103 He suggested 'a war chest' of $7-10 billion to be spent annually on a global campaign against AIDS - a massive increase on the $1 billion per year that was then being spent.104 A few weeks after, it was announced that a new Global AIDS and Health Fund would not only target AIDS (as had at first been suggested) but would also address tuberculosis and malaria.105

"In this effort, there is no us and them, no developed and developing countries, no rich and poor - only a common enemy that knows no frontiers and threatens all people."Kofi Annan at the G8 summit in Genoa106

There were some concerns about how this new initiative was going to be governed and implemented, and the U.S. government was criticised for contributing only $200 million to the fund. Later on in the year, it was officially named as The Global Fund to Fight AIDS, Tuberculosis and Malaria.107 The amount of money donated to the Fund was a disappointingly low $1.6 billion108much less than the $10 billion that Kofi Annan had called for.

Newspapers all over the world marked the 20th anniversary of the first published report on the disease that came to be known as AIDS.

"At the time, I read the report with great interest, but I never imagined I was looking at the first sign of an epidemic, that in just 20 years would have infected 60 million people, killed 22 million and achieved the status of the most devastating epidemic in human history."Peter Piot recalling the first mention of AIDS109

Ugandan president Yoweri Museveni opened a regional centre for treatment of HIV-positive patients in Kampala. One of the main aims of the centre was to train health workers from all over Africa.

"Our hope is that the hundreds trained here will train thousands who will treat millions."110

Kofi Annan appointed the Canadian Stephen Lewis as his 'Special Envoy for AIDS in Africa'.111
Stephen Lewis

Stephen Lewis

Kofi Annan opened the UN General Assembly Special Session (UNGASS) on HIV/AIDS in New York. This was the first ever UN meeting devoted to a public health issue.112

During the UNGASS, representatives of all 189 members of the UN signed a Declaration of Commitment on HIV and AIDS. This document contained many significant pledges, including one to reduce HIV prevalence among young people (aged 15 to 24) by 25% in the most affected countries by 2005, and to reduce it by 25% globally by 2010.113

There was a sudden explosion in HIV cases among injecting drug users in Dublin, Ireland. It was reported that diagnoses jumped fivefold between January 1999 and June 2000. Diagnoses fell to a low of 12 in 1998, but in the next 18 months 96 people tested positive. Doctors blamed this on a sudden tightening of regulations around the supply of the heroin substitute methadone, which caused more people to start injecting street heroin.114

Stephen Kelly was found guilty at Glasgow High Court of 'culpable and reckless conduct' for having unprotected sex despite knowing that he had HIV. He infected his girlfriend in 1994. Kelly was the first person to be tried under Scottish law for this type of offence. It was feared that the threat of legal action would make people more reluctant to be tested for HIV.115

President George Bush appointed an openly gay man, Scott Evertz, as Director of the Office of National AIDS Policy, but did not find any extra money in his 2002 budget for AIDS prevention or treatment.116

The US Food and Drug Administration (FDA) issued a warning letter to manufacturers of HIV/AIDS drugs, cautioning them to tone down the optimistic tone of their antiretroviral drug advertisements.117

"Examples of such images range from robust individuals engaged in strenuous physical activity to healthy-looking individuals giving testimonials of a specific drug's benefit. However, not all individuals have a response to ARV therapy; in fact, some patients will still have disease progression despite ARV therapy."118

A former Japanese Health Ministry official was found guilty of negligence for failing to stop the sale of untreated blood products. Over 1,800 haemophiliacs had contracted HIV in Japan since the early 1980s from untreated blood and more than 500 had died.119
Publicty for the UN special sessions on HIV/AIDS 2001

Publicty for the UN special session on HIV/AIDS 2001

In August, AIDS activists took legal action against the South African health ministry over its continuing refusal to supply antiretrovirals to prevent mother-to-child transmission (MTCT) of HIV.120 In December, it was ruled that the South African government should give pregnant women free access to the drug nevirapine. The judge ordered the government to set up a nationwide MTCT programme with a deadline for an implementation report to be handed back to the court by March 2002.121

Ministers meeting at the World Trade Organisation conference in Doha, Qatar, agreed a new declaration on intellectual property rights. This made it easier for developing country governments to license the production of drugs against AIDS and other diseases without having to get permission from patent holders. It was hoped that the new rules would help improve access to antiretrovirals.122

It was reported that some Asian countries had reduced the transmission of HIV through widespread condom use. In Thailand, the rate of new infections had plummeted from 143,000 in 1991 to 20,000 in 2000.123 Meanwhile HIV was spreading fastest in Eastern Europe and Russia.124

A senior Iranian health official warned that the number of AIDS cases in the country had risen dramatically. In the past, Iranian officials estimated the number of HIV-positive people to be around 2,000, but the Deputy Health Minister said that the real figure was more than 15,000.125
2002 History

Ukraine became the first nation in Europe to have 1% of its adult population infected with HIV.126

Botswana became the first African country to begin providing antiretroviral treatment through the public sector. It was estimated the programme would cost $24.5 million in its first year and would reach 19,000 people.127

The US Secretary of State Colin Powell strongly advocated condom use to prevent the spread of AIDS and other sexually transmitted diseases, setting himself apart from President Bush's views on sex education in an MTV broadcast:

"In my own judgement, condoms are a way to prevent infection… Therefore, I not only support their use, I encourage their use among people who are sexually active and need to protect themselves."128

A new line of condoms carrying the logos of most important Brazilian football teams went on sale. The campaign was helped by a TV advertisement in which supporters wore caps with their team colours in the shape of a condom.

"The level of success was more than we had expected… We are selling the condoms in places not normally associated with this sort of product, such as news stands and bakeries."129

Later in the year, for the first time ever in Brazil, an HIV prevention campaign was being aimed at male homosexuals.130

A study showed that approximately 50% of Americans still believed they could acquire HIV through everyday contact, and most supported the mandatory testing of groups at highest risk of HIV infection.131

The Chinese Government announced a 17% jump in AIDS cases. The government estimated that the number of people with full-blown AIDS was as high as 200,000, of whom more than half were presumed already dead. It also estimated that up to 850,000 people were infected with HIV by the end of 2001. These figures were still far below the estimates by experts at the UN and the WHO, who said that as many as 1.5 million people could have been infected in China.132

The National Statistics Institute in Lisbon announced that there were 104.2 HIV cases per one million Portuguese residents in 2000, compared with 88.3 cases in 1999. This was the highest rate of HIV infection in the European Union. The European average was just under 25 cases per million residents. Injecting drug use was thought to be the main source of HIV infection in Portugal.133

The board of directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria selected Richard Feachem to be its first leader.134 In the first funding round the Fund received applications for more than six times the amount they had anticipated. During the year the Global Fund announced their first round of payments of $600 million over a two-year period; the first $1 million was given out in December.135

The WHO published guidelines for providing antiretroviral drugs for treating HIV infection in resource poor countries. They also released a list of 12 essential AIDS drugs. These two moves were seen as "vital steps in the battle against the AIDS pandemic [that] should encourage both industrialised and developing country governments to make HIV treatment more widely available."136

In April, the South African government promised to start providing nevirapine to HIV-positive pregnant women and their babies to reduce the risk of HIV transmission. It was also going to be possible to offer AZT as post-exposure prophylaxis (PEP) to women who had been raped.137

A World Bank report said that HIV was spreading so rapidly in parts of Africa that it was killing teachers faster than the nations could train them. The report noted that for example in parts of Uganda and Malawi, nearly a third of all teachers were HIV-positive.138

"With more than 113 million children not in school in the poorest countries already presents a major challenge. However, HIV/AIDS makes this much greater in those countries where the education system is already struggling to grow, teachers are dying, or are too sick to teach. And every year more children are losing their parents and the support that allows them to go to school. Achieving education for all in a world of AIDS presents an unprecedented challenge to the world education community."World Bank President James D. Wolfensohn139

A report warned that Papua New Guinea was on the brink of an HIV/AIDS epidemic and the country could face losing 13-38% of its working population by 2020. It was estimated that Papua New Guinea had between 10,000 to 15,000 people infected with HIV. In comparison, Australia with a population almost 5 times that of Papua New Guinea had less than 12,000 HIV positive people. It was feared that HIV/AIDS could spread rapidly since 90% of infections were transmitted through heterosexual sex.140

A major Spanish study found that over 19,000 instances of unprotected oral sex did not lead to a single case of HIV transmission among 135 HIV-negative heterosexuals in a sexual relationship with a person with HIV.141

The WHO warned that HIV could spread rapidly throughout Afghanistan due to high levels of injecting drug use and unsafe blood transfusions. It also said that refugees were especially vulnerable to HIV infection because of sexual abuse, violence and lack of information and education. To learn more about this problem, the WHO was funding the first survey of HIV/AIDS in Afghanistan.142
Treatment activist protesting during the 2002 conference

Treatment activist protesting during the 2002 AIDS conference

In July, the 14th World AIDS Conference was held in Barcelona, Spain. Issues around providing HIV treatment for resource-poor countries dominated the mood and agendas of the conference.

"If we can get cold Coca Cola and beer to every remote corner of Africa, it should not be impossible to do the same with drugs."Joep Lange, the President of the International AIDS Society speaking at the closing ceremony143

At the Barcelona conference, there were encouraging results from trials of T-20, an injectable drug from a new class of treatments called fusion inhibitors. The results provided good news for people who had become resistant to existing drugs; the fusion inhibitors were called 'the most exciting advance since protease inhibitors were introduced'.144

The number of children orphaned by HIV/AIDS had risen three-fold in six years to reach an all time high of 13.4 million. It was estimated that India had the largest number of AIDS orphans of any country in the world, with an estimated at 1.2 million in 2001; this was predicted to rise to 2 million in five years and 2.7 million in ten years.145

"Children are taking the role of adults in many places affected by HIV because a generation has disappeared. They can't go through normal development. They have to work 40 hours a week. The very fabric of society is disappearing, with family structures crumbling."Peter Piot

Indonesia, the world's fourth most populous country, demonstrated how suddenly HIV/AIDS epidemics could emerge. After more than a decade of low HIV prevalence, the country was seeing rates increasing rapidly among injecting drug users and sex workers, with as many as 40% of people in drug treatment centres in Jakarta testing positive.146

Swiss researchers reported the first fully documented case of HIV-positive man who was additionally infected with a second strain of HIV through unprotected sex more than two years after he was first infected.147

Kami, a fluffy, mustard-coloured, HIV-positive character joined the cast of the South African version of Sesame Street. Kami's name was derived from the Tswana word for 'acceptance'.148

In the U.S., the Food and Drug Administration for the first time approved a rapid HIV test. It was hoped that this test, which could provide results in as little as 20 minutes, would counter the problem of people not returning to collect test results, and would also be useful for diagnosing pregnant women during labour.149

It emerged that several batches of cut priced drugs destined for Africa had been illegally sold at full European prices in the Netherlands and Germany. The drugs were supposed to be exported to Africa for 10% of the European price.150
HIV+ woman South Africa

For the first time, it was reported that women accounted for about half of all HIV-infected adults.

"The face of HIV/AIDS has become that of a young African woman - seven of 10 people living with the disease are in sub-Saharan Africa, and 58% of infected Africans are female. Of the 38.6 million adults living with the disease worldwide, 19.2 million are women."151

A study controversially suggested that more people in Africa may have been infected with HIV through medical injections and treatments than was previously thought.152

"Our observations raise the serious possibility that an important portion of HIV transmission in Africa may occur through unsafe injections and other unsterile medical procedures."153

In December the US Agency for International Development (USAID) announced it was adopting a new approach to preventing sexual transmission of HIV around the world, which would be known as "ABC" (Abstinence, Being faithful and Condom use). USAID said its ABC approach was based on the strategies adopted in Uganda, which it credited with reducing HIV prevalence in that country. The decision to adopt the ABC approach came three months after USAID hosted an experts technical meeting on behaviour change approaches to HIV prevention.154

The UN Secretary General, Kofi Annan, used World AIDS Day as a platform to speak out against HIV-related stigma and discrimination. He said that, 'the impact of stigma can be as detrimental as the virus itself,' and he urged people to replace 'fear with hope, silence with solidarity'. He went on to say that, 'the fear of stigma leads to silence and when it comes to fighting AIDS, silence is death'. The use of phrase 'silence is death' was interesting, as it had been used around the world for many years by AIDS activists, initially by the group ACT UP.155

These are some of the most important events that occurred in the history of AIDS from 2003 to 2006.
2003 History

Reports in January suggested that the rate of HIV in Swaziland was the world's highest with almost four out of ten adults infected. Prime Minister Sibusiso Dlamini said that prevalence had risen to 38.6% from 34.2% in January 2002. Although this figure was just under Botswana's rate of 38.8%, health officials said that Swaziland's figures were already out of date.1

Botswana was struggling to expand its antiretroviral treatment programme, largely because of a shortage of health workers. The government had hoped to provide drugs to 19,000 people by the end of 2002, but had enrolled only 3,200 by the end of January 2003.2

Jerry Thacker, a controversial Christian extremist chosen by the White House to sit on a presidential AIDS advisory panel and who once described the virus as the 'gay plague', was forced to withdraw his name after protests from gay rights groups.3

In his State of the Union address on 28th January, US president George Bush proposed spending $15 billion in combating AIDS in Africa and the Caribbean over the next 5 years. He called the scheme 'a great mission of rescue'.4

"This comprehensive plan will prevent 7 million new 'AIDS' infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS." President Bush5

Just two days later, US Health Secretary Tommy Thompson was elected as the new chairman of the Global Fund for HIV, TB and Malaria. It was hoped this move would prevent a conflict between the Bush administration and the international health community.6

In February, a rare case of female-to-female sexual transmission of HIV was reported. Doctors suggested the woman may have been infected through sharing sex toys after drug resistance tests found striking similarities between the HIV strains in her and her female partner.7

There had still been no dramatic increase in HIV transmission in Cuba since the beginning of the epidemic. The rate of infection was 0.03% and thought to be one of the lowest in the world. There had been virtually no transmission of HIV through injecting drug use, blood transfusion or from mother to child. The government had ensured that all HIV-positive mothers were treated with prophylactic AZT therapy and that their babies were delivered by caesarean section. The country had produced enough antiretrovirals to supply the country's patients.8

Globally the epidemic continued to expand, reducing world population estimates by 0.4 billion to 8.9 billion for 2050.

"The long-term impact of the epidemic remains dire… HIV/AIDS is a disease of mass destruction and we do not see a vaccine coming soon." - Joseph Chamie, director of the UNPD -9

An expert group reaffirmed that unsafe sexual practices were responsible for the majority of HIV infections in sub-Saharan Africa. This announcement was a response to claims made in 2002 that unsafe medical practises were to blame for an important portion of HIV transmission in Africa.10
AIDS vaccine development

AIDS vaccine development

Vaxgen announced that their AIDS vaccine had failed to reduce overall HIV infection rates among those who were vaccinated. The vaccine showed a reduction in certain ethnic groups, indicating that black and Asian volunteers may have produced higher levels of antibodies against HIV than white and Hispanic volunteers. However, many outside observers were sceptical of the ethnic group part of the study.11 In November, the AIDS vaccine also failed in a clinical trial in Thailand.

"The outcome of this trial is one more reminder of how difficult it is to combat HIV and how important it is for the international public health community to redouble the effort to develop an effective vaccine." - Donald P. Francis, Vaxgen President -12

Researchers warned that the number of women being diagnosed with HIV in Europe was rapidly catching up with men. The researchers also noted that initiatives supplying drug users with clean needles had been effective in Europe. HIV transmission through injecting drug use was said to have been almost eliminated in France, Germany and the UK, and significantly reduced in Spain and Italy.13

In March the Treatment Action Campaign (TAC) filed manslaughter charges against the health minister and the trade and industry minister in South Africa. The TAC held the ministers responsible for the deaths of 600 people a day whose lives could have been saved if they had had access to antiretroviral drugs.14

Russia received an approval for a long delayed loan from the World Bank to tackle HIV/AIDS and TB. For its part, the Russian Government promised to match the loan with $134 million in new money over 5 years for HIV/AIDS and TB. This contribution from the government signalled growing recognition that both HIV/AIDS and TB epidemics represented a threatening crisis for Russia's development.15
The antiretroviral Fuzeon (T-20)

The antiretroviral Fuzeon (T-20)

The first of a new type of anti-HIV drug gained approval in the USA. Unlike all previously approved drugs, Fuzeon (also known as enfuvirtide or T-20) was designed to prevent the entry of HIV into human cells. The drug was not available as a pill and had to be injected. It could be used as part of combination treatment only by patients who had already become resistant to other antiretroviral drugs.16

In April the US Centers for Disease Control and Prevention (CDC) announced a new initiative called Advancing HIV Prevention (AHP), designed to reduce the number of new HIV infections in the US. For two decades before AHP, the CDC mainly targeted its prevention efforts at persons at risk of becoming infected with HIV. In contrast, the new initiative would focus mainly on people already infected with the virus. AHP proposed making HIV testing a routine part of medical care and putting more resources into partner tracing. The recently-licensed rapid HIV test would play a key role in the new initiative.17

The US Senate approved President Bush's international AIDS bill in May, setting a timetable for spending $15 billion over five years.18

A team of Belgian researchers reported on the probable origins of HIV-2. They concluded that the virus had probably transferred from sooty mangabeys to humans in Guinea Bissau during the 1940s.19

South Korean Lee Jong-wook took office as the new Director-General of the World Health Organisation (WHO) and named HIV/AIDS as his top priority in his first speech.20

Meanwhile concerns were mounting over the Global Fund's sustainability as it faced a serious funding shortfall.21

New HIV/AIDS figures were released in India in July, and it was estimated that between 3.82 and 4.58 million Indians were HIV positive.22

In September the WHO declared that the failure to deliver treatment to nearly six million people with HIV/AIDS in developing countries was a global public health emergency. Only about 300,000 people in developing countries received the drugs at all, and in sub-Saharan Africa, where 4.1 million people were infected, just over 1% or about 50,000 people had access to antiretroviral treatment.23

Vatican cardinal Alfonso Lopez Trujillo stated that condoms were not safe and did not protect against the transmission of HIV.

"I simply wished to remind the public, seconding the opinion of a good number of experts, that when the condom is employed as a contraceptive, it is not totally dependable, and that the cases of pregnancy are not rare. In the case of the AIDS virus, which is around 450 times smaller than the sperm cell, the condom's latex material obviously gives much less security." - Cardinal Trujillo -24

In response the WHO said that it was "totally wrong" to claim that condoms did not protect against HIV and:

"It is quite dangerous to claim the contrary when you realize that today we are facing an epidemic which has already killed 20 million people and 42 million people are infected today."25

There was a sharp rise in trafficking of heroin through central Asia. This caused an increase in drug addiction and cases of HIV in many impoverished states including Tajikistan. Since the fall of the Taliban, who had banned the growing of opium poppies (the raw material for making heroin), production had skyrocketed in Afghanistan.26

In the US, estimates suggested there had been fewer than 100 AIDS diagnosses among children during 2002, compared to nearly 1,000 in 1992. The dramatic reduction was due to widespread use of antiretroviral drugs and avoidance of breastfeeding.27

South Africa approved the long-awaited provision of free antiretroviral drugs in public hospitals

In November the UN World Food Programme said it would shift its humanitarian aid effort in southern Africa from traditional emergency food supply to a greater response to HIV/AIDS including providing nutritional support, awareness campaigns, food baskets and other services to HIV-positive people.28

Many drug manufacturers lowered their prices of antiretroviral drugs in resource-poor countries during 2003. Although these price reductions were welcomed by many countries and organisations, it was understood that 'lower price medicines alone will not deliver treatment'. What was also needed was the ability of countries to deliver these drugs, building of stronger health systems and training of more health care workers in resource-poor countries.29

South Africa approved the long-awaited provision of free antiretroviral drugs in public hospitals in November. The cabinet instructed the Department of Health to proceed with implementation of the plan, which envisaged that within a year there would be at least one service point in every health district across the country, and within five years, one service point in every local municipality.30

UNAIDS warned that the efforts to stem the world's AIDS epidemic were 'entirely inadequate'. It was estimated that every day in 2003, around 14,000 people became infected with HIV. It was estimated that 40 million around the world including 2.5 million children were living with HIV/AIDS.31

Meanwhile India's health minister said that there would never be a widespread AIDS epidemic in the country.

"I will prove all experts wrong. We are taking on the disease from all fronts. We are tackling it very bravely." - Sushma Swaraj -32

On World AIDS Day the WHO announced a new plan called '3 by 5' to provide HIV/AIDS treatment for many resource-poor countries. The plan had many different elements, but the WHO were not planning to provide the drugs themselves. The WHO was hoping to have 3 million people in resource poor countries on AIDS drugs by the end of 2005.33

"Nothing close to this has ever been tried. It's not like finding babies with diarrohea and treating them for a week, or adults with tuberculosis and treating them for six months - both of which have been major efforts by the WHO in recent decades... HIV infection is a chronic disease. The 3 million - and the millions who will come after them - will have to take their medicine for years, until they die."34

Also on World AIDS Day, Wen Jiabao became the first Chinese premier to shake the hand of an AIDS patient. Mr Wen's handshake broadcast in close-up was the most dramatic of a series of government moves that demonstrate a new determination to fight AIDS.

"This was like breaking the ice… It's something that a lot of people working in the AIDS field inside China and outside have been hoping for and waiting for." - Joel Rehnstrom, the co-ordinator in China for UNAIDS -35

The Chinese government announced a policy of 'Four Frees and One Care', which promised free antiretrovirals to poor city dwellers and to everyone in the countryside; free voluntary counselling and testing; free drugs to prevent mother-to-child transmission; free schooling for AIDS orphans; and care and economic assistance to the households of people living with HIV/AIDS.36

According to new estimates, the number of people infected with HIV in the UK increased by almost 20% between 2001 and 2002, from 41,700 to 49,500, of whom 31% were undiagnosed.

"World AIDS Day reminds us that the problems we face with HIV are not going away, despite it being a disease that is largely preventable." - Kevin Fenton, a public health consultant -37

2004 History

In January Brazil's government reached a deal with pharmaceutical companies to reduce the price of HIV/AIDS drugs by around a third. It was believed that the deal saved the government about $100 million in 2004 and cut the average treatment cost per patient to a new low of $1,200.38 Also, 10 million free condoms were given out to people in Brazil during the carnival season as part of an AIDS-prevention campaign.39

In parts of Russia and Eastern Europe, HIV was spreading faster than anywhere else in the world.

In February, President Bakili Muluzi of Malawi announced that his brother had died from AIDS. This was intended to highlight issues of stigma and discrimination related to HIV/AIDS. President Muluzi made the announcement as he launched the first AIDS policy in a country where an estimated 15% of the 15 million population were HIV-positive.40

The Global Fund to Fight AIDS, Tuberculosis and Malaria suspended payments to three HIV/AIDS programmes in Ukraine, citing concerns over slow progress and management problems. It was the first time in its history that the Global Fund had stopped funding to a scheme that it had supported.41

In parts of Russia and Eastern Europe, HIV was spreading faster than anywhere else in the world. A survey by the United Nations Development Programme estimated that almost one in 100 Russians were HIV-positive and that AIDS could claim up to 20.7 million lives by 2045.42 The head of the UN Development Programme, Mark Malloch Brown, criticised Russia's efforts to combat the virus:

"President Putin mentioned it last May, but one speech is not enough and one reference in a speech is not enough." 43

Stephen Lewis, the UN special envoy for HIV/AIDS in Africa warned that the WHO's attempt to get three million people onto treatment by the end of 2005 was compromised by lack of financial support from the world's richest countries.

"There has never been a more determined plan of action… If 3 by 5 fails, as it surely will without the dollars, then there are no excuses left, no rationalizations to hide behind, no murky slanders to justify indifference. There will only be the mass graves of the betrayed." - Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa -44

In March, the US Food and Drug Administration approved the first oral fluid rapid HIV test.45

South Africa began a programme to give out free HIV/AIDS drugs after years of confusion and delays. The program started in South Africa's richest province, Gauteng, where five major hospitals, including Chris Hani Baragwanath, the largest in Africa, were selected to administer the drugs.46

"To me, it means a lot," said the frail man, whose girlfriend and 2-year-old daughter have also tested positive for HIV. "I have a child to raise... I want to take her to her first day of school, and I can only do that if I am healthy." - 27-year-old HIV-positive South African man -47

A study found that the HIV prevalence rate in Uganda had been reduced by 70% since the early 1990s. It was estimated that half a million Ugandans were HIV positive in 2004, compared with 1.5 million a decade before. It was believed that the reduction in HIV prevalence was due to people having fewer sexual partners as well as to effective prevention efforts in local communities.48

"In Uganda people became engaged with the epidemic at the community level. Local care groups, religious movements, non-governmental organisations and care networks all spread the message. Families, friends and neighbours began talking about HIV prevention and care, and sexually transmitted diseases stopped being a taboo subject."

A survey of US media coverage of the AIDS epidemic revealed that the number of AIDS-related stories peaked in 1987 and rapidly declined in the early 1990s, despite these being the peak years for AIDS deaths. The stories increased slightly in 1991, when Magic Johnson spoke publicly about his HIV status. The number of stories revived again in 1996-7 with the introduction of combination therapy.49

In May, five Bulgarian nurses and a Palestinian doctor accused of deliberately infecting children with HIV were sentenced to death by a Libyan court. The medical staff had been detained in 1998 and the trial had started in 2000.50

The US porn industry was hit by fears of HIV outbreak among its stars. By May, five porn actors had been found to be HIV-positive.51 52

President Bush's $15 billion initiative to combat the global AIDS pandemic, by now known as PEPFAR (President's Emergency Plan For AIDS Relief), began full implementation in June, having received its first funding in January. PEPFAR was to concentrate on fifteen focus countries, all of them in Africa except Guyana, Haiti and Vietnam (which was a late addition to the list). The initiative set a goal of providing AIDS treatment to 200,000 people living in the focus countries by June 2005.53

A new UNAIDS report estimated that 37.8 million people were living with HIV at the end of 2003, including 17 million women and 2.1 million children under 15 years old. It was estimated that there were nearly 8,000 AIDS deaths per day during 2003. These were slightly lower than previous estimates because improvements had been made to the estimation process, but without doubt the epidemic was still expanding. The number of AIDS orphans had risen to 15 million, of whom 12.1 million lived in sub-Saharan Africa.54

The WHO announced that, by the end of June, 440,000 people in developing and transitional countries were receiving antiretroviral treatment, an improvement of 40,000 since the end of 2003.55

The Bill and Melinda Gates Foundation announced that it would donate $50 million to the Global Fund, bringing its total Fund contributions so far to $150 million.56

The South African Treatment Action Campaign and its leader, Zackie Achmat, were jointly nominated for the 2004 Nobel Peace Prize, but were not chosen to win.57

In November the Global Fund said that it would delay launching its fifth round of grants for five months because of a funding shortfall. Some commentators said the US was not providing enough support for the Global Fund because it preferred its own PEPFAR initiative.58

Botswana's antiretroviral treatment programme, which had made dramatic progress during 2004, was providing medication to around 36,000 and 39,000 people by the end of the year - around half of the number who needed the drugs.59

Women, Girls, HIV and AIDS was chosen as the theme of World AIDS Day 2004. Events to mark the occasion took place around the world, including in China, where Premier Wen Jiabao called for "unremitting efforts" against the epidemic, and the Executive of the Global Fund warned of catastrophic consequences should such efforts fail.60 61 62

"Today the face of AIDS is increasingly young and female... We will not be able to stop this epidemic unless we put women at the heart of the response to AIDS." - Peter Piot, head of UNAIDS, on World AIDS Day63

2005 History

At the start of the year, UNAIDS published a report predicting the future of the global AIDS epidemic. Three very different scenarios highlighted how much would depend on the responses of governments, donors and civil society.64

Also in January, both the WHO and PEPFAR published figures detailing numbers of people receiving AIDS drugs. PEPFAR said it had helped to provide treatment to nearly 155,000 people in its fifteen focus countries by end of September.65 The WHO said that the total number receiving treatment in all developing and transitional countries had risen to 700,000 by the end of 2004, meaning that the 3 by 5 initiative had achieved its latest target.66

The US Food and Drug Administration (FDA) for the first time approved a generic AIDS drug made by a foreign company. PEPFAR had decided not to trust any drug that had not been approved by the FDA, which meant that all PEPFAR-funded programmes had had to stick to the more expensive brand-named products. However in January the FDA gave its approval to two drugs made by the South African company Aspen Pharmacare. This came just weeks after a product of the US company Barr Laboratories had become the first ever FDA-approved generic, and was predicted to mark a turning point in providing cheaper treatment in Africa.67

Nelson Mandela announced that his eldest son Makgatho had died of AIDS, aged 54.

"Let us give publicity to HIV/AIDS and not hide it, because [that is] the only way to make it appear like a normal illness."- Nelson Mandela68

Publication of death certificate data from South Africa revealed that the total number of reported deaths had increased by 57% between 1997 and 2002. Among those aged 25-49 years, the rise was 116% in the same six year period.69 Based on an analysis of a sample of death certificates, the South African Medical Research Council estimated that nearly two-thirds of deaths related to HIV had been misclassified (wrongly attributed to other causes) during 2000-2001.70

In April, the US Institute of Medicine published the results of an extensive review of data relating to the use of the drug nevirapine. It found that the drug was a safe and effective way to prevent mother-to-child transmission of HIV, and that news stories suggesting otherwise had distorted the facts.

"It is conceivable that thousands of babies will become infected with HIV and die if single-dose nevirapine for mother-to-infant HIV prevention is withheld because of misinformation." - National Institute of Allergy and Infectious Diseases -71

Brazil turned down $40 million offered by PEPFAR because it refused to agree to a declaration condemning prostitution. The director of Brazil's HIV/AIDS programme said the government had taken the decision "in order to preserve its autonomy on issues related to national policies on HIV/AIDS as well as ethical and human rights principles".72

A new set of international treatment figures were published by the WHO in June. They revealed that the 3 by 5 initiative was a long way off track, because only 970,000 people (15% of those in need) were receiving treatment, compared to a target of 1.6 million. The WHO admitted that it would be unlikely to achieve its goal of 3 million by the end of the year.73

PEPFAR said it had exceeded one of its own targets by helping to provide treatment to 235,000 people in its focus countries by the end of March.74 The figure given for Botswana was disputed by the country's health officials. They said the US was claiming credit for helping thousands of people whose treatment had in fact been funded overwhelmingly by the Botswanan government.75

Speaking at the 2005 National HIV Conference, the acting director of the CDC announced a new estimate of HIV prevalence in the USA. The CDC had calculated that between 1.039 million and 1.185 million Americans were living with HIV at the end of 2003, of whom 47% were black. One in four HIV-positive people did not know they were infected. Other studies presented at the conference showed that new infections among African Americans were rising, and the total number of new cases was remaining stable at around 40,000 per year.76
Make Poverty History rally

Over 225,000 people gather to form a human

white band around Edinburgh city centre,

as part of the Make Poverty History campaign.

In the UK at least, 2005 had been hailed as the ‘Year of Africa’ - the year in which real progress would be made towards relieving poverty and disease in that continent. The UK held the presidency of the European Union for the second half of the year, and in July the UK hosted the G8 (Group of Eight) summit of world leaders in Gleneagles, Scotland. Prime Minister Tony Blair promised that the main themes of the summit would be Africa and climate change. The meeting was preceded by massive "Live8" pop concerts around the world, and other events associated with the Make Poverty History campaign.

At the summit the leaders promised to double aid to Africa by 2010, and to cancel the debts of 18 poor countries, but no progress was made in improving trade justice, which many groups considered to be the most important issue. However, the leaders were praised for pledging to ensure as near as possible to universal access to antiretroviral treatment worldwide by 2010.77

South Africa's latest antenatal clinic survey showed that 29.5% of pregnant women were HIV positive at the end of 2004. According to the report, the total number of people living with the virus had risen to an estimated 6.29 million - far more than in any other country.78

The Global Fund to Fight AIDS, TB and Malaria in August suspended all grants to Uganda following concerns about possible corruption within the country's health ministry. Uganda's suspension was lifted in November, after an agreement was reached with the ministry over better financial management. Meanwhile the Fund announced its global AIDS programmes had exceeded targets for 2005.79 80 81

By August, nine generic antiretroviral drugs had been approved by the American Food and Drug Administration (FDA). However several African countries refused to allow the drugs to be imported until they had also been approved by the WHO.82 PEPFAR would not begin distributing generic drugs until near the end of the year.83

PEPFAR's approach to HIV prevention (described as "ABC") came under increasingly heavy fire from commentators who said it was motivated by ideology, and was focusing too much on abstinence until marriage while downplaying the role of condoms. Among the fiercest critics were Professor Duff Gillespie, a public health expert and former senior USAID official, who called PEPFAR's policies "outrageous and stupid", and Stephen Lewis, the UN Special Envoy for HIV/AIDS in Africa, who said the approach to HIV prevention would "cause a significant number of infections which should never have occurred". Two prominent US medical associations, the IDSA and the HIVMA, were also critical. However PEPFAR officials maintained that their approach to HIV prevention was balanced and based on evidence of effectiveness.84 85 86

At the UN World Summit in September, the General Assembly followed the example set by the G8 leaders, by committing themselves to:

"Developing and implementing a package for HIV prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need it"87

Russian President Vladimir Putin promised that his country would allocate at least 20 times more money to fight HIV and AIDS in 2006 than it did in 2005. The President said that AIDS in Russia was a "serious problem", and that current spending of $5 million per year was "practically nothing for Russia on the scale of things".88 89

In September the antiretroviral drug zidovudine (AZT) reached the end of its patent period in the US. This meant that any pharmaceutical company could now produce the drug legally and cheaply for the US market without having to pay royalties to the patent owner, GlaxoSmithKline. The FDA immediately approved four generic forms of AZT for sale within America.90

Zimbabwe, one of the countries worst affected by AIDS, was suffering from a severe economic crisis made worse by droughts and the government's controversial land redistribution programme. One consequence was a sharp rise in the price of AIDS drugs in the public sector, from $7.70 per month in July to $46 per month in October. At the same time the state-run treatment programme was handicapped by a lack of foreign assistance, due to Western opposition to land reform and reported violence and intimidation during elections.

"People are giving up [their] drugs - they have to choose between feeding and educating their kids or taking ARVs" 91

Zimbabwean President Robert Mugabe was accused of further worsening the AIDS crisis in his country through his slum clearance campaign, which left thousands of families homeless. But UNAIDS announced that Zimbabwe's HIV prevalence rate had fallen over the previous five years, from around one in four to around one in five infected.92 93

In 2005 skepticism about the cause of AIDS was still thriving in South Africa. The Democratic Alliance gave a list of the country's twelve most influential "AIDS dissidents" (people who question the theory that HIV causes AIDS), whom it said had an "ongoing and bizarrely powerful" influence on national HIV/AIDS policy. The list was headed by attorney Anthony Brink, the convenor and national chairperson of the Treatment Information Group and spokesperson for the Dr Rath Health Foundation, an organisation dedicated to promoting the use of vitamin supplements rather than antiretrovirals to treat AIDS. Also featured were President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

"South Africa has become a safe haven for AIDS denialists and is the AIDS denialist capital of the world... Were it not for the influence of dissidents, South Africa would long ago have been able to take the steps that countries like Brazil and Thailand have taken to stop new AIDS infections, provide appropriate education and offer meaningful treatment to those already infected." - Democratic Alliance health spokeswoman, Dianne Kohler-Barnard -94

London bus appeals for universal access to AIDS treatment

A London bus covered with hundreds of hand-written messages from campaigners appealing for universal access to AIDS treatment, on World AIDS Day 2005.

By late 2005, it was clear that the World Health Organisation's 3 by 5 plan would fail to achieve its goal of 3 million people on treatment in resource-poor countries by end of the year. With refreshing honesty, the head of the WHO's HIV/AIDS programme admitted as much and said sorry.

"All we can do is apologise. I think we just have to admit we’ve not done enough and we started way too late." - Dr Jim Yong Kim

However, Dr Kim said the initiative should certainly not be deemed a failure:

"Before Three by Five, there was not an emphasis on saving lives... Many leaders in the world were saying we just have to forget about this generation of people who are infected, we're really thinking about the next generation... So something has happened that's extraordinary."95

The WHO estimated that expanded access to treatment had saved between 250,000 and 350,000 lives during 2005. However, their estimates also revealed there were more new HIV infections and more AIDS deaths in 2005 than in any previous year.

"2005 is likely to be remembered more for the 3 million deaths and almost 5 million new infections it heralded than for the 300 000 lives saved through treatment for HIV"- Front cover of The Lancet Volume 366 Number 950096

2006 History

In January, the rock star Bono announced the creation of a new commercial brand designed to help raise money to fight AIDS in Africa. “Product RED” originally involved four large companies (Armani, Gap, American Express and Converse), each of which would sell special red products and donate a portion of the profits to the Global Fund. The first merchandise would become available in the UK in March.97

The final results of the 3 by 5 initiative were revealed in March. By the end of 2005, only around 1.3 million people in low- and middle-income countries had been receiving antiretroviral treatment – less than half of the 3 million target. Though this result was highly disappointing, the WHO stressed that it still represented a more than three-fold increase within two years. Of the 152 countries involved in the initiative, only 18 met the target of 50% treatment coverage. Among the worst performers were Russia and India, and among the best was Botswana, where coverage had reached around 85%.

"Two years ago, political support and resources for the rapid scale-up of HIV treatment were very limited. Today ‘3 by 5’ has helped to mobilize political and financial commitment to achieving much broader access to treatment. This fundamental change in expectations is transforming our hopes of tackling not just HIV/AIDS, but other diseases as well." - WHO Director-General, Dr Lee Jong-wook98

PEPFAR announced that it was helping to provide treatment to 401,000 people in its fifteen focus countries,99 but this news was soon overshadowed by yet more criticism of the plan’s HIV prevention policies. A report by the Government Accountability Office revealed that, by allocating one third of its prevention budget to programmes promoting abstinence and fidelity, PEPFAR was forcing countries to cut funding for efforts to help high-risk groups and to prevent mother-to-child transmission.100

A new study suggested that the rate of new HIV infections in Southern India might have declined between 2000 and 2004, perhaps because of changes in sexual behaviour. One of the authors, Professor Prabhat Jha, said their results contradicted previous assumptions:

“There have been many predictions, mostly based on guesswork, that India's AIDS problem will explode – as it did in southern Africa – but we now have direct evidence of something positive.”101

Reports that an HIV-positive orphan, Isaiah Gakuyo, had been violently murdered by his uncle sparked protest marches in Kenya. Before his death, the teenager had been mistreated and isolated by his relatives because of his infection.

“The boy was facing violence on a daily basis. We don't want this to happen again.” - March organiser, Inviolata Mwali M'Mbwari -102

Dr Lee Jong-wook, Director General of the WHO, died after undergoing emergency surgery in May. Dr Lee had led the 3 by 5 initiative, and was especially passionate about achieving universal access to HIV/AIDS prevention, treatment and care.103

At the end of May, twenty-five years after doctors first became aware of AIDS, UNAIDS published an especially comprehensive report on the global epidemic. Although the number of people living with HIV was still rising, there was new evidence of HIV prevalence declines in Kenya, as well as urban areas of Burkina Faso and Haiti.104

The UNAIDS report also revealed that funding for the response to AIDS in low- and middle-income countries had risen from $300 million in 1996 to $8.3 billion in 2005, yet was still a long way short of what was required for meaningful action. Of the $18.1 billion that would be needed in 2007, only $10 billion was likely to be available.105

June also contained the fifth anniversary of the UNGASS declaration, in which UN member states had set ambitious targets for combating HIV and AIDS worldwide. Another High-level Meeting was therefore convened to agree a new “Declaration of Commitment on HIV/AIDS”, which would guide the global response over coming years. The final document was criticised by some campaigners for being vaguely worded, and for omitting any definite spending commitments.

“I wish we could have been a bit more frank in our declaration about telling the truth that some groups – like sex workers, drug users and men who have sex with men – are more at risk… This is not a time for embarrassment, this is about telling it straight because it is about saving people's lives. Openness, honesty, frankness, giving people enough information, not being squeamish and telling the truth is really, really, important.”- Hilary Benn, UK International Development Secretary106

The Vatican sparked excitement among AIDS campaigners when it suggested it was planning a review of its stance on condom use as a method of HIV prevention. However, it soon became clear that a major change in policy was unlikely, and that the Catholic Church would probably continue to oppose condom use in all circumstances.107
Bill Gates with President Bill Clinton at the International AIDS Conference in Toronto

Bill Gates with President Bill Clinton at the International AIDS Conference in Toronto

The Gates Foundation – the world’s largest private source of funding for HIV and AIDS – received a substantial boost to its finances in June, when the billionaire Warren Buffet promised to donate $31 billion over ten years. Bill Gates announced that he would step down as head of Microsoft to concentrate on the work of the Foundation.108

The first one-a-day pill for effectively treating HIV infection was approved for sale in the USA. A result of unprecedented cooperation between two major pharmaceutical companies, the pill, called Atripla, combined three types of drug widely used in first-line treatment. The advent of once-daily treatment represented great progress since the mid-1990s, when people with HIV usually had to take several pills every few hours.109

In August, attention turned to the XVI International AIDS Conference in Toronto. One major talking point was how to accelerate the expansion of antiretroviral therapy worldwide, and in particular how to alleviate dire shortages of healthcare workers in the most needy countries. Delegates also discussed the pros and cons of routine HIV testing, whereby everyone attending medical settings is offered an HIV test, regardless of symptoms. The WHOand others suggested that wider use of this approach would increase take-up of treatment and help to counter stigma.

The conference provided a platform for critics of the South African government’s response to AIDS. Activists protested at the country’s exhibition stand, which was dominated by unproven nutritional remedies, with almost no reference to effective medication. Conference co-chair Mark Wainberg said it was “unconscionable” that South Africa’s leaders would not talk openly about AIDS.110 Stephen Lewis (UN Special Envoy for HIV/AIDS in Africa) went further in his closing speech:

“South Africa is the unkindest cut of all. It is the only country in Africa … whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state... The government has a lot to atone for. I'm of the opinion that they can never achieve redemption.”111

Shortly after the conference, more than 80 prominent international scientists wrote an open letter to South African President Thabo Mbeki calling on him to sack health minister Manto Tshabalala-Msimang, whom they blamed for “disastrous, pseudo-scientific policies” on HIV/AIDS.112 Instead, the South African government set up a new inter-ministerial committee to take charge of the national AIDS response, to be headed by the deputy president, thus seeming to sideline the controversial health minister.113

To coincide with the Toronto conference, medical journal The Lancet produced a special issue with a red cover to help promote the Product RED brand. The 130-page journal was entirely devoted to AIDS-related articles, and included prominent adverts for Product RED merchandise.114 The Independent, a British newspaper, had been the first publication to produce a RED edition in May; it would repeat the stunt in September and December.115

In September, the WHO issued an emergency warning to health care professionals to be on the lookout for a new strain of tuberculosis, against which most existing drugs were ineffective. The WHO had been aware of XDR-TB (extreme drug-resistant tuberculosis) for several years, and it had been recorded in Asia, Eastern Europe and the United States. The alarm was raised when doctors reported 53 new patients in South Africa, 52 of whom died within 25 days. It was thought that most, if not all, of these people had been co-infected with HIV. Experts were concerned that they might be seeing the beginning of a devastating new epidemic.
The Lancet's RED edition

The Lancet's RED edition, August 2006

“There is no point in investing hugely in [AIDS treatment] programmes if patients are going to die a few weeks later from extreme drug-resistant tuberculosis… This is raising the spectre of something that we have been worried about for a decade – the possibility of virtually untreatable TB.” - Dr Paul Nunn of the WHO116

In the USA, the Centers for Disease Control and Prevention (CDC) issued new guidelines recommending routine HIV testing for all adults and adolescents attending healthcare services. Routine testing had already proved highly successful in identifying HIV among pregnant women; the CDC hoped that more general use of this approach would help to cut the rate of new infections, and would result in more people receiving treatment before becoming very ill.117

Product RED was launched in the USA in October, by which time Apple and Motorola were also supporting the brand.118

Kevin De Cock, director of the World Health Organisation's HIV/AIDS department, expressed growing concern about HIV in Papua New Guinea. Adult HIV prevalence in this Pacific nation was estimated to be 1.8% - a level not usually seen outside Africa. The country's health minister said that some isolated pockets could have rates as high as 30%.

“Papua New Guinea probably is somewhat in a class of its own in this region.” - Dr. Kevin De Cock119

In December, South Africa’s deputy health minister Nozizwe Madlala-Routledge decided to speak out against her own government, admitting there had been “denial at the very highest level” over the country’s AIDS crisis. She also acknowledged that leaders had created confusion about treatment by appearing to promote nutrition as a viable alternative. Activists greeted these statements as a “defining moment” in the country’s response to HIV and AIDS.120 121

The most important scientific announcement of the year was made in December, when the US National Institutes of Health revealed the results of two African trials of male circumcision as an HIV prevention method. The studies were halted early for ethical reasons because they had already provided clear evidence that the intervention reduced HIV transmission by around 50%. The WHO and other organisations suggested they would soon begin promoting male circumcision in areas with severe HIV epidemics. However, they also stressed that there were many difficulties associated with this intervention, including acceptability, demands on resources, and infections resulting from unsafe operations. Furthermore, it was clear that the benefit would be lost if circumcised men became over-confident, and began to engage in more risky sexual behaviour.122

At their second trial within two years, five Bulgarian medics and a Palestinian doctor were again found guilty of deliberately infecting 426 Libyan children with HIV, and were again sentenced to death. This verdict was condemned by the USA, the European Union and the UN human rights office. Leading experts in HIV and genetic testing had declared that the healthcare workers were almost certainly innocent, and that poor hygiene had led to the children becoming infected.123

These are some of the most important events that occurred in the history of AIDS from 2007 onwards.
2007 History

A large-scale international microbicide study was halted in January after preliminary results found that the product was not achieving its aims of preventing HIV infection in women. In fact, trials of the drug in some sites found that there was a higher infection rate amongst women who used the cellulose sulphate vaginal gel, compared to the placebo group.1 UNAIDS regarded the news as “a disappointing and unexpected setback” as “[t]he need to continue research to find a user-controlled means of preventing HIV infection in women is urgent.”2
President Yahya Jammeh sitting & dressed in white

President Jammeh of The Gambia claimed he could cure AIDS

Also in January came the dramatic announcement by President Jammeh of The Gambia that he had found a cure for AIDS.

“I can treat asthma and HIV/AIDS and the cure is a day’s treatment. Within three days the person should be tested again and I can tell you that he/she will be negative...”3

Jammeh’s claim was soon revealed to be unfounded. A scientist who conducted the tests rebutted the study’s findings, saying that none of the trial patients “could be described as cured.”4 Despite the negative outcomes of the trial, the president continued in his belief of his treatment plan, which was also endorsed by the Gambian health ministry and administered in state hospitals. The President of the International AIDS Society Dr. Pedro Cahn called the Gambian president’s claims “shocking and irresponsible”5, not only for providing false hope, but also for risking people’s lives by taking them off potent combination antiretroviral therapy.

Good news came to South Africa in March when the government finally developed an ambitious and comprehensive plan to try and tackle the epidemic after years of inaction. Headed up by the deputy president, Phumzile Mlambo-Ngcuka, and the deputy health minister Nozizwe Madlala-Routledge, the plan aimed to try and reduce the number of new infections by fifty percent, and bring treatment care and support to at least eighty percent of all HIV-positive people and their families.6 The new plan was welcomed by national and international health experts, although it was made clear that in order for the new goals to be realised there needed to be a fast track restructuring of the health care system.

Also that month came the first publication by the World Health Organisation (WHO) and the Joint UN Programme on HIV/AIDS (UNAIDS) regarding recommendations on circumcision and HIV. The guidance came three months after trials in Uganda and Kenya provided conclusive evidence that circumcision reduces the risk of transmission from women to men by around 50-60%. The publication stressed that men should be taught that circumcision provides only partial protection against HIV, to prevent them developing a false sense of security, and should only be provided as part of a comprehensive HIV prevention package. It also stressed that well-trained practitioners working in sanitary conditions should perform the procedure only after obtaining informed consent.7

In April, it was revealed by the WHO that at the end of 2006 two million HIV-positive people in low- and middle-income countries were accessing antiretroviral treatment. This means that around 28% of those in need of the life-saving drugs were receiving them. The speed of expansion remained too slow to meet the global AIDS treatment targets agreed by the G8 summit.8

By June the G8 had revised its universal treatment pledge to give every person in need of HIV treatment access by 2010. Instead, it proposed a new weaker target stating that the G8 would, “over the next few years” aim to ensure access for “approximately five million people”.9 The weakening of the original G8 pledge caused anger, as it was felt that a commitment had been broken which had been at the very heart of the fight against AIDS for the past two years.10 Although it was acknowledged that universal treatment by 2010 was more idealistic than feasible, many people believed that having such a demanding target put pressure on country governments to get as many people as possible into treatment programmes and highlighted the scale and urgency of the task.

In July, it was revealed that new methods of sampling led to a massive reduction in the estimated number of people living with HIV in India. Previous estimates had suggested that there were around 5.7 million people living with HIV in India, giving it the largest HIV caseload in the world. The new figures suggested that the actual total was somewhere between 2 and 3.1 million people - around 60% lower than the original estimate - and placed India third after South Africa and Nigeria for countries with the highest HIV infected populations. The previously inflated HIV numbers for India were due to figures being obtained in areas of particularly high HIV prevalence and taken from samples from surveillance sites visited mainly by pregnant women, injecting drug users and prostitutes.11

"“Today we have a far more reliable estimate of the burden of HIV in India,”" said the Indian Health Minister, Anbumani Ramadoss. He did however warn of complacency, as "“in terms of human lives affected, the numbers are still large, in fact very large.”"12

Later in July, there were reports of counterfeit antiretroviral drugs (ARVs) flooding the market in Zimbabwe, potentially putting many lives at risk. The adverse economic and political conditions in Zimbabwe meant that supplies of government-funded ARVs dried up in many parts of the country, leaving those with HIV at serious risk of developing AIDS. This left the door open for dealers to sell fake or illegally obtained pills to HIV positive people desperate to maintain their health. A spokesperson for the Medicines Control Authority of Zimbabwe (MCAZ) said “Such medicines may be counterfeited, adulterated and contaminated, thus rendering them ineffective and sometimes dangerous.”13
People wearing purple protesting

Protest at South African Deputy Health Minister's sacking

As July drew to a close so to did the eight-year ordeal of the six Bulgarian medics facing the death sentence in Libya for allegedly infecting hundreds of children with HIV. They had always denied the claim, saying their confessions were extracted under torture. Expert evidence from various scientists claimed that the infections began long before the medics had arrived in the country, and that they were due to poor hygiene and the reuse of equipment and needles.14 The Libyan authorities finally agreed to release the medics to spend the rest of their sentences in Bulgaria, but on arrival, they were pardoned by the Bulgarian President and returned home to their friends and families.15

Optimism regarding South Africa’s response to the AIDS crisis was short lived after it was announced in August that the Deputy Health Minister Nozizwe Madlala-Routledge had been fired. After years of denial and inaction in the country it was felt that Madlala-Routledge was a government member who finally recognised the seriousness of the epidemic and was determined to take effective action. The official reason for Madlala-Routledge’s dismissal was cited as her inappropriate labelling of infant deaths at Frere Hospital as ‘a national emergency’ and accusations of her attendance at an AIDS conference in Spain without the President’s permission. But it was felt that the underlying motive for her dismissal was her ongoing conflict with Tshabalala-Msimang, the Health Minister, and in particular their contrasting opinions on how to confront AIDS.16

It was revealed that the African nation of Botswana had managed to dramatically reduce rates of mother to child HIV transmission. Botswana, with one of the highest HIV prevalence rates in the world, set up a comprehensive treatment and care programme, to ensure that all women were being tested for HIV in pregnancy and offered appropriate drugs to prevent HIV being passed to their babies. Without intervention, around one in three babies born to HIV positive mothers will become infected with HIV themselves; but by implementing this programme, Botswana successfully cut the mother-to-child transmission rate to under 4%.17

In August, the U.S. Food and Drug Administration (FDA) granted accelerated approval to the new HIV drugs maraviroc (Selzentry) and raltegravir (Isentress). These two new drugs offered hope to patients infected with virus strains resistant to almost all other classes of drugs designed to fight AIDS.18

In October, it was revealed that hundreds of South Africans who had been involved in an AIDS vaccine trial might have an increased risk of HIV infection as a result. The trial, which was being conducted by the Merck pharmaceutical company, had been halted in the previous month after initial results showed the vaccine to be ineffective, an outcome that was described by leading vaccine researcher Dr. Gary Nabel as “a big blow to the field.”19 It was revealed that the infection rate was higher among people who received the vaccine than among those given a placebo. Experts said the vaccine itself could not have caused HIV infection, but it may have increased the risk of transmission by affecting immune responses.20

The biographer of Thabo Mbeki revealed in November that the South African President remained unconvinced that HIV caused AIDS. Mbeki had previously stepped back from the AIDS debate in South Africa in 2000 after causing much controversy.21
2008 History

At the beginning of 2008 the Swiss Federal Commission for HIV/AIDS published the findings of four studies, showing that people living with HIV who take effective antiretroviral therapy cannot pass on the virus through unprotected sex, as long as they adhere to the drugs, have an undetectable viral load for at least six months, and have no other sexually transmitted infections. It was not possible to prove conclusively that transmission is impossible, however the commission reported that scientific evidence showed the risk to be “negligibly small”. 22

The Swiss statement was met by immediate controversy, with questions over the reliability of its conclusions coming from HIV/AIDS advocacy groups as well as scientists. Concerns focused on the fact that the research was based solely on heterosexual couples and therefore neglected to include anal sex 23. UNAIDS and the WHO quickly issued a statement stressing that consistent use of condoms was still the safest protection against HIV. 24
Michel Sidibe, Executive Director of UNAIDS giving a speach.

Michel Sidibé, Executive Director of UNAIDS

In April, the Executive Director of UNAIDS, Peter Piot, announced that he would be stepping down at the end of the year. An editorial in The Lancet praised Piot for having “raised the profile of HIV/AIDS so successfully that the epidemic has remained a high priority on health, political and security agendas". 25 Later in the year it was announced that Michel Sidibé would be Piot’s successor. 26 27

In June, a team of scientists in South Africa were tried and found guilty by a South African court for conducting unauthorised medical trials and selling unregistered vitamin supplements as a treatment for AIDS. One of the supervisors of the illegal trials, Matthias Rath, was already widely criticised for his promotion of vitamins as a substitute for antiretroviral drugs. The South African court halted the medical trials and banned Rath from advertising his natural AIDS remedies. It also highlighted the responsibility of the South African government and its failure in not preventing Rath from distributing his products. 28

The American PEPFAR funding program was renewed on 30th July, committing $48 billion to HIV/AIDS, malaria and tuberculosis for fiscal years 2009-2013.29 This was triple the amount of money that the fund had distributed in its initial five years, and was commended by international HIV/AIDS activists and organisations. However, they stressed that the bill only authorised the expenditure and the money would still need to be appropriated each year. 30

The Reauthorization Act 31 also repealed a policy that had received substantial criticism: the requirement that one third of funding be spent exclusively on the promotion of sexual abstinence. However, it was replaced with a ‘reporting requirement’ for recipients who spend less than 50 percent of prevention funds on abstinence-only programmes. It was argued that this perpetuated bias in PEPFAR spending. 32

The political and economic climate in Zimbabwe worsened dramatically in 2008, exacerbating an already severe AIDS epidemic. A cholera outbreak that began in August was so critical that by December, UK Prime Minister Gordon Brown was describing the crisis as an “international emergency”. 33 The effect of the outbreak on people living with HIV and AIDS was compounded by the collapse of the health system, the government’s block on foreign aid, and widespread malnutrition, leading to an equally devastating AIDS crisis. 34 35

Medicines Sans Frontiers (MSF) estimated that in Bulawayo (the second largest city in Zimbabwe) there were 2,500 patients still waiting to receive antiretroviral drugs by the end of 2008. Even those who were able to access drugs were put at risk by the widespread lack of food, with 2008 producing the worst harvest Zimbabwe had experienced since the country gained independence in 1980. 36 The government’s decision to ban most international aid groups, which was imposed at the beginning of June and lasted throughout July and August, exacerbated food and drug shortages farther. MSF called for an urgent increase in the humanitarian response to the crisis, and stressed the importance of HIV and AIDS being a prominent part of this response 37

The seventeenth International AIDS Conference took place in Mexico City in August. For the first time in the history of the Conference, 2008 saw the use of ‘conference hubs’: a network of locations around the world where conference sessions were screened and accompanied by moderated discussion. The ‘hubs’ were considered very successful in widening the reach of the conference. 38

In the same month, UNAIDS published its 2008 report on the global AIDS epidemic. The report warned that with 2010 only two years away, the target of universal access by 2010 would be unattainable unless the global response to HIV was substantially strengthened and accelerated. However it also emphasised that signs of major progress in the HIV response were being seen for the first time in 2008.

“The 2008 Report on the global AIDS epidemic confirms that the world is, at last, making some real progress in its response to AIDS.” - Peter Piot, Executive Director of UNAIDS

Describing a "stabilization of the global epidemic", the report estimated that by the end of 2007 there were 33 million people living with HIV worldwide (down from the 39.5 million estimate made at the end of 2006). Although much of the reduction was attributed to better surveillance techniques in many countries, it also reflected the drop in HIV prevalence in certain areas, including sub-Saharan Africa. The report estimated that the annual number of AIDS deaths had declined from 2.2 million in 2005 to 2 million in 2007, reflecting an increase in the number of people receiving antiretroviral drugs. 39
Dr. Robert Gallo

Dr. Robert Gallo

In September, the resignation of president Thabo Mbeki was welcomed as a potential turning point in the controversial history of HIV and AIDS in South Africa. A Harvard study published shortly after asserted that more than 330,000 lives were lost between 2000 and 2005 as a direct result of the South African government’s failures in the provision of antiretroviral drugs. 40 The decision of interim president Kgalema Motlanthe to immediately appoint a new health minister, Barbara Hogan, was celebrated by AIDS activists as a sign of a new commitment to the AIDS response. 41 42

An old controversy was revived in October with the announcement of the winners of the Nobel Prize for medicine. The prize was split between Françoise Barré-Sinoussi and Luc Montagnier of the Pasteur Institute in Paris for their discovery of HIV, and a third scientist for his work on a separate disease. The decision not to credit American researcher Robert Gallo for his contribution to early work on AIDS resurrected a bitter dispute over who claimed rights to the discovery. In awarding the prize, the chair of the Nobel committee, Professor Bertil Fredholm, stated:

"I think it is really well established that the initial discovery of the virus was in the Institute Pasteur." 43

In November, German haematologist Gero Huetter announced that he had cured a man of HIV through a bone marrow transplant from a donor who had a genetic resistance to the virus. Huetter spoke at a press conference in Berlin stating that the patient, who was taken off antiretroviral drugs after the transplant two years before, continued to show no traces of the virus, leading doctors to declare him “functionally cured”. 44 However, it was generally accepted that the operation did not present a viable cure for AIDS. Researchers cautioned that further testing was needed to ensure that the virus had been completely eradicated and not just suppressed to very low levels or become latent. 45
100 days to fight AIDS March in washington D.C.

"100 days to fight AIDS" march in Washington D.C.

Also in November, Barack Obama was elected President of the United States of America. As part of his election campaign, Obama released a plan to combat global HIV and AIDS promising a move away from ideology and a greater focus on “best practice” in America’s HIV/AIDS strategy. 46 At home, Obama committed to implementing a comprehensive national strategy on HIV and AIDS in America in his first year, and to signing universal health care legislation by the end of his first term. In terms of America’s response to HIV and AIDS overseas, Obama pledged that he would substantially increase funding to both PEPFAR and the Global Fund. 47 However, commentators have questioned the likelihood of this pledge being followed through in the context of the unfolding international financial crisis.

Obama also openly supported lifting the ban on states using federal funding for needle exchange programmes 48 and pledged to overturn the controversial policy banning funding to international organisations that perform or promote abortion (known as the global gag rule). As the year drew to a close, HIV/AIDS advocacy groups and commentators expressed high expectations for the future of America's response to the AIDS epidemic under Obama. However there was emphasis on the need to maintain pressure to ensure that campaign promises are followed through. 49

History of AIDS up to 1986

2009-12-03T04:39:00.000-08:00

These are some of the most important events that occurred in the history of AIDS up to 1986.
Up to 1980

We do not know how many people developed AIDS in the 1970s, or indeed in the years before. We do now know that the origin of AIDS and the virus HIV was probably in Africa. What we also know is:

"The dominant feature of this first period was silence, for the human immunodeficiency virus (HIV) was unknown and transmission was not accompanied by signs or symptoms salient enough to be noticed. While rare, sporadic case reports of AIDS and sero-archaeological studies have documented human infections with HIV prior to 1970, available data suggest that the current pandemic started in the mid- to late 1970s. By 1980, HIV had spread to at least five continents (North America, South America, Europe, Africa and Australia). During this period of silence, spread was unchecked by awareness or any preventive action and approximately 100,000-300,000 persons may have been infected." - Jonathan Mann 1

1981 History

Kaposi's Sarcoma (KS) was a rare form of relatively benign cancer that tended to occur in older people. But by March 1981 at least eight cases of a more aggressive form of KS had occurred amongst young gay men in New York.2

At about the same time there was an increase, in both California and New York, in the number of cases of a rare lung infection Pneumocystis carinii pneumonia (PCP)3. In April this increase in PCP was noticed at the Centers for Disease Control (CDC) in Atlanta. A drug technician, Sandra Ford, noticed a high number of requests for the drug pentamine, used in the treatment of PCP:

"A doctor was treating a gay man in his 20s who had pneumonia. Two weeks later, he called to ask for a refill of a rare drug that I handled. This was unusual - nobody ever asked for a refill. Patients usually were cured in one 10-day treatment or they died" - Sandra Ford for Newsweek 4

In June, the CDC published a report about the occurrence, without identifiable cause, of PCP in five men in Los Angeles5. This report is sometimes referred to as the "beginning" of AIDS, but it might be more accurate to describe it as the beginning of the general awareness of AIDS in the USA.

A few days later, following these reports of PCP and other rare life-threatening opportunistic infections, the CDC formed a Task Force on Kaposi's Sarcoma and Opportunistic Infections (KSOI).6
Dr. Curran

Dr. Conant and Dr Volverg discussing

Kaposi's Sarcoma. Circa 1981

Around this time a number of theories were developed about the possible cause of these opportunistic infections and cancers. Early theories included infection with cytomegalovirus, the use of amyl nitrite or butyl nitrate "poppers", and "immune overload".7 8 9

Because there was so little known about the transmission of what seemed to be a new disease, there was concern about contagion, and whether the disease could by passed on by people who had no apparent signs or symptoms.10 Knowledge about the disease was changing so quickly that certain assumptions made at this time were shown to be unfounded just a few months later. For example, in July 1981 Dr Curran of the CDC was reported as follows:

"Dr. Curran said there was no apparent danger to non homosexuals from contagion. 'The best evidence against contagion', he said, 'is that no cases have been reported to date outside the homosexual community or in women'" - The New York Times 11

Just five months later, in December 1981, it was clear that the disease affected other population groups, when the first cases of PCP were reported in injecting drug users.12 At the same time the first case of AIDS was documented in the UK.13
1982 History

The disease still did not have a name, with different groups referring to it in different ways. The CDC generally referred to it by reference to the diseases that were occurring, for example lymphadenopathy (swollen glands), although on some occasions they referred to it as KSOI, the name already given to the CDC task force.14 15

In contrast some still linked the disease to its initial occurrence in gay men, with a letter in The Lancet calling it "gay compromise syndrome".16 Others called it GRID (gay-related immune deficiency), AID (acquired immunodeficiency disease), "gay cancer" or "community-acquired immune dysfunction".17 18

In June a report of a group of cases amongst gay men in Southern California suggested that the disease might be caused by an infectious agent that was sexually transmitted.19

By the beginning of July a total of 452 cases, from 23 states, had been reported to the CDC.20

Later that month the first reports appeared that the disease was occurring in Haitians, as well as haemophiliacs.21 22 This news soon led to speculation that the epidemic might have originated in Haiti, and caused some parents to withdraw their children from haemophiliac camps.23

The occurrence of the disease in non-homosexuals meant that names such as GRID were redundant. The acronym AIDS was suggested at a meeting in Washington, D.C., in July.24 By August this name was being used in newspapers and scientific journals.25 26 27 AIDS (Acquired Immune Deficiency Syndrome) was first properly defined by the CDC in September.28

By the beginning of July a total of 452 cases, from 23 states, had been reported to the CDC

An anagram of AIDS, SIDA, was created for use in French and Spanish.29 Doctors thought AIDS was an appropriate name because people acquired the condition rather than inherited it; because it resulted in a deficiency within the immune system; and because it was a syndrome, with a number of manifestations, rather than a single disease.30

Still very little was known about transmission and public anxiety continued to grow.

"It is frightening because no one knows what's causing it, said a 28-year old law student who went to the St. Mark's Clinic in Greenwich Village last week complaining of swollen glands, thought to be one early symptom of the disease. Every week a new theory comes out about how you're going to spread it." - The New York Times 31

By 1982 a number of AIDS specific voluntary organisations had been set up in the USA. They included the San Francisco AIDS Foundation (SFAF), AIDS Project Los Angeles (APLA), and Gay Men's health Crisis (GMHC).32 In November 1982 the first AIDS organisation, the "Terry Higgins Trust" (later known as the Terrence Higgins Trust), was formally established in the UK, and by this time a number of AIDS organisations were already producing safer sex advice for gay men.33 34

In December a 20-month old child who had received multiple transfusions of blood and blood products died from infections related to AIDS.35 This case provided clearer evidence that AIDS was caused by an infectious agent, and it also caused additional concerns about the safety of the blood supply. Also in December, the CDC reported the first cases of possible mother to child transmission of AIDS.36

By the end of 1982 many more people were taking notice of this new disease, as it was clearer that a much wider group of people was going to be affected.

"When it began turning up in children and transfusion recipients, that was a turning point in terms of public perception. Up until then it was entirely a gay epidemic, and it was easy for the average person to say 'So what?' Now everyone could relate." - Harold Jaffe of the CDC for newsweek 37

It was also becoming clear that AIDS was not a disease that just occurred in the USA. Throughout 1982 there were separate reports of the disease occurring in a number of European countries.38

Meanwhile in Uganda, doctors were seeing the first cases of a new, fatal wasting disease. This illness soon became known locally as 'slim'.39
1983 History

In January, reports of AIDS among women with no other risk factors suggested the disease might be passed on through heterosexual sex.40

At about the same time the CDC convened a meeting to consider how the transmission of AIDS could be prevented, and in particular to consider the newly emerged evidence that AIDS might be spread through blood clotting factor and through blood transfusions. As James Curran, the head of the CDC task force, said:

"The sense of urgency is greatest for haemophiliacs. The risk for others [who receive blood products] now appears small, but is unknown."41

The risk for haemophiliacs was so great because the blood concentrate that some haemophiliacs used exposed them to the blood of up to 5,000 individual blood donors.

In March, the CDC stated that,

"persons who may be considered at increased risk of AIDS include those with symptoms and signs suggestive of AIDS; sexual partners of AIDS patients; sexually active homosexual or bisexual men with multiple partners; Haitian entrants to the United States; present or past abusers of IV drugs; patients with haemophilia; and sexual partners of individuals at increased risk for AIDS."

The same report also said,

"each group contains many persons who probably have little risk of acquiring AIDS... Very little is known about risk factors for Haitians with AIDS."42

Nevertheless, the inclusion of Haitians as a risk group caused much controversy. Haitian Americans complained of stigmatisation, officials accused the CDC of racism, and Haiti suffered a serious blow to its tourism industry.43 44 Before long people were talking colloquially of a "4-H Club" at risk of AIDS: homosexuals, haemophiliacs, heroin addicts and Haitians.45 46 Some people substituted hookers for haemophiliacs.47

In May 1983, doctors at the Institute Pasteur in France reported that they had isolated a new virus, which they suggested might be the cause of AIDS

In the UK there were public concerns about the blood supply with references in newspapers to "killer blood".48 The media more generally started to take notice of AIDS, with the screening of a TV Horizon programme, "The Killer in the Village", and a number of newspaper articles on the subject of the "gay plague".49 50

In May 1983, doctors at the Institute Pasteur in France reported that they had isolated a new virus, which they suggested might be the cause of AIDS.51 Little notice was taken of this announcement at the time, but a sample of the virus was sent to the CDC.52 A few months later the virus was named lymphadenopathy-associated virus or LAV, patents were applied for, and a sample of LAV was sent to the National Cancer Institute.53

But whilst progress was being made by scientists there was at the same time increasing concern about transmission, and not just in relation to the blood supply. A report of AIDS occurring in children suggested quite incorrectly the possibility of casual household transmission.54

AIDS transmission became a major issue in San Francisco, where the Police Department equipped patrol officers with special masks and gloves for use when dealing with what the police called "a suspected AIDS patient".

"The officers were concerned that they could bring the bug home and their whole family could get AIDS." - The New York Times 55

And in New York:

"landlords have evicted individuals with AIDS" and "the Social Security Administration is interviewing patients by phone rather than face to face." - Dr David Spencer, Commisioner of Health, New York City 56

There was considerable fear about AIDS in many other countries as well:

"In many parts of the world there is anxiety, bafflement, a sense that something has to be done - although no one knows what." - The New York Times 57

As anxiety continued, the CDC tried to provide reassurance that children with AIDS had probably acquired it from their mothers and that casual transmission did not occur:

"The cause of AIDS is unknown, but it seems most likely to be caused by an agent transmitted by intimate sexual contact, through contaminated needles, or, less commonly, by percutaneous inoculation of infectious blood or blood products. No evidence suggests transmission of AIDS by airborne spread. The failure to identify cases among friends relatives, and co-workers of AIDS patients provides further evidence that casual contact offers little or no risk [...] the occurrence in young infants suggests transmission from an affected mother to a susceptible infant before, during, or shortly after birth."58

Reports from Europe suggested that two rather separate AIDS epidemics were occurring. In the UK, West Germany and Denmark, the majority of people with AIDS were homosexual, and many had a history of sex with American nationals. However in France and Belgium AIDS was occurring mainly in people from Central Africa or those with links to the area.59

Examples of this second epidemic included a number of previously healthy African patients who were hospitalised in Belgium with opportunistic infections (such as PCP and cryptosporidosis), Kaposi's sarcoma, or other AIDS-like illnesses. All of these Africans had immune deficiency similar to that of American AIDS patients. However they had no history of blood transfusion, homosexuality, or intravenous drug abuse.60 In light of such reports, European and American scientists set out to discover more about the occurrence of AIDS in Central Africa.

By this time, doctors working in parts of Zambia and Zaire had already noticed the emergence of a very aggressive form of Kaposi's sarcoma. This cancer was endemic in Central Africa, but previously it had progressed very slowly and responded well to treatment, whereas the new cases looked very different and were often fatal.61 62

In September the CDC published their first set of recommended precautions for health-care workers and allied professionals designed to prevent "AIDS transmission".63 In the UK, people who might be particularly susceptible to AIDS were asked not to donate blood.64

In October, the first European World Health Organisation (WHO) meeting was held in Denmark. At the meeting it was reported that there had been 2,803 AIDS cases in the USA.65

That meeting was followed in November by the first meeting to assess the global AIDS situation. This was the start of global surveillance by the WHO and it was reported that AIDS was present in the U.S.A., Canada, fifteen European countries, Haiti and Zaire as well as in seven Latin American countries. There were also cases reported from Australia and two suspected cases in Japan.66

By the end of the year the number of AIDS cases in the USA had risen to 3,064 and of these 1,292 had died.67
1984 History

At the CDC researchers had been continuing to investigate the cause of AIDS through a study of the sexual contacts of homosexual men in Los Angeles and New York. They identified a man as the link between a number of different cases and they named him "patient O" for "Out of California".68 The research appeared to confirm that AIDS was a transmittable disease, and the co-operation of "patient O" contributed to the study.69

However a problem arose when other people read the scientific paper.

"I called this guy Patient O... But my colleagues read it as Patient Zero." - Darrow for Newsweek 70

And so in March 1984 the myth of Patient Zero began.71 See 1987 for more information about Patient Zero.

Just one month later, on April 22nd, Dr Mason of the CDC was reported as saying:

"I believe we have the cause of AIDS."

He was referring to the French virus, LAV, and he was basing his opinion on the findings made in the preceding weeks by the researchers at the Pasteur Institute who had discovered the virus the previous year.72
Margaret Heckler

Margaret Heckler

Just one day later, on April 23rd, the United States Health and Human Services Secretary Margaret Heckler announced that Dr. Robert Gallo of the National Cancer Institute had isolated the virus which caused AIDS, that it was named HTLV-III, and that there would soon be a commercially available test able to detect the virus with "essentially 100 percent certainty". It was a dramatic and optimistic announcement that also included:

"We hope to have a vaccine [against AIDS] ready for testing in about two years."

And it concluded with:

"yet another terrible disease is about to yield to patience, persistence and outright genius".73 74

The same day patent applications were filed covering Gallo's work, but there was clearly a possibility that LAV and HTLV-III were the same virus.75 76 The scientific papers regarding Gallo's discovery of HTLV-III were published on 4th May.77 By 17th May, private companies were already applying to the Department of Health & Human Services for licences to develop a commercial test, which would detect evidence of the virus in blood, a test which it had already been said would be used to screen the entire supply of donated blood in the USA.78 79

Meanwhile there continued to be concern about the public health aspects of AIDS. This was particularly the case in San Francisco where all the gay bath houses and private sex clubs were closed. Some gay men regarded the closures as an attack on their civil rights. But Mervyn Silverman, Director of the San Francisco Department of Public Health stated the public health view as follows:
Dr Robert Gallo

Dr Robert Gallo

"There are certain places where things are allowed and certain places where they are not. You can't have sex at the McDonald's. You generally cannot have sex in the pews of a church or in a synagogue. People don't feel their civil liberties are being in any way abrogated because of that."80

Researchers who had visited Central Africa in late 1983 reported they had identified 26 patients with AIDS in Kigali, Rwanda, and 38 in Kinshasa, Zaire. The Rwandan study concluded that, "an association of an urban environment, a relatively high income, and heterosexual promiscuity could be a risk factor for AIDS in Africa".81 The Zairian study found there to be a "strong indication of heterosexual transmission".82

In light of these findings the Zairian Department of Public Health, in collaboration with American and European scientists, launched a national AIDS research programme called Project SIDA.83

By the end of 1984, there had been 7,699 AIDS cases and 3,665 AIDS deaths in the USA, and 762 cases had been reported in Europe.84 85 In the UK there had been 108 cases and 46 deaths.86
1985 History

In January 1985 a number of more detailed reports were published concerning LAV and HTLV-III, and by March it was clear that the viruses were the same.87 The same month the U.S Food and Drug Administration (FDA) licensed, for commercial production, the first blood test for AIDS. The test would reveal the presence of antibodies to HTLV-III/LAV, and it was announced that anyone who had antibodies in their blood would not in future be allowed to donate blood.88

There were a number of social and ethical issues, as well as certain medical matters, that had to be considered before the new test could be used even to ensure the safety of the blood supply. And even more aspects needed to be considered before the test could be more widely used. Concern particularly centred on issues of confidentiality and the meaning of a positive test result.89 90

"Richard Dunne, director of the Gay Men's Health Crisis, said that the group would not object to the wider availability of the procedure provided that certain safeguards were assured: informed consent, good counselling and confidentiality, 'which means anonymity,' he said. He stressed that the city must prevent insurance companies, employers, schools and others from gaining access to test results." - The New York Times 91

The first small-scale needle and syringe exchange project had been started in 1984 in Amsterdam, the Netherlands, but more projects were started in 1985 as a result of growing concerns about HTLV-III/LAV.92

In April more than 2000 people attended the first international Conference on AIDS held in Atlanta. Three major topics of discussion were the new HTLV-III/LAV test, the situation with regard to AIDS internationally, and the extent of heterosexual transmission.93
'AIDS is everyone's problem' campaign poster

"Some experts are sceptical that AIDS will spread as rapidly among heterosexuals as it has among homosexuals. Yet other experts, taking their cues from data emerging from preliminary studies from Africa showing equal sex distribution among males and females, are less sure." - The New York Times 94

Immediately after the conference, the World Health Organization (WHO) organized an international meeting to consider the AIDS pandemic and to initiate concerted worldwide action.95

Meanwhile in many countries there was a separate "epidemic of fear" and prejudice.96

In the UK tabloid press, AIDS gained many headlines and caused alarm among the public. In some newspapers, the prejudice was obvious. The haemophiliacs were seen as the "innocent victims" of AIDS whereas gays and drug-users were seen as having brought the disease upon themselves.97 The fear of AIDS caused firemen to ban the kiss of life, and caused holidaymakers to cut their holiday short for fear of contracting AIDS from an HTLV-III positive passenger on the Queen Elizabeth 2.98 99 A 9-year old HTLV-III positive haemophiliac was allowed to attend the local school, but some of the pupils where kept home by anxious parents.100
'This is not a setting for AIDS' campaign poster

In the US, it was feared that drinking communion wine from a common cup could transmit AIDS, and Ryan White, a 13-year old haemophiliac with AIDS, was barred from school.101 102

"In 1985, at 13, Ryan White became a symbol of the intolerance that is inflicted on AIDS victims. Once it became known that White, a haemophiliac, had contracted the disease from a tainted blood transfusion, school officials banned him from classes." - Time Magazine 103

The CDC removed Haitians from their list of AIDS risk groups, in light of information that suggested both heterosexual contact and exposure to contaminated needles played a role in transmission.104

On September 17th, President Reagan publicly mentioned AIDS for the first time, when he was asked about AIDS funding at a press conference. At the same press conference he was also asked a question whether he would send his children if they were younger to school with a child who has AIDS.

"It is true that some medical sources had said that this cannot be communicated in any way other than the ones we already know and which would not involve a child being in the school. And yet medicine has not come forth unequivocally and said, 'This we know for a fact, that it is safe.' And until they do, I think we just have to do the best we can with this problem. I can understand both sides of it." - Ronald W. Reagan 105

Drugs such as ribavirin, thought to be active against HTLV-III/LAV, were being smuggled from Mexico into the USA.106

The actor Rock Hudson died of AIDS on October 3rd 1985. He was the first major public figure known to have died of AIDS.107

All UK blood transfusion centres began routine testing of all blood donations for HTLV-III/LAV in October.108

For the Global Surveillance of AIDS, the WHO had initially used the definition of AIDS as developed in the USA in 1982. But this definition was difficult to use in developing countries where there was a lack of sophisticated laboratory tests. So in order to help with the surveillance of AIDS, particularly in Africa, a new WHO definition was adopted in October. This definition of AIDS became known as the Bangui definition.109

Towards the end of the year, Western scientists became much more aware of the "slim disease" that had become increasingly common in South West Uganda since 1982. Studies found that most cases were among promiscuous heterosexuals, the majority of whom tested positive for antibodies to HTLV-III/LAV. The site and timing of the first reported cases suggested that the disease arose in neighbouring Tanzania. Some scientists who studied slim concluded: " "Although slim disease resembles AIDS in many ways, it seems to be a new entity."110 ". However, others thought differently:

""[Evidence] suggests that slim disease cannot be distinguished from AIDS and ARC [AIDS related complex] by extreme weight loss and diarrhoea. Thus slim disease may not be a new syndrome but simply identical with AIDS as seen in Africa."111"

In December 1985, the Pasteur Institute filed a lawsuit against the National Cancer Institute to claim a share of the royalties from the NCI's patented AIDS test.112

During the year, knowledge of transmission routes was to change again, when the first report appeared of the transmission of the virus from mother to child through breast feeding.113 The first case of AIDS was also reported in China, and AIDS had as a result been reported in every region in the world.114

By the end of 1985, 20,303 cases of AIDS had been reported to the World Health Organisation.115 In the USA 15,948 cases of AIDS had been reported,116 and in the UK 275 cases.117
1986 History

In the UK the first needle exchange scheme started in Dundee 118 and the AIDS charity AVERT was also started.

In the UK, the government launched, in March, the first public information campaign on AIDS, with the slogan "Don't Aid AIDS". There were a series of advertisements in national newspapers.119

There was still at this time disagreement about the name of the virus.

"The name of the virus had itself become a political football as the French insisted on LAV (lymphadenopathy-associated virus), while Gallo's group used HTLV-3 (human T-cell lymphotropic virus, type 3)." - Time Magazine 120

In May 1986, the International Committee on the Taxonomy of Viruses ruled that both names should be dropped and the dispute solved by a new name, HIV (Human Immunodeficiency Virus).121

At the opening speech of the International Conference in Paris, held from 23rd to 25th June 1986, Dr H Mahler, the Director of WHO, announced that as many as 10 million people worldwide could already be infected with HIV.122

In August, the USA Federal Government accused an employer of illegal discrimination against a person with AIDS for the first time. A hospital had dismissed a nurse and refused to offer him an alternative job. This was seen as a violation of his civil rights.123

In September there was dramatic progress in the provision of medical treatment for AIDS, when early results of clinical tests showed that a drug called azidothymidine (AZT) slowed down the attack of HIV. AZT was first synthesised in 1964 as a possible anticancer drug but it proved ineffective.

The AZT clinical trial divided patients into two groups: one received AZT and the other received placebo, or dummy drugs. At the end of six months, only one patient in the AZT group was dead, whilst there were 19 deaths among the placebo group. The clinical trial was stopped early, because it was thought to be unethical to deny the patients of the placebo groups a better chance of survival.124
US surgeons general report on AIDS logo

"The announcement set off a flurry of excitement and controversy. AIDS hotlines and doctors' offices were flooded with calls, community leaders warned about undue optimism, and doctors debated the ethical and medical issues raised by the early cancellation of the AZT study." - Time Magazine 125

In the United States, the Surgeon General's Report on AIDS was published. The report was the Government's first major statement on what the nation should do to prevent the spread of AIDS. The "unusually explicit" report urged parents and schools to start "frank, open discussions" about AIDS.126

By this time, scientists had accumulated enough evidence to form an overview of AIDS in Africa. Studies of medical records showed there had been marked increases in a number of AIDS-related conditions during the late 1970s and early 1980s. In particular:

* Slim disease in Kinshasa, Zaire (late 1970s)
* Slim disease in Uganda and Tanzania (early 1980s)
* Esophagel candidiasis in Rwanda (from 1983)
* Aggressive Kaposi's sarcoma in Kinshasa, Zaire (early 1980s)
* Aggressive Kaposi's sarcoma in Zambia and Uganda (from 1982 and 1983)
* Crypotococcal meningitis in Kinshasa, Zaire (late 1970s to early 1980s).

In conclusion:

"These studies suggested that while isolated cases of AIDS may have occurred in Africa earlier, it was probably rare until the late 1970's and early 1980's, a pattern similar to that in the United States and Haiti."127

As in developed countries, AIDS in Africa was found to primarily affect young and middle-aged people, especially those who were unmarried. The sex and age distributions were seen to reflect other sexually transmitted diseases, and the major transmission routes had been identified:

"Available data suggest that heterosexual activity, blood transfusions, vertical transmission from mother to infant, and probably frequent exposure to unsterilized needles account for the spread of HIV infection and AIDS in Africa."128

HIV and AIDS had also been detected in India, among sex workers in the southern state of Tamil Nadu, igniting fears that the disease would soon spread across the subcontinent. In response, the Indian government decided to increase the number of HIV testing centres and improve the screening of blood donations.129

By the end of the year, 85 countries had reported 38,401 cases of AIDS to the World Health Organisation. By region these were: Africa 2,323, Americas 31,741, Asia 84, Europe 3,858, and Oceania 395.130History of AIDS up to 1986

The Origin of AIDS and HIV May Not Be What You Have Learned

2009-12-03T04:33:00.000-08:00

Most people believe that the origin of HIV, the AIDS virus, derives from some natural evolutionary event. Key among these HIV origin theories is the so called "cut hunter theory" in which a human, allegedly African native, received a bloody wound or infected splash while preparing a chimpanzee carrying a similar virus (i.e., SIVcpz). Most recent research, along with the scientific consensus, holds that the origin of HIV and AIDS could never have happened this way.

In 2001, The Royal Society of London's conference proceedings, which sought to determine the initial cause of AIDS and the origin of HIV, were published for the world to behold. The most highly respected scientists and academicians debated the possibility that HIV-1, the most widespread and deadly human AIDS virus, evolved from accidental vaccine contaminations and subsequent transmissions to mostly African villagers. The oral polio vaccine (OPV) received the focus of interest here since that vaccine was partially derived from growing live polio viruses in monkey kidney cells that have historically proven to be contaminated with cancer viruses such as SV40 -- the 40th monkey virus ever discovered. This virus, like HIV-1, is currently linked by medical scientists to widespread human cancers. By the end of the symposium, the esteemed delegates concluded HIV's origin, and AIDS, was not likely to have come from polio vaccine transmissions as chimpanzees were not proven to have been used during the manufacture of this vaccine

The hepatitis B vaccine was not considered by this esteemed gathering. Suspiciously neglected, this vaccine was produced in chimpanzees during pilot testing conducted in New York City, among gay men, and Central African villagers between 1972 and 1974. This was precisely timed for the emergence of AIDS in these exact, demographically distinct, communities by the late 1970s. The fact that this fact was neglected proves shoddy science or gross negligence at best.

Importantly, among the most respected of all HIV/AIDS origin theorists, the U.S. Government's chief DNA sequence analyst at the Los Alamos Laboratory in New Mexico , Dr. Gerald Myers, reported with his colleagues that the origin of HIV could not have begun with "cut hunters" or other single isolated cross species transmissions (called "zoonosis"). He reported that genetic sequencing studies prove some "punctuated origin of AIDS event" took place during the mid-1970s giving rise, virtually simultaneously, to at least ten different HIV "clades" (or genetic subtypes) associated with ten different distinguishable AIDS epidemics in Africa alone. The most likely cause of this widespread bizarre zoonosis was some man-made (i.e., iatrogenic) event involving chimpanzees.

Myers and his colleagues offered the following best explanation for the origin of HIV: "It is not far-fetched," they wrote, "to imagine the ten or so clades deriving from a single animal (perhaps immunosuppressed and possessing a swarm of variants) [as might have been the case with chimpanzees used in the process of hepatitis B vaccine manufacture] or from a few animals that might have belonged to a single troop or might have been gang-caged together. The number of animals required is secondary to the extent of variation in the source at the time of the zoonotic or iatrogenic event. The [vaccine] hypothesis makes a case for such a punctuated origin . . ." (See: Burr T, Hyman JM and Myers G. The origin of acquired immune deficiency syndrome: Darwinian or Lamarchkian? Phil. Trans. R. Soc. Lond. B (2001) 356:877-887.)

So if chimpanzees were not used to make the polio vaccine, and therefore the origin of HIV and AIDS did not come from this vaccine nor time period (1950s-early 1960s), then what other vaccine, given during the early to mid 1970s, might have used one or more SIVcpz-infected chimpanzees in the manufacturing process?

The answer to this question was singularly advanced by a Harvard-degreed independent investigator, Dr. Leonard Horowitz in the award winning book Emerging Viruses: AIDS & Ebola -- Nature, Accident or Intentional? (Tetrahedron Press, 1998; 1-888-508-4787; http:www.tetrahedron.org) Dr. Horowitz unearthed and reprinted stunning scientific documents and National Institutes of Health contracts proving that chimpanzees, contaminated with numerous viruses, were used to produce hundreds of hepatitis B vaccine doses administered to central African Blacks along with homosexual men in New York City at precisely the time Dr. Myers and colleagues claim the origin of HIV "punctuated event" occurred.

Unfortunately, as another Royal Society conference presenter, Dr. Julian Cribb, protested, too little attention is given by drug-industry-influenced medical journals, and the mainstream media, to controversial truths in science regarding the origin of HIV and AIDS. (See: Cribb J. The origin of acquired immune deficiency syndrome: can science afford to ignore it? Phil. Trans. R. Soc. Lond B (2001) 356:935-938.) As a result, documents such as those published by Dr. Horowitz, and others, showing AIDS apparently derives from contaminated hepatitis B vaccines, have never received adequate attention.

he origin of AIDS and HIV has puzzled scientists ever since the illness first came to light in the early 1980s. For over twenty years it has been the subject of fierce debate and the cause of countless arguments, with everything from a promiscuous flight attendant to a suspect vaccine programme being blamed. So what is the truth? Just where did AIDS come from?

The first recognised cases of AIDS occurred in the USA in the early 1980s (more about this period can be found on our history of aids page). A number of gay men in New York and California suddenly began to develop rare opportunistic infections and cancers that seemed stubbornly resistant to any treatment. At this time, AIDS did not yet have a name, but it quickly became obvious that all the men were suffering from a common syndrome.

The discovery of HIV, the Human Immunodeficiency Virus, was made soon after. While some were initially resistant to acknowledge the connection (and indeed some remain so today), there is now clear evidence to prove that HIV causes AIDS. So, in order to find the source of AIDS, it is necessary to look for the origin of HIV, and find out how, when and where HIV first began to cause disease in humans.
HOW?
What type of virus is HIV?

HIV is a lentivirus, and like all viruses of this type, it attacks the immune system. Lentiviruses are in turn part of a larger group of viruses known as retroviruses. The name 'lentivirus' literally means 'slow virus' because they take such a long time to produce any adverse effects in the body. They have been found in a number of different animals, including cats, sheep, horses and cattle. However, the most interesting lentivirus in terms of the investigation into the origins of HIV is the Simian Immunodeficiency Virus (SIV) that affects monkeys.
So did HIV come from an SIV?
It is now thought that HIV came from a similar virus found in chimpanzees.

It is now generally accepted that HIV is a descendant of a Simian Immunodeficiency Virus because certain strains of SIVs bear a very close resemblance to HIV-1 and HIV-2, the two types of HIV.

HIV-2 for example corresponds to SIVsm, a strain of the Simian Immunodeficiency Virus found in the sooty mangabey (also known as the White-collared monkey), which is indigenous to western Africa.

The more virulent, pandemic strain of HIV, namely HIV-1, was until recently more difficult to place. Until 1999, the closest counterpart that had been identified was SIVcpz, the SIV found in chimpanzees. However, this virus still had certain significant differences from HIV.
What happened in 1999?

In February 1999 a group of researchers from the University of Alabama1 announced that they had found a type of SIVcpz that was almost identical to HIV-1. This particular strain was identified in a frozen sample taken from a captive member of the sub-group of chimpanzees known as Pan troglodytes troglodytes (P. t. troglodytes), which were once common in west-central Africa.

The researchers (led by Paul Sharp of Nottingham University and Beatrice Hahn of the University of Alabama) made the discovery during the course of a 10-year long study into the origins of the virus. They claimed that this sample proved that chimpanzees were the source of HIV-1, and that the virus had at some point crossed species from chimps to humans.

Their final findings were published two years later in Nature magazine2. In this article, they concluded that wild chimps had been infected simultaneously with two different simian immunodeficiency viruses which had "viral sex" to form a third virus that could be passed on to other chimps and, more significantly, was capable of infecting humans and causing AIDS.

These two different viruses were traced back to a SIV that infected red-capped mangabeys and one found in greater spot-nosed monkeys. They believe that the hybridisation took place inside chimps that had become infected with both strains of SIV after they hunted and killed the two smaller species of monkey.

They also concluded that all three 'groups' of HIV-1 - namely Group M, N and O (see our strains and subtypes page for more information on these) - came from the SIV found in P. t. troglodytes, and that each group represented a separate crossover 'event' from chimps to humans.
How could HIV have crossed species?

It has been known for a long time that certain viruses can pass between species. Indeed, the very fact that chimpanzees obtained SIV from two other species of primate shows just how easily this crossover can occur. As animals ourselves, we are just as susceptible. When a viral transfer between animals and humans takes place, it is known as zoonosis.

Below are some of the most common theories about how this 'zoonosis' took place, and how SIV became HIV in humans:
The 'Hunter' Theory

The most commonly accepted theory is that of the 'hunter'. In this scenario, SIVcpz was transferred to humans as a result of chimps being killed and eaten or their blood getting into cuts or wounds on the hunter. Normally the hunter's body would have fought off SIV, but on a few occasions it adapted itself within its new human host and become HIV-1. The fact that there were several different early strains of HIV, each with a slightly different genetic make-up (the most common of which was HIV-1 group M), would support this theory: every time it passed from a chimpanzee to a man, it would have developed in a slightly different way within his body, and thus produced a slightly different strain.

An article published in The Lancet in 20043, also shows how retroviral transfer from primates to hunters is still occurring even today. In a sample of 1099 individuals in Cameroon , they discovered ten (1%) were infected with SFV (Simian Foamy Virus), an illness which, like SIV, was previously thought only to infect primates. All these infections were believed to have been acquired through the butchering and consumption of monkey and ape meat. Discoveries such as this have led to calls for an outright ban on bushmeat hunting to prevent simian viruses being passed to humans.
The Oral Polio Vaccine (OPV) theory
Could production of the oral polio vaccine have contributed to the spread of HIV?

Could production of the oral polio vaccine

have contributed to the spread of HIV?

Some other rather controversial theories have contended that HIV was transferred iatrogenically (i.e. via medical interventions). One particularly well-publicised idea is that polio vaccines played a role in the transfer.

In his book, The River, the journalist Edward Hooper suggests that HIV can be traced to the testing of an oral polio vaccine called Chat, given to about a million people in the Belgian Congo, Ruanda and Urundi in the late 1950s. To be reproduced, live polio vaccine needs to be cultivated in living tissue, and Hooper's belief is that Chat was grown in kidney cells taken from local chimps infected with SIVcmz. This, he claims, would have resulted in the contamination of the vaccine with chimp SIV, and a large number of people subsequently becoming infected with HIV-1.

Many people have contested Hooper's theories and insist that local chimps were not infected with a strain of SIVcmz that is closely linked to HIV. Furthermore, the oral administration of the vaccine would seem insufficient to cause infection in most people (SIV/HIV needs to get directly into the bloodstream to cause infection - the lining of the mouth and throat generally act as good barriers to the virus).4

In February 2000 the Wistar Institute in Philadelphia (one of the original manufacturers of the Chat vaccine) announced that it had discovered in its stores a phial of polio vaccine that had been used as part of the program. The vaccine was subsequently analysed and in April 2001 it was announced that no trace had been found of either HIV or chimpanzee SIV.5 A second analysis confirmed that only macaque monkey kidney cells, which cannot be infected with SIV or HIV, were used to make Chat.6 While this is just one phial of many, it means that the OPV theory remains unproven.

The fact that the OPV theory accounts for just one (group M) of several different groups of HIV also suggests that transferral must have happened in other ways too, as does the fact that HIV seems to have existed in humans before the vaccine trials were ever carried out. More about when HIV came into being can be found below.
The Contaminated Needle Theory

This is an extension of the original 'hunter' theory. In the 1950s, the use of disposable plastic syringes became commonplace around the world as a cheap, sterile way to administer medicines. However, to African healthcare professionals working on inoculation and other medical programmes, the huge quantities of syringes needed would have been very costly. It is therefore likely that one single syringe would have been used to inject multiple patients without any sterilisation in between. This would rapidly have transferred any viral particles (within a hunter's blood for example) from one person to another, creating huge potential for the virus to mutate and replicate in each new individual it entered, even if the SIV within the original person infected had not yet converted to HIV.
The Colonialism Theory

The colonialism or 'Heart of Darkness' theory, is one of the more recent theories to have entered into the debate. It is again based on the basic 'hunter' premise, but more thoroughly explains how this original infection could have led to an epidemic. It was first proposed in 2000 by Jim Moore, an American specialist in primate behaviour, who published his findings in the journal AIDS Research and Human Retroviruses.7

During the late 19th and early 20th century, much of Africa was ruled by colonial forces. In areas such as French Equatorial Africa and the Belgian Congo, colonial rule was particularly harsh and many Africans were forced into labour camps where sanitation was poor, food was scarce and physical demands were extreme. These factors alone would have been sufficient to create poor health in anyone, so SIV could easily have infiltrated the labour force and taken advantage of their weakened immune systems to become HIV. A stray and perhaps sick chimpanzee with SIV would have made a welcome extra source of food for the workers.

Moore also believes that many of the labourers would have been inoculated with unsterile needles against diseases such as smallpox (to keep them alive and working), and that many of the camps actively employed prostitutes to keep the workers happy, creating numerous possibilities for onward transmission. A large number of labourers would have died before they even developed the first symptoms of AIDS, and those that did get sick would not have stood out as any different in an already disease-ridden population. Even if they had been identified, all evidence (including medical records) that the camps existed was destroyed to cover up the fact that a staggering 50% of the local population were wiped out there.

One final factor Moore uses to support his theory, is the fact that the labour camps were set up around the time that HIV was first believed to have passed into humans - the early part of the 20th century.
The Conspiracy Theory

Some say that HIV is a 'conspiracy theory' or that it is 'man-made'. A recent survey carried out in the US for example, identified a significant number of African Americans who believe HIV was manufactured as part of a biological warfare programme, designed to wipe out large numbers of black and homosexual people.8 Many say this was done under the auspices of the US federal 'Special Cancer Virus Program' (SCVP), possibly with the help of the CIA. Linked in to this theory is the belief that the virus was spread (either deliberately or inadvertently) to thousands of people all over the world through the smallpox inoculation programme, or to gay men through Hepatitis B vaccine trials. While none of these theories can be definitively disproved, the evidence given to back them up is usually based upon supposition and speculation, and ignores the clear link between SIV and HIV or the fact that the virus has been identified in people as far back as 1959.
WHEN?

During the last few years it has become possible not only to determine whether HIV is present in a blood or plasma sample, but also to determine the particular subtype of the virus. Studying the subtype of virus of some of the earliest known instances of HIV infection can help to provide clues about the time it first appeared in humans and its subsequent evolution.

Four of the earliest known instances of HIV infection are as follows:

1. A plasma sample taken in 1959 from an adult male living in what is now the Democratic Republic of the Congo.9
2. A lymph node sample taken in 1960 from an adult female, also from the Democratic Republic of the Congo.10
3. HIV found in tissue samples from an American teenager who died in St. Louis in 1969.11
4. HIV found in tissue samples from a Norwegian sailor who died around 1976.12

A 1998 analysis of the plasma sample from 1959 suggested that HIV-1 was introduced into humans around the 1940s or the early 1950s.13

In January 2000, the results of a new study14 suggested that the first case of HIV-1 infection occurred around 1931 in West Africa. This estimate (which had a 15 year margin of error) was based on a complex computer model of HIV's evolution.

However, a study in 200815 dated the origin of HIV to between 1884 and 1924, much earlier than previous estimates. The researchers compared the viral sequence from 1959 (the oldest known HIV-1 specimen) to the newly discovered sequence from 1960. They found a significant genetic difference between them, demonstrating diversification of HIV-1 occurred long before the AIDS pandemic was recognised.

The authors suggest a long history of the virus in Africa and call Kinshasa the “epicentre of the HIV/AIDS pandemic” in West Africa. They propose the early spread of HIV was concurrent with the development of colonial cities, in which crowding of people increased opportunities for transmission. If accurate, these findings imply that HIV existed before many scenarios (such as the OPV and conspiracy theories) suggest.
What about HIV-2? When did that get passed to humans?

Until recently, the origins of the HIV-2 virus had remained relatively unexplored. HIV-2 is thought to come from the SIV in Sooty Mangabeys rather than chimpanzees, but the crossover to humans is believed to have happened in a similar way (i.e. through the butchering and consumption of monkey meat). It is far rarer, significantly less infectious and progresses more slowly to AIDS than HIV-1. As a result, it infects far fewer people, and is mainly confined to a few countries in West Africa.

In May 2003, a group of Belgian researchers led by Dr. Anne-Mieke Vandamme, published a report16 in Proceedings of the National Academy of Science. By analysing samples of the two different subtypes of HIV-2 (A and B) taken from infected individuals and SIV samples taken from sooty mangabeys, Dr Vandamme concluded that subtype A had passed into humans around 1940 and subtype B in 1945 (plus or minus 16 years or so). Her team of researchers also discovered that the virus had originated in Guinea-Bissau and that its spread was most likely precipitated by the independence war that took place in the country between 1963 and 1974 (Guinea-Bissau is a former Portuguese colony). Her theory was backed up by the fact that the first European cases of HIV-2 were discovered among Portuguese veterans of the war, many of whom had received blood transfusions or unsterile injections following injury, or had possibly had relationships with local women.
WHERE?

The question of exactly where the transfer of HIV to humans took place, and where the 'epidemic' officially first developed has always been controversial. Some have suggested that it is dangerous to even try to find out, as AIDS has frequently been blamed on an innocent person or group of individuals in the past. However, scientists remain keen to find the true origin of HIV, as most agree it is important to understand the virus and its epidemiology in order to fight it.
So did it definitely come from Africa?

Given the evidence we have already looked at, it seems highly likely that Africa was indeed the continent where the transfer of HIV to humans first occurred (monkeys from Asia and South America have never been found to have SIVs that could cause HIV in humans). In May 2006, the same group of researchers who first identified the Pan troglodytes troglodytes strain of SIVcpz, announced that they had narrowed down the location of this particular strain to wild chimpanzees found in the forests of Southern Cameroon17. By analysing 599 samples of chimp droppings (P. T. troglodytes are a highly endangered and thus protected species that cannot be killed or captured for testing), the researchers were able to obtain 34 specimens that reacted to a standard HIV DNA test, 12 of which gave results that were virtually indistinguishable from the reactions created by human HIV. The researchers therefore concluded that the chimpanzees found in this area were highly likely the origin of both the pandemic Group M of HIV-1 and of the far rarer Group N. The exact origins of Group O however remain unknown.

HIV Group N principally affects people living in South-central Cameroon, so it is not difficult to see how this outbreak started. Group M, the group that has caused the worldwide pandemic, was however first identified in Kinshasa, in the Democratic Republic of Congo. It is not entirely clear how it transferred from Cameroon to Kinshasa, but the most likely explanation is that an infected individual travelled south down the Sangha river that runs through Southern Cameroon to the River Congo and then on to Kinshasa, where the Group M epidemic probably began.

Just as we do not know exactly who spread the virus from Cameroon to Kinshasa, how the virus spread from Africa to America is also not entirely clear. However, recent evidence suggests that the virus may have arrived via the Caribbean island of Haiti.
Why is Haiti significant?

The AIDS epidemic in Haiti first came to light in the early 1980s, at around the same time that cases in the USA were being uncovered. Following the discovery of a number of Haitians with Kaposi's Sarcoma and other AIDS-related conditions, medical journals and books began to claim that AIDS had come from Haiti, and that Haitians were responsible for the AIDS epidemic in the United States.

These claims, which were often founded on dubious evidence, fuelled pre-existing racism in the US and many Haitians suffered severe discrimination and stigmatisation as a result. A large number of Haitian immigrants living in the US lost their jobs and were evicted from their homes as Haitians were added to homosexuals, haemophiliacs and heroin users to make the 'Four-H Club' of groups at high risk of AIDS.18

The emotionally-charged culture of blame and prejudice that surrounded HIV and AIDS in the early years meant that it soon became politically difficult to present epidemiological findings in a neutral and objective way. For many years the link between Haiti and the US epidemic was therefore dropped as a subject.

In March 2007 however, it returned to the public eye at the Fourteenth Conference on Retroviruses and Opportunistic Infections (CROI) in Los Angeles. A group of international scientists presented data based on complex genetic analysis of 122 early samples of HIV-1, group M, subtype B (the most common strain found in the USA and in Haiti) showing that the strain had probably been brought to Haiti from Africa by a single person in around 1966; a time when many Haitians would have been returning from working in the Congo.19

Genetic analysis then showed that subtype B spread slowly from person to person on the island, before being transferred to the US, again probably by a single individual, at some point between 1969 and 1972. A paper published in October 2007 by Worobey and colleagues gave a 99.7% certainty that HIV subtype B originated in Haiti before passing to the US.20

It is possible that HIV had entered the US several times before subtype B took a firm hold (which would explain the infection of the St. Louis teenager in the early to mid-1960s), but it was the late 1960s / early 1970s transfer that is believed to be responsible for the widespread epidemic seen in the US today. Once the virus had established itself in the gay community, in would have spread fairly rapidly (anal intercourse carries a very high transmission risk), with transmission occurring within and between the US and Haiti, and internationally, until the original route taken by the virus was largely obscured.

Dr Michael Worobey, lead researcher in the study, claimed that his data was not intended to place any blame on Haiti, or on Central Africans, and stressed that none of the people who first transmitted HIV would have been aware they were infected. His work still received strong protests from one Haitian delegate at the CROI conference however, demonstrating the extent to which tracing HIV’s origins remains a politically sensitive exercise.
What caused the epidemic to spread so suddenly?

There are a number of factors that may have contributed to the sudden spread of HIV, most of which occurred in the latter half of the twentieth century.
Travel
International travel has undoubtedly played a major role in the spread of HIV.

International travel has undoubtedly played

a major role in the spread of HIV.

Both national and international travel undoubtedly had a major role in the initial spread of HIV. In the US, international travel by young men making the most of the gay sexual revolution of the late 70s and early 80s would certainly have played a large part in taking the virus worldwide. In Africa, the virus would probably have been spread along truck routes and between towns and cities within the continent itself. However, it is quite conceivable that some of the early outbreaks in African nations were not started by Africans infected with the 'original' virus at all, but by people visiting from overseas where the epidemic had been growing too. The process of transmission in a global pandemic is simply too complex to blame on any one group or individual.

Much was made in the early years of the epidemic of a so-called 'Patient Zero' who was the basis of a complex "transmission scenario" compiled by Dr. William Darrow and colleagues at the Centre for Disease Control in the US. This epidemiological study showed how 'Patient O' (mistakenly identified in the press as 'Patient Zero') had given HIV to multiple partners, who then in turn transmitted it to others and rapidly spread the virus to locations all over the world. A journalist, Randy Shilts, subsequently wrote a book21 based on Darrow's findings, which named Patient Zero as a gay Canadian flight attendant called Gaetan Dugas. For several years, Dugas was vilified as a 'mass spreader' of HIV and the original source of the HIV epidemic among gay men. However, four years after the publication of Shilts' article, Dr. Darrow repudiated his study, admitting its methods were flawed and that Shilts' had misrepresented its conclusions.

While Gaetan Dugas was a real person who did eventually die of AIDS, the Patient Zero story was not much more than myth and scaremongering. HIV in the US was to a large degree initially spread by gay men, but this occurred on a huge scale over many years, probably a long time before Dugas even began to travel.
The Blood Industry

As blood transfusions became a routine part of medical practice, an industry to meet this increased demand for blood began to develop rapidly. In some countries such as the USA , donors were paid to give blood, a policy that often attracted those most desperate for cash; among them intravenous drug users. In the early stages of the epidemic, doctors were unaware of how easily HIV could be spread and blood donations remained unscreened. This blood was then sent worldwide, and unfortunately most people who received infected donations went on to become HIV positive themselves.

In the late 1960's haemophiliacs also began to benefit from the blood clotting properties of a product called Factor VIII. However, to produce this coagulant, blood from hundreds of individual donors had to be pooled. This meant that a single donation of HIV+ blood could contaminate a huge batch of Factor VIII. This put thousands of haemophiliacs all over the world at risk of HIV, and many subsequently became infected with the virus.
Drug Use

The 1970s saw an increase in the availability of heroin following the Vietnam War and other conflicts in the Middle East , which helped stimulate a growth in intravenous drug use. This increased availability and together with the development of disposable plastic syringes and the establishment of 'shooting galleries' where people could buy drugs and rent equipment, provided another route through which the virus could be passed on.
CONCLUSIONS

It is likely that we will never know who the first person was to be infected with HIV, or exactly how it spread from that initial person. Scientists investigating the possibilities often become very attached to their individual 'pet' theories and insist that theirs is the only true answer, but the spread of AIDS could quite conceivably have been induced by a combination of many different events. Whether through injections, travel, wars, colonial practices or genetic engineering, the realities of the 20th Century have undoubtedly had a major role to play. Nevertheless, perhaps a more pressing concern for scientists today should not be how the AIDS epidemic originated, but how those it affects can be treated, how the further spread of HIV can be prevented and how the world can change to ensure a similar pandemic never occurs again.

Risk factors for HIV/AIDS

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In HIV negative individuals

*
Education regarding HIV/AIDS- Regarding routes of transmission of HIV
*
To know the HIV status of any sexual partner
*
To use latex condoms every time you have sex if the HIV status of the partner is unknown
*
Male circumcision- a study conducted has showed 53 percent reduction of HIV infection in circumcised HIV-negative men compared with uncircumcised men
*
Use sterile disposable needles- not to share needles and syringes
*
Blood and blood products always need to be HIV screened
*
Regular screening tests- if you're a man or woman, who has had sex with one or more new partners, are tested annually.

In HIV positive individuals

*
Avoid sexual practices that expose them to blood, semen or vaginal secretions.
*
Using a new latex condom every time you have vaginal or anal sex and using a dental dam, condom or piece of plastic wrap during oral sex
*
Don’t share needles and syringes
*
Don’t donate blood or organs
*
Don’t share razor blades or tooth brushes
*
If your partner is pregnant, tell her you have HIV - She needs to receive treatment to protect her own health and that of her baby.

Safer sex

*
Safer sex is sex between 2 people who don't have HIV infection or any STDs
*
Only have sex with each other
*
Not using injectable drugs
*
Using male latex condoms if you have any doubts about whether your partner is infected or whether he or she is having sex with someone else.
*
If a man doesn't want to use a male condom, use a female condom. Female condoms may not be as effective as male condoms, but they offer some protection.
*

isk factors for HIV/AIDS

Unprotected sexual intercourse

*
Unprotected vaginal, anal or oral sex with multiple partners (heterosexual, homosexual or bisexual)
*
Unprotected sex with HIV-positive partner
*
During sex, HIV can be transmitted through cuts and tears on the penis, vagina, or anus.
*
Through these cuts and tears, infected blood, semen, vaginal fluids, and anal fluids may enter the uninfected person's body.
*
Cuts and scrapes are more likely during anal sex, forced sex, dry sex, or when women are very young (because their cervixes are not fully developed and therefore more likely to rip or tear during intercourse).

Role of STD’s in HIV/AIDS

Increased susceptibility

STDs probably increase susceptibility to HIV infection by two different mechanisms.

*
Genital ulcers (e.g., syphilis, herpes, or chancroid) result in breaks in the genital tract lining or skin. These breaks create a portal of entry for HIV.
*
Non-ulcerative STDs (e.g., chlamydia, syphilis, herpes, gonorrhea, and trichomoniasis) increase the concentration of cells in genital secretions that can serve as targets for HIV (e.g., CD4+ cells).

Increased infectiousness

When HIV-infected individuals are also infected with other STDs, they are more likely to have HIV in their genital secretions.

HIV in semen is as much as 10 times higher in men who are infected with both gonorrhea and HIV than in men infected only with HIV.
Unsafe drug abuse behaviors

*
Sharing or injecting drug use paraphernalia, such as needles and syringes, increases the risk of HIV transmission.
*
People who use illegal injectable drugs are also more likely to have STI/STD, which increase their risk for both contracting and transmitting HIV.
*
Mixing sex, drugs and alcohol interact in many ways to increase a person's risk of getting or giving HIV.
*
The use of these substances can increase sexual desire and enhance underlying personality characteristics, such as and sexual compulsivity.

Blood transfusion

Blood transfusion or received blood a blood clotting factors before 1985.
Mother- to- fetus/infant transmission (vertical transmission)

*
Infants are infected with HIV, either during pregnancy or delivery or through breast-feeding.
*
But if women receive treatment for HIV infection during pregnancy, the risk to their babies is significantly reduced.
*
Pregnant women who are HIV-infected and who are co-infected with genital herpes have a higher risk of transferring AIDS to their child.

Psychological risk factors

*
Psychological disorders such as hypersexuality, sexual obsession, and depression, are associated with high-risk sexual behaviors with multiple partners.
*
They are also associated with drug abuse and addiction, which can increase HIV risk through needle sharing and injection

HIV/AIDS is not transmitted by hugging, kissing, dancing or shaking hands — with someone who has HIV or AIDS.
Not to enter blood, semen, urine, vaginal fluid or feces get into anus, vagina or mouth, in HIV infected individuals

Prevention of AIDS

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HIV infection finally leads to the development of the AIDS. After the HIV infection it takes some years for the AIDS to set in. Once a patient starts getting opportunistic infections then the stage is termed as Acquired Immune Deficiency Syndrome (AIDS). It is a very dangerous disease and there is no vaccine and definitive treatment available for the effective protection and treatment of the disease. Therefore the prevention is only cure for the disease. The transmission of the disease will be by blood, semen, vaginal secretions and breast milk into the body. Measures to prevent HIV infection are -

* Education is the most important tool to improve the social awareness regarding the disease and is the effective mean to prevent the transmission.
* Before going for unprotected sex HIV status of the partner should be confirmed.
* New condom should be used every time the vaginal or anal sex is performed. Old condom should be thrown away and should not be repeated at all. One can chose from polyurethane or latex condoms. Females can also use female condoms. One should not use oil based lubricant along with the latex condoms as they tend to weaken the condom. Along with latex condoms only water based lubricants should be used. While doing oral sex, flavored condoms, dental dam or plastic wrap can be used.
* Male circumcision reduces a man's risk of acquiring HIV through heterosexual intercourse by more than 50%. Medically performed circumcision although carries a lot of other benefits also.
* Drug users should use new needle every time to inject the drug.
* Blood or blood products transfusion should be taken into account only after ensuring personally that the product is free from HIV. One should not only rely on the blood bank but he/she should check the certificate of the laboratory themselves.
* If someone has multiple sexual partners than he/she shall take the tests yearly to rule out any infection. Like women are advised Pap smear yearly.
* Although the number of deaths have decreased due to the AIDS by the newer drugs available in the market and due to the latest modalities of treatment but still one should keep in mind that AIDS is not curable and there is no vaccine available for the HIV yet.
* HIV infected persons should always follow the safe sex practices and should take effective protection so that they will not pass on infection to others.
* All the partners of HIV infected person need to be tested and if positive then they will need the proper medical care.
* Pregnant lady if infected with HIV should take appropriate treatment so that the transmission of the disease to the fetus is prevented.
* HIV infected person should not share needles or syringes, donate blood or organs, share razor blades or toothbrushes to prevent the effective transmission of the virus to others.

The ‘ART’ of managing HIV

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HIV is one of the greatest public health challenges the world is facing today. However, the response mankind mounted against this epidemic is historic. There is no other disease in the history which provoked such a comprehensive, prompt and effective response within a short span of time.

When HIV first struck in the world, the virtual absence of any hope regarding possible treatment or vaccine led to widespread scare, stigma and discrimination against the infected. The only measure we could take was spreading preventive messages.

But by 1996, we had an effective drug therapy which could bring back the lost immunity by suppressing the virus in the human body. From a death sentence, it changed to a chronic manageable disease. India started its Antiretroviral Programme with just eight ART centres in high prevalence States and the national capital in 2004 which grew to 224 full-fledged ART centres providing regular ART to more than 2,70,000 individuals today. It is worth mentioning that Kerala has achieved a unique distinction for starting its own ART programme in 2004 by providing free ART through all Government Medical Colleges which has been merged with the national programme now. Currently, the State has six ART centres and eight Link Art Centres. 4,018 People Living with HIV (PLHIV) are taking ART drugs from our centres, which are branded as Ushus Centres, for awareness purposes. 11,024 PLHIVs have registered themselves at the Ushus Centres for whom regular check-ups are provided. The availability of ART through the public healthcare system has changed the way world looked at HIV. It gradually became a chronic manageable disease. The mortality rate of HIV has suddenly reduced.

Earlier, the drug regime was complicated. Now it has been simplified, which helps the treatment adherence. Management of opportunistic infections for PLHIVs have helped them to gather confidence for a positive living. All these have increased the quality of living of PLHIVs. This led to large number of people who are at the risk of having this infection to come openly seeking HIV tests.

HIV is a developmental issue and several studies so far from various parts of the world have showed that HIV care has a role in the macro and micro economy of the society. For example, a study at the Thrissur Medical College showed that 74 percent of PLHIVs taking ART are employed at 10 months of ART and many of them got employed for the first time after the initiation of ART.

It is also possible that ART can reduce the transmission significantly, as the virus circulating in the blood reduces to undetectable level in few months of regular treatment. Also, ART can reduce the chance of a person - a healthcare provider getting infected during a surgery or a child getting infected from the mother. Proper care during pregnancy can reduce the transmission rate from mother to child to less than 2 percent from 30-40 percent without care. Even though we have many success stories, it is not the time to be complacent.

The recently published AIDS epidemic update by UNAIDS and WHO shows that even though there is a significant fall in new infections worldwide since 2006, the epidemic is still evolving and even the factors affecting the spread is not uniform.

Stigma and discrimination continue to be a big stumbling block in providing quality care and support services. Human rights violations in the name of HIV is also continuing. Hence, this World AIDS Day is the time for us to renew our pledge and promises we have made to the present and future generations.

The Impact of HIV/AIDS

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Over the past 27 years, nearly 25 million people have died from AIDS.1 HIV/AIDS causes debilitating illness and premature death in people during their prime years of life and has devastated families and communities. Further, HIV/AIDS has complicated efforts to fight poverty, improve health, and promote development by:2

* Diminishing a person’s ability to support, work and provide for his or her family. At the same time, treatment and health-care costs related to HIV/AIDS consume household incomes. The combined effect of reduced income and increased costs impoverishes individuals and households.

* Deepening socioeconomic and gender disparities. Women are at high risk of infection and have few options for providing for their families. Children affected by HIV/AIDS, due to their own infection or parental illness or death, are less likely to receive an education, as they leave school to care for ailing parents and younger siblings.

* Straining the resources of communities – hospitals, social services, schools and businesses. Health care workers, teachers, and business and government leaders have been lost to HIV/AIDS. The impact of diminished productivity is felt on a national scale.

Through unprecedented global attention and intervention efforts, the rate of new HIV infections has slowed and prevalence rates have leveled off globally and in many regions. Despite the progress seen in some countries and regions, the total number of people living with HIV continues to rise.

* In 2007, globally, about 2 million people died of AIDS, 33 million were living with HIV and 2.7 million people were newly infected with the virus.1

* HIV infections and AIDS deaths are unevenly distributed geographically and the nature of the epidemics vary by region. Epidemics are abating in some countries and burgeoning in others. More than 90 percent of people with HIV are living in the developing world.3

* There is growing recognition that the virus does not discriminate by age, race, gender, ethnicity, sexual orientation, or socioeconomic status – everyone is susceptible. However, certain groups are at particular risk of HIV, including men who have sex with men (MSM), injecting drug users (IDUs), and commercial sex workers (CSWs).

* The impact of HIV/AIDS on women and girls has been particularly devastating. Women and girls now comprise 50 percent of those aged 15 and older living with HIV.1

* The impact of HIV/AIDS on children and young people is a severe and growing problem. In 2007, 370,000 children under age 15 were infected with HIV and 270,000 died of AIDS.1, 4 In addition to the estimated 2 million children living with HIV/AIDS, about 15 million children have lost one or both parents due to the disease.1, 4

* There are effective prevention and treatment interventions, as well as research efforts to develop new approaches, medications and vaccines.

* The sixth Millennium Development Goal (MDG) focuses on stopping and reversing the spread of HIV/AIDS by 2015.

* Global funding is increasing, but global need is growing even faster – widening the funding gap. Services and funding are disproportionately available in developed countries.

Growing Up with HIV

2009-12-02T02:52:00.000-08:00

LUSAKA, Dec 1 (IPS) - Sixteen-year-old Andela Milambo* wants a husband. She is not looking for love, but for someone to share the burden of living with HIV. She wants to be able to take her medicine without having to hide, to discuss the recurring herpes with someone who understands.

Living with HIV since the age of six, she wants someone else to make the decisions, "while I read a magazine."

Milambo, says she got infected through a contaminated needle. She describes a life dominated by the fear of dying from AIDS but says the worst times are when she gets herpes flare-ups that make it hard to walk, talk or eat.

She skips school often due to "small illnesses" like colds which are usually accompanied by a bad cough that debilitate her body. Her grades are bad and she has little hope of obtaining a full certificate when she completes secondary school next year. "But that's alright, I was not intending to go to college anyway."

She has made no lasting friendships for fear that people will find out her HIV status. While her parents and a few close relatives who know her condition try to offer support, they actually make things worse, she says.

"I see them just age in front of me when I am sick, they get so stressed and sad, I prefer to suffer in silence."

She hears how young people talk about HIV and AIDS and the level of discrimination and ignorance frightens her. "I can never confide in a young person that I am positive, the stigma would kill me faster than AIDS."

Milambo envies other young girls going to movies, laughing, dancing. She has no time for that, she says, because she has to work to save her life. Instead she does "boring" things like peer education for her local clinic.

Rather wryly, she says, "Though I say it's boring, the clinic is the one place I feel comfortable at. As a peer educator I have the run of the place with no questions asked. So treatment and information for me is free and easy to get."

It is also the place Milambo is looking for a husband. "Men at the clinic are knowledgeable and because they work around HIV, they are compassionate. When I turn 18 I will choose one. As head of household, my husband will make the decisions regarding our welfare, while I watch television or read a fashion magazine… being married would make me a "proper person" because everyone aspires to be married, at least that's the one thing I can achieve."

James Banda also wants a normal life. The eighteen-year-old is openly living with HIV and confines himself to dating HIV positive girls because he hates having to explain to every new girl why he has to take pills on a regular basis. The girls usually run away from him after that, he says. "The ones that stick around see me as a charity challenge and I am their good Christian deed."

Infected with HIV on his first sexual encounter, his life's mission now is to find a girl with whom he can have a child.

Banda says after his diagnosis he did things "by the book."

"I went for rigorous counseling, came out in a big way, telling anyone that would listen about my status, I did the whole nine yards. I was celebrated by NGOs who made me the poster boy of an HIV positive youth. But after a while, the novelty wore off and I got tired of always talking about HIV as if that's what defines me."

He says there are times when he wishes he had not disclosed his status. Like when he goes to a disco and people come up to him to caution him not to drink, or whisper that he shouldn't be there, that he has not "learnt his lesson."

"The books on living positively with HIV says I should continue to live as much of a normal life as possible. The reality is different; there can never be anything normal about my life."

Bouts of opportunistic infections, always being on the lookout for a cure or better therapy, not being able to plan ahead ten or even twenty years are some of the things that make his life abnormal, Banda says.

Having passed his school leaving exams with distinction, he is going to college next year to study accounting. He says he has it all; the support of his family, a few good friends and good future prospects. But living with HIV "is still damn hard."

Living with HIV in secrecy is what is harder still for Adam Malik*.

Drinking himself "senseless once in a while" is how Malik copes with his situation. A Zambian of Indian extraction, he lives in the close knit community that refuses to acknowledge HIV in their midst and openly stigmatises people with HIV.

Eighteen-year-old Malik knows this only too well, that's why not even his parents know that he contracted HIV at the age of 14 from the house maid with whom he had a sexual relationship for over a year, and has recently started treatment.

Malik says because he has always been a quiet solitary kind of person, no one notices when he is depressed or feeling unwell. He has not suffered any of the major opportunistic infections.

But, he adds: "Keeping such a secret is a heavy burden. I suffer tension headaches and have developed a facial tick from the stress."

Malik says he is fortunate Zambia has an efficient roll out for ARVs. He was surprised how easy it was to get onto the programme. Of course he chose an out of the way clinic where no one was likely to recognise him.

He reads up on the latest treatments but does not go for counseling as he is scared of being recognised.

Malik is also frightened that he will be coerced into jumping onto the HIV conference circuit as a young HIV positive Indian male. "I will be a novelty that the AIDS activists will not be able to resist. They will show me around like a trophy. I have seen it happen to youth who have come out."

His life on the outside has not changed, he says. He is still the good son, taking his mother and sisters shopping, helping his father in the family store, hanging out with the boys on a Friday night.

Soon a wife will be chosen for him and he will be expected to have children, he says. He wonders what will happen then. "It will kill my mother to know that I have HIV. My father will kick me out of his home. My sisters' chances of a good marriage will be ruined. When I think of all this, I hit the bottle to forget."

He knows that this will interfere with the efficacy of his medication, but finds it's the only way he can cope. "I am frightened," Malik says

YMCA to use peer educators to fight HIV prevalence

2009-12-02T02:48:00.001-08:00

Accra, Dec. 1, GNA - Young Men Christian Association (YMCA), a Christian youth organisation in Ghana, has committed its peer educator model to bring down the high HIV prevalence rate in the Eastern Region.

The HIV prevalence rate is steadily increasing in the region, with the last official figures putting it at 4.2 per cent in comparison to the national official figure of 1.9 per cent

"Of concern is that 90 per cent of new infections are in the 15 - 49 age bracket. This is the productive age meaning the country's labour force is at risk of dying in their prime time," Prosper K Hoeyi, National General Secretary of YMCA said in a statement issued in Accra, on Monday.

He said research had revealed that the high prevalence rate in the area was due to the rural nature of the communities and lack of education on HIV and AIDS, coupled with traditional beliefs.

The region is also bordered by four regions whilst there is migration of the people to Côte d'Ivoire in search of greener pastures.

"Côte d'Ivoire has the highest HIV prevalence rate in West Africa and we think this may be having a major impact on the increase of infection rates in the Eastern Region," he said.

In order to deal with the threat, YMCA has instituted the peer educator model under its national Adolescent Reproductive Health (ARH) programme, which is now in its fourth year and being funded by the YMCA of Greater Toronto.

Under this programme, students are trained and supervised for a number of years to become peer educators.

In Koforidua alone, 700 peer educators visit and interact with the youth and educate them about HIV/AIDS. More importantly the peer educators disabuse the minds of their friends, classmates and family members about the stereotypes, and myths about the disease.

Through peer education, beneficiaries are beginning to move away from old habits such as unprotected sex, sharing of blades and razors.

Families which have benefited from the programme no longer shy away from discussing sex with their adolescent children.

"Our peer educators in the Eastern and other regions are bringing positive feedback and are hopeful that as the programme takes root, YMCA will be complementing government efforts in no small way to fight HIV/AIDS," the statement added.

The statement encouraged the public to avail themselves of the peer education programme dotted around the country and get informed about AIDS.

GNA

YMCA to use peer educators to fight HIV prevalence

2009-12-02T02:48:00.000-08:00

When was HIV discovered, and how is it diagnosed?

2009-12-01T07:08:00.000-08:00

In 1981, homosexual men with symptoms of a disease that now are considered typical of the acquired immunodeficiency syndrome (AIDS) were first described in Los Angeles and New York. The men had an unusual type of lung infection (pneumonia) called Pneumocystis carinii (now known as Pneumocystis jiroveci) pneumonia (PCP) and rare skin tumors called Kaposi's sarcomas. The patients were noted to have a severe reduction in a type of cell in the blood that is an important part of the immune system, called CD4 cells. These cells, often referred to as CD4 T cells, help the body fight infections. Shortly thereafter, this disease was recognized throughout the United States, Western Europe, and Africa. In 1983, researchers in the United States and France described the virus that causes AIDS, now known as the human immunodeficiency virus (HIV) and belonging to the group of viruses called retroviruses. In 1985, a blood test became available that measures antibodies to HIV that are the body's immune response to the HIV. This blood test remains the best method for diagnosing HIV infection. Recently, tests have become available to look for these same antibodies in blood and saliva, some providing results within 20 minutes of testing.

How is HIV spread (transmitted)?

HIV is present to variable degrees in the blood and genital secretions of virtually all individuals infected with HIV, regardless of whether or not they have symptoms. The spread of HIV can occur when these secretions come in contact with tissues such as those lining the vagina, anal area, mouth, or eyes (the mucus membranes), or with a break in the skin, such as from a cut or puncture by a needle. The most common ways in which HIV is spreading throughout the world include sexual contact, sharing needles, and by transmission from infected mothers to their newborns during pregnancy, labor (the delivery process), or breastfeeding. (See the section below on treatment during pregnancy for a discussion on reducing the risk of transmission to the newborn.)

Sexual transmission of HIV has been described from men to men, men to women, women to men, and women to women through vaginal, anal, and oral sex. The best way to avoid sexual transmission is abstinence from sex until it is certain that both partners in a monogamous relationship are not HIV-infected. Because the HIV antibody test can take up to six months to turn positive after infection occurs, both partners would need to test negative six months after their last potential exposure to HIV. If abstinence is out of the question, the next best method is the use of latex barriers. This involves placing a condom on the penis as soon as an erection is achieved in order to avoid exposure to pre-ejaculatory and ejaculatory fluids that contain infectious HIV. For oral sex, condoms should be used for fellatio (oral contact with the penis) and latex barriers (dental dams) for cunnilingus (oral contact with the vaginal area). A dental dam is any piece of latex that prevents vaginal secretions from coming in direct contact with the mouth. Although such dams occasionally can be purchased, they are most often created by cutting a square piece of latex from a condom.

The spread of HIV by exposure to infected blood usually results from sharing needles, as in those used for illicit drugs. HIV also can be spread by sharing needles for anabolic steroids to increase muscle, tattooing, and body piercing. To prevent the spread of HIV, as well as other diseases including hepatitis, needles should never be shared. At the beginning of the HIV epidemic, many individuals acquired HIV infection from blood transfusions or blood products, such as those used for hemophiliacs. Currently, however, because blood is tested for both antibodies to HIV and the actual virus before transfusion, the risk of acquiring HIV from a blood transfusion in the United States is extremely small and is considered insignificant.

There is little evidence that HIV can be transferred by casual exposure, as might occur in a household setting. For example, unless there are open sores or blood in the mouth, kissing is generally considered not to be a risk factor for transmitting HIV. This is because saliva, in contrast to genital secretions, has been shown to contain very little HIV. Still, theoretical risks are associated with the sharing of toothbrushes and shaving razors because they can cause bleeding, and blood can contain large amounts of HIV. Consequently, these items should not be shared with infected people. Similarly, without sexual exposure or direct contact with blood, there is little if any risk of HIV contagion in the workplace or classroom.
What happens after an exposure to the blood or genital secretions of an HIV-infected person? What are symptoms of primary HIV infection?

The risk of HIV transmission occurring after any potential exposure to bodily fluids is poorly defined. The highest risk sexual activity, however, is thought to be anal intercourse without a condom. In this case, the risk of infection may be as high as 3%-5% for each exposure. The risk is probably less for vaginal intercourse without a condom and even less for oral sex without a latex barrier. Despite the fact that no single sexual exposure carries a high risk of contagion, HIV infection can occur after even one sexual event. Thus, people must always be diligent in protecting themselves from potential infection.

Within two to six weeks of an exposure, the majority of infected people will have a positive HIV antibody test, with virtually all being positive by six months. The test used most commonly for diagnosing infection with HIV is referred to as an ELISA. If the ELISA finds the HIV antibody, the presence of the antibody is confirmed by a test called a Western blot. There are now several rapid antibody tests that can be performed on blood or saliva and provide preliminary results within 20 minutes. These tests are fairly accurate but also need be confirmed with a Western blot. It is currently recognized that approximately 20% of HIV-infected individuals in the United States are not aware that they are infected, largely as a result of not having been tested. In September 2007, the Centers for Disease Control and Prevention recommended that HIV antibody testing be performed as part of routine care for individuals presenting to medical attention for any reason. The hope is that this strategy will reduce the number of infected individuals who are not aware of their status in order to both get them into medical care earlier and to counsel them as to how they can prevent spread to others. This strategy can be markedly enhanced with the rapid testing which can provide preliminary results before the patient leaves the medical facility.

During this period of time shortly after infection, more than 50% of those infected will experience a "flu-like" or "infectious mono-like" illness for up to several weeks. This illness is considered the stage of primary HIV infection. The most common symptoms of primary HIV infection are

* fever,

* aching muscles and joints,

* sore throat, and

* swollen glands (lymph nodes) in the neck.

It is not known, however, why only some HIV-infected people develop these symptoms. It also is unknown whether or not having the symptoms is related in any way to the future course of HIV disease. Regardless, infected people will become symptom-free (asymptomatic) after this phase of primary infection. During the first weeks of infection when a patient may have symptoms of primary HIV infection, antibody testing, if performed, may still be negative. If there is suspicion of early infection based upon the types of symptoms present and a potential recent exposure, consideration should be given to having a test performed that specifically looks for the virus circulating in the blood, such as a viral load test. Once the patient enters the asymptomatic phase, infected individuals will know whether or not they are infected if a test for HIV antibodies is done. Therefore, anyone who might possibly have been exposed to HIV should seek testing even if they are not experiencing symptoms.

During all stages of infection, literally billions of HIV particles (copies) are produced every day and circulate in the blood. This production of virus is associated with a decline (at an inconsistent rate) in the number of CD4 cells in the blood over the ensuing years. Although the precise mechanism by which HIV infection results in CD4 cell decline is not known; it probably results from a direct effect of the virus on the cell as well as the body's attempt to clear these infected cells from the system. In addition to virus in the blood, there is also virus throughout the body, especially in the lymph nodes, brain, and genital secretions. The time from HIV infection to the development of AIDS varies. Rarely, some individuals develop complications of HIV that define AIDS within one year, while others remain completely asymptomatic after as many as 20 years from the time of infection. However, the time for progression from initial infection to AIDS is usually approximately eight to10 years. The reason why people experience clinical progression of HIV at different rates remains an area of active research.
What laboratory tests are used to monitor HIV-infected people?

Two blood tests are routinely used to monitor HIV-infected people. One of these tests, which counts the number of CD4 cells, assesses the status of the immune system. The other test, which determines the so-called viral load, directly measures the amount of virus in the blood.

In individuals not infected with HIV, the CD4 count in the blood is normally above 400 cells per cubic milliliter (mm3) of blood. HIV-infected people generally do not become at risk for complications until their CD4 cells are fewer than 200 cells per mm3. At this level of CD4 cells, the immune system does not function adequately and is considered suppressed. A declining number of CD4 cells means that HIV disease is advancing. Thus, a low CD4 cell count signals that the person is at risk for one of the many unusual infections (the so-called opportunistic infections) that occur in individuals who are immunosuppressed. In addition, the actual CD4 cell count indicates which specific therapies should be initiated to prevent those infections.

The viral load actually measures the amount of virus in the blood and may partially predict whether or not the CD4 cells will decline in the coming months. In other words, those people with high viral loads are more likely to experience a decline in CD4 cells and progression of disease than those with lower viral loads. In addition, the viral load is a vital tool for monitoring the effectiveness of new therapies and determining when drugs are and are not working. Thus, the viral load will decrease within weeks of initiating an effective antiviral regimen. If a combination of drugs is very potent, the number of HIV copies in the blood will decrease by as much as 100-fold, such as from 100,000 to 1,000 copies per ml of blood in the first two weeks and gradually decrease even further during the ensuing 12-24 weeks. The ultimate goal is to get viral loads to below the limits of detection by standard assays, usually less than 50 or 75 copies per ml of blood. When viral loads are reduced to these low levels, it is believed that as long as the patient consistently takes their medications the viral suppression will persist for many years.

Drug resistance testing also has become a key tool in the management of HIV-infected individuals. Details of these tests will be discussed later. Clearly, resistance testing is now routinely used in individuals experiencing poor responses to HIV therapy or treatment failure. In general, a poor response to initial treatment would include individuals who fail to experience a decline in viral load of approximately 100-fold in the first weeks, have a viral load of greater than 500 copies per ml by week 12, or have levels greater than 50 or 75 copies per ml by week 24. Treatment failure would generally be defined as an increase in viral load after an initial decline in a person who is believed to be consistently taking his or her medications. More recent guidelines from the U.S. Department of Health and Human Services (DHHS) (http://www.hivatis.org) and International AIDS Society-USA (IAS-USA) have suggested that resistance testing be performed in individuals who have never been on therapy to determine if they might have acquired HIV that is resistant to drugs.

What are the key principles in managing HIV infection?

First of all, there is no evidence that people infected with HIV can be cured by the currently available therapies. In fact, individuals who are treated for years and are repeatedly found to have no virus in their blood experience a prompt rebound in the number of viral particles when therapy is discontinued. Consequently, the decision to start therapy must balance the risk versus the benefits of treatment. The risks of therapy include the short- and long-term side effects of the drugs, described in subsequent sections, as well as the possibility that the virus will become resistant to the therapy which can limit options for future treatment.

A major reason that resistance develops is the patient's failure to correctly follow the prescribed treatment, for example, by not taking the medications at the correct time. If virus remains detectable on any given regimen, resistance eventually will develop. Indeed, with certain drugs, resistance may develop in a matter of weeks, such as with lamivudine (Epivir, 3TC), emtricitabine (Emtriva, FTC), and the drugs in the class of nonnucleoside analogue reverse transcriptase inhibitors (NNRTI) such as nevirapine (Viramune, NVP), delavirdine (Rescriptor, DLV), and efavirenz (Sustiva, EFV). Thus, if these drugs are used as part of a combination of drugs that does not suppress the viral load to undetectable levels, resistance will develop rapidly and the treatment will lose its effectiveness. In contrast, HIV becomes resistant to certain other drugs, such as zidovudine (Retrovir, AZT), stavudine (Zerit, D4T), and protease inhibitors (PIs), over months. In fact, for some PIs whose effects are enhanced by giving them in combination with the PI, ritonavir (Norvir, RTV) to delay their clearance by the body, resistance appears to be markedly delayed. These drugs are discussed in more detail in subsequent sections, but it is important to note that when resistance develops to one drug, it often results in resistance to other related drugs, so called cross-resistance. Nevertheless, HIV-infected individuals must realize that antiviral therapy can be and typically is very effective. This is the case even in those who have a low CD4 cell count and advanced disease, as long as drug resistance has not developed.

Factors to consider before starting antiviral therapy

One of the most controversial areas in the management of HIV disease is deciding the best time to start antiviral treatment. Clearly, therapy during the mildly symptomatic stage of the disease delays progression to AIDS, and treating individuals with AIDS postpones death. Consequently, most experts have long agreed that patients who have experienced complications of HIV disease, such as oral thrush (yeast infection in the mouth), chronic unexplained diarrhea, fevers, weight loss, opportunistic infections, or dementia (for example, forgetfulness) should be started on antiviral treatment even if the symptoms are mild. In patients who do not have symptoms, however, there is more uncertainty. Most recommendations for this group are based on the predictors of clinical progression, such as the number of CD4 cells. One can envision that as treatments become easier to take, better tolerated, and increasingly effective, therapy will begin to be started earlier in the course of infection.

When to start antiviral therapy

Guidelines for starting antiviral therapy have been proposed by panels of experts from several groups including the DHHS and IAS-USA. They recommend treating all patients who have symptoms and those who have CD4 cell counts of less than 350 cells per mm3. Recent data supporting even earlier initiation of therapy includes analyses of groups of patients followed over time. Although the data is imperfect, a recent study showed that those who started treatment with CD4 cells greater than 500 cells per mm3 actually were less likely to die than those who did not start treatment until their CD4 cells declined to less than 500 cells/mm3. In addition, there is increasing evidence that ongoing viral replication, even in the setting of high CD4 cells may be associated with damage to the brain, kidneys, heart, and possibly even liver. Along with these studies arguing for earlier treatment, there is growing evidence that currently used treatments are usually very well tolerated and effective in suppressing viral load. Guidelines will continue to change with time, but for now, the emphasis should be on discussing all of the potential benefits and risks of therapy and deciding when is best for each individual. Regardless, all agree that HIV is generally a slowly progressive disease, and therapy rarely needs to be started abruptly. Therefore, there usually is time for each patient to carefully consider options prior to starting treatment.

Before starting treatment, patients must be aware of the short- and long-term side effects of the drugs, including the fact that some long-term complications may not be known. Patients also need to realize that therapy is a long-term commitment and requires consistent adherence to the drugs. In addition, clinicians and patients should recognize that depression, feelings of isolation, substance abuse, and side effects of the antiviral drugs can all be associated with the failure to follow the treatment program.

Initial therapy for HIV

Guidelines for using antiviral therapy have been developed and are updated on a regular basis by an expert panel assembled by the DHHS, the IAS-USA panel, and others. The DHHS guidelines are available at http://www.hivatis.org. The most recent IAS-USA guidelines were published in the Journal of the American Medical Association (JAMA) in the summer of 2008.

Antiviral treatment options have primarily included combinations of two nucleoside analogue reverse transcriptase inhibitors (NRTI), often referred to as "nucs," and one PI, typically with a low dose of RTV, a PI used at low doses to increase the level of the principle PI being used, so called "boosting." Alternative, preferred options include the use of two NRTIs with a nonnucleoside analogue reverse transcriptase inhibitor (NNRTI), the latter often called "non-nucs." These NNRTI-containing combinations generally are easier to take than PI-containing combinations and tend to have different side effects. Recently, NRTIs were combined with the integrase inhibitor raltegravir (Isentress, RAL) with very good viral suppression and tolerability. This novel combination has now been approved by the Food and Drug Administration as another treatment option for those initiating therapy for the first time.

Nucleoside and nucleotide analogue reverse transcriptase inhibitors

NRTIs block an enzyme of the HIV called reverse transcriptase that allows HIV to infect human cells, particularly CD4 T cells or lymphocytes. Reverse transcriptase converts HIV genetic material, which is RNA, into human genetic material, which is DNA. The human-like DNA of HIV then becomes part of the infected person's own cells, allowing the cell to produce RNA copies of the HIV that can then go on to attack other not yet infected cells. Thus, blocking reverse transcriptase prevents HIV from taking over (infecting) human cells.

In general, most antiviral regimens for HIV disease contain a backbone of at least two NRTIs. The NRTIs include ZDV, d4T, ddI, zalcitabine (HIVID, ddC), 3TC, FTC, abacavir (Ziagen, ABC) or TDF. The NRTIs FTC and 3TC are highly related compounds and, although data is somewhat limited, most experts agree that they probably can be used interchangeably. That said, many combinations of NRTIs can be used together, with current guidelines generally recommending the fixed-dose combination of TDF with FTC with alternatives being the fixed-dose combinations of ABC/3TC or ZDV/3TC. Other options would include ddI plus 3TC or FTC. ABC has been associated with severe allergic reaction in approximately 5% of patients. Recent studies have shown that a blood test can be performed to determine who is at risk for this reaction so that the drug can be avoided in these individuals and be used in others with greater confidence that there will not be such a reaction.

Usual dosing schedule and meal restrictions for NRTIs

ZDV
d4T
ddl
ddC
3TC
ABC
TDF
FTC

Dose in each pill (mg)
300 30 or 40 100 or 400 0.75 150 or 300 300 300 200
Schedule
1 twice/day 1 twice/day
2 (100) twice/day or
1 (400) once/day
1 thrice/day 1 (150) twice/day or 1(300) once/day 1 twice/day or 2 once/day 1 once/day 1 once/day
Meal restrictions None None
30 minutes before or 60 minutes after a meal None None None None None

ZDV, zidovudine; d4T, stavudine; ddI, didanosine; ddC, zalcitabine; 3TC, lamivudine; ABC, abacavir; TDF, tenofovir; FTC, emtricitabine.

The following are available fixed-dose combination pills of NRTIs:

* ZDV/3TC (300 mg/150 mg) as Combivir; one twice per day

* ZDV/3TC/ABC (300 mg/150 mg/300 mg) as Trizivir; one twice per day

* ABC/3TC (600 mg/300 mg) as Epzicom; one per day

* TDF/FTC (300 mg/200 mg) as Truvada; one per day

These are standard doses for average-sized adults, and dosing may vary depending upon the weight of a patient. When TDF is taken with ddI, the standard ddI dose should be reduced to 250 mg per day and can be taken with food.

Nonnucleoside analogue reverse transcriptase inhibitors

Like NRTIs, NNRTIs block the reverse transcriptase enzyme preventing uninfected cells from becoming infected.

NNRTIs include NVP, DLV, EFV and the recently approved etravirine (Intelence, ETR). ETR was developed specifically to be an option for patients that have developed resistance to the earlier drugs in the class. NVP, DLV, and EFV are typically used with two NRTIs, and ETR is primarily being used as part of regimens for those with a history of different types of treatment to which they have developed resistance.

Usual dosing schedule and meal restrictions for NNRTIs

NVP
DLV
EFV
ETR

Dose in
each pill (mg)
200 200 600 100
Schedule
1 twice/day
(start with 1 once/day
for first 14 days)
2 thrice/day 1 once/day 2 twice/day

Meal restrictions

None

None

Avoid high-fat meals

After meals

NVP, nevirapine; DLV, delavirdine; EFV, efavirenz; ETR, etravirine.

For people without a history of drug resistance, there is a very effective fixed-dose combination pill that includes TDF with FTC and EFV as a single pill that can be taken once per day.

Protease inhibitors

PIs block the action of an HIV enzyme called protease that allows HIV to produce infectious copies of itself within HIV-infected human cells. Thus, blocking protease prevents HIV in already-infected cells from producing HIV that can infect other, not yet infected cells.

PIs include

* saquinavir (SQV) which comes as the hard gel capsule Invirase (INV),

* ritonavir (Norvir, RTV),

* indinavir (Crixivan, IDV),

* nelfinavir (Viracept, NFV),

* fosamprenavir (Lexiva, FPV),

* lopinavir/ritonavir (Kaletra, LPV/r)

* atazanavir (Reyataz, ATV),

* tipranavir (Aptivus, TPV), and

* darunavir (Prezista, DRV).

Each of these drugs has been shown to effectively reduce the viral load when used in combination with other active drugs.

Usual dosing schedule and meal restrictions for PIs

SQV+ IDV NFV FPV LPV/r ATV TPV DRV
Dose in each pill (mg) 500 400 625 700 200/50 200 or 300 250 400 or 600
Schedule 21 twice/day 2 every 8 hours
2 twice/day 2 twice/day or with RTV2 2 twice/day or 4 once/day 2 (200) or 1 (300) with RTV3 once/day 24 twice/day 8005 once/day or 600 twice/day
Meal restrictions With large meals
1 hour before or 2 hours after meals, or with low-fat meals
With meals None With meals With meals With meals With meals

SQV, saquinavir; IDV, indinavir; NFV, nelfinavir; FPV, fosamprenavir; LPV/r, lopinavir plus ritonavir; ATV, atazanavir; TPV, tipranavir; DRV, darunavir.

1Administered with RTV at a dose of 100 mg twice/day.
2FPV can be given without RTV in patients without resistance to PIs or at a dose of 1,400 mg once daily with either 100 mg or 200 mg of RTV once daily. In treatment-experienced patients, FPV is given at a dose of 700 mg twice daily with RTV 100 mg twice daily.
3ATV can be given alone at a dose of 400 mg once daily or at a dose of 300 mg once daily with RTV 100 mg once/daily.
4TPV is always given at a dose of 500 mg twice/daily with RTV 200 mg twice daily.
5DRV can be given to those with a history of drug resistance at a dose of 600 mg twice daily with 100 mg RTV twice daily. For those without resistance, it can be given at a dose of 800 mg (two 400 mg tablets) with 100 mg RTV once daily.

Although RTV is approved for treatment of HIV-infected patients at a dose of 600 mg twice daily, it is virtually never used at this dose because of severe side effects. Because of this, it is not included in the above table. However, PIs are frequently dosed with low doses of RTV. RTV delays the clearance of the other drugs from the system, making them easier to take and more effective. The dose of RTV varies depending upon which drugs it is being taken with and how it is being administered. The only PI that is not substantially affected by RTV is NFV.

LPV/r comes coformulated as Kaletra while all other RTV-containing regimens require taking RTV along with the other PI. In the case of TPV, RTV must be given as 200 mg with each dose of TPV twice per day. In contrast, ATV can be given without RTV at a dose of two 200 mg capsules once daily or 300 mg with 100 mg RTV once daily. The latter should always be used in PI-experienced subjects and when used in combination with TDF or NNRTIs which can reduce the drug levels of ATV. Similarly, FPV is also used differently in PI-naïve and experienced individuals. In treatment-naïve individuals, it can be given as two 700 mg tablets twice daily or two 700 mg tablets (1,400 mg total) with either 100 or 200 mg RTV, all once daily. In treatment-experienced patients, or when used with NNRTIs, it should be given as one 700 mg tablet with 100 mg RTV, both twice daily. The most recently approved of the PIs is DRV which was initially used exclusively in treatment-experienced patients with drug-resistant virus. In this setting, it is given as 600 mg with 100 mg RTV, both given twice daily. More recently, DRV was approved for those who have never been treated before given at a dose of two 400 mg tablets (800 mg total) once daily with 100 mg of RTV once daily.

Fusion inhibitors

A fusion inhibitor blocks an early step in the viral life cycle. Enfuvirtide (Fuzeon, T-20) attaches to the envelope surrounding the virus and prevents it from entering the CD4 cells. This prevents the infection of CD4 cells by HIV. T-20 is the first approved drug in this class. It is given as a twice daily subcutaneous injection (90 mg). It is used primarily in individuals who have developed resistance to other classes of drugs in order to create a new potent combination. Like all other antivirals, it is most useful in those taking other active drugs at the same time in order to optimize the chance of getting viral loads to undetectable levels and to prevent the development of drug resistance.

CCR5 antagonist

The first available drug in this class is called maraviroc (Selzentry, MVC), which was recently approved for use in combination therapy in treatment-experienced patients with drug-resistant virus who do not have detectable CXCR4-using virus as determined by a tropism assay. This is a unique drug in a new class that blocks viral entry by interacting with the CCR5 molecule on the surface of the CD4 cell. It is known that HIV first binds to the CD4 molecule on the surface of CD4 cells and then connects with the CCR5 or CXCR4 molecule. Only after this second step is the virus able to enter the cell. The CCR5 antagonist prevents viruses that use CCR5 from getting into the cell. What is unique about this drug compared to others is that 20%-50% of patients have viruses that are able to use the CXCR4 receptor. In these cases, CCR5 antagonists do not appear to be active at suppressing virus. Therefore, in order to know if the drug will work for a given patient, a new test needs to be performed, the so called "tropism" assay. This test will tell the provider and patient whether there is virus that uses CXCR4, in which case the patient would not be a candidate for MVC, or if they only have viruses that use CCR5, in which case MVC should be an active drug. Without tropism results, it is impossible to know whether MVC will be an active drug for a given patient.

MVC is dosed at either 300 mg or 150 mg twice daily, depending upon what other drugs it is given with. If the patient is taking any RTV, then they would usually receive the 150 mg dose. If RTV is not being used as part of the regimen, they would generally receive the 300 mg dose and sometimes even higher if it is being used with drugs like ETR. HIV providers are aware that whenever using any anti-HIV medications attention must be given to possible drug interactions.

Integrase inhibitor

The first available drug in this class is RAL and represents a new drug in a new class that appears to be very potent at suppressing HIV in all patients who have never been on this drug or other integrase inhibitors in development. It was initially approved for treatment-experienced patients with drug-resistant virus. It is also now approved for those starting therapy for the first time. The approved dose of RAL is 400 mg twice daily.

Drugs in development

There are many drugs currently in development that may simplify therapy and provide important options for those who have developed extensive drug resistance. Drugs that show promise in early clinical trials are often made available by the manufacturer with approval of the Food and Drug Administration (FDA), to certain individuals. In particular, these drugs are used in individuals no longer responding or able to tolerate currently available agents. The most promising new drugs at this time are those in existing classes, such as a new integrase inhibitor, CCR5 antagonist, and NNRTI.

Side effects of HIV therapy

There are many potential side effects associated with antiviral therapies. The most common ones for each class of drug are summarized in readily available product information. Some specific toxicities are summarized by class below.

NRTIs

Most NRTIs can cause mild nausea and loose stools. In general, these symptoms resolve with time.

ZDV has been associated with decreased production of blood cells by the bone marrow, most often causing anemia, and occasionally hyperpigmentation (most often of the nails).

D4T can damage nerves and cause peripheral neuropathy, a neurological condition with numbness and/or tingling of the feet and hands, and inflammation of the pancreas (pancreatitis) that causes nausea, vomiting, and mid upper abdominal pain.

DDI also causes pancreatitis and, to a lesser extent, peripheral neuropathy. Peripheral neuropathy can become permanent and painful, and pancreatitis can be life-threatening if therapy is not discontinued. The drug ddC also is associated with peripheral neuropathy as well as oral ulcers.

ABC can cause a hypersensitivity reaction during the first two to six weeks of therapy in approximately 5% of individuals. The hypersensitivity reaction most often causes fever and other symptoms, such as muscle aches, nausea, diarrhea, rash, or cough. The symptoms generally get worse with each dose of ABC and, if suspected, therapy must be discontinued and never restarted for fear of developing a life-threatening reaction. There is now a simple blood test that can be performed to determine whether a patient is at risk for developing the hypersensitivity reaction. If the test is positive, the patient should never receive this medication.

TDF is generally well tolerated although there may be rare kidney damage.

FTC is also well tolerated except for the occasional development of hyperpigmentation, most often on the palms and soles. This hyperpigmentation occurs more frequently in people of color.

Although all NRTIs can be associated with lactic acidosis (a serious condition in which lactic acid accumulates in the blood), it may occur more often with some drugs, such as d4T. Although this complication of treatment is rare, it can be severe and life-threatening. Early symptoms of lactic acidosis are nausea, fatigue, and sometimes, shortness of breath. Lactic acidosis needs to be watched for and, if suspected, requires that therapy be discontinued until symptoms and laboratory test abnormalities resolve.

There has been a great deal of attention given to the more recently identified problem of "lipodystrophy." Individuals suffering from this syndrome can be categorized as having lipohypertrophy (fat accumulation) syndromes, such as the "buffalo hump" on the back of the neck, breast enlargement, or increased abdominal girth. Others primarily suffer from lipoatrophy with fat loss under the skin with complaints of prominent veins on the arms and legs, sunken cheeks, and decreased gluteal (buttock) size. These syndromes appear to be related to multiple factors including, but not limited to, drug therapy. The NRTIs appear to be most closely linked to lipoatrophy, in particular D4T and to a lesser extent ZDV. In fact, some studies have suggested slow accumulation of fat in those who modify the NRTI component of their regimen. Some NRTIs also have been linked to elevation in lipid (fat) levels in the blood. While switching therapy is always a consideration in those experiencing potential drug-related toxicity, this should only be done under the careful supervision of an experienced HIV provider.

NNRTIs

The most common side effect associated with NNRTIs is a rash, typically occurring during the first weeks of therapy. This is most common in individuals treated with NVP. In this case, the overall risk of rash is reduced if therapy is started as a single, 200 mg NVP pill once per day during the first two weeks before increasing to the full dose of 200 mg twice per day. If the rash is mild, therapy usually can be continued if antihistamines are given, and if the rash resolves, treatment with the NNRTI can be continued. If the rash is severe, associated with liver inflammation or blisters, changes in the mouth or around the eyes, or with high fevers, therapy with the NNRTI usually needs to be discontinued. Decisions regarding continuing or stopping treatment need to be made with the primary-care provider. In some patients, NVP can cause a severe allergic reaction characterized by fever, rash, and severe liver inflammation. Recent data suggests that the groups at the greatest risk for the severe reaction are those with stronger immune systems, such as HIV-uninfected people given this treatment after an exposure to HIV, women with CD4+ T cells >250 cells per mm3 and men with CD4+ T cells >400 cells per mm3. There is also likely to be increased risk in pregnant women and individuals with other underlying liver diseases. Consequently, NVP probably should not be used in any of these groups, or if used, used with caution. In addition, whenever NVP is started, liver tests that are markers for liver inflammation should be monitored at regular intervals during the first several months of treatment.

Side effects associated with EFV are mostly dizziness, confusion, fatigue, and vivid dreams. These tend to be most prominent during the first weeks of therapy and then often decrease in severity. It is generally recommended that EFV be taken at bedtime so that the patient is asleep during the time dizziness and confusion may be most severe. It is also noteworthy that there may be an increased risk of depression associated with the use of this drug, and it should be used with caution in those with poorly managed depression. Rash and liver inflammation can occur with both EFV and DLV, and these drugs may also be linked to abnormalities of lipids in the blood.

The most common side effect reported with the most recently approved NNRTI, ETR, is rash and it was generally mild and rarely required that medications needed to be stopped.

PIs

There are currently nine approved PIs that all have distinct toxicities. The most common side effects associated with these drugs are nausea and diarrhea, which occur more often with some PIs than others. For example, diarrhea is more common with NFV than other PIs but can occur with any and all drugs in this class. Many of the drugs in this class also increase blood lipid levels, some more than others with ATV and possibly DRV appearing to have less effect on lipids than other drugs in the class. Other unique toxicities associated with various PIs are kidney stones with IDV and ATV and increased blood bilirubin levels with IDV and ATV. Some of these drugs also have been associated with elevations in blood sugar levels and bleeding in hemophiliacs. Finally, little is known regarding the role these drugs may play in the development of lipodystrophy.

Fusion inhibitors

The only drug in this class is T-20, which is administered as a twice daily subcutaneous injection. The most common side effect is redness and pain at the site of injection. Rarely, infection can occur at the injection site. There also are reports of generalized allergic reactions.

CCR5 antagonist

Although there were some early concerns of liver inflammation for drugs in this class, MVC appeared to be well tolerated in clinical trials without any specific toxicities attributable to the drug. However, it is a new drug in a new class and the first to actually target the cell. For these reasons, longer follow-up from clinical trials and those followed in the clinic will be very important for assessing the overall safety of the drug.

Integrase inhibitor

RAL has not been strongly linked to any specific side effect in clinical trials. However, there have been some cases of muscle problems that need to be watched for when starting this or any new medications. As with all new medications, more data will come from extended follow-up of patients in the clinic and in clinical trials.

Monitoring antiviral therapy

The goals of antiviral therapy are to enhance immunity and delay or prevent clinical advancement to symptomatic disease without inducing important side effects or selecting for drug resistant virus. Currently, the best marker of a drug's activity is a decrease in the viral load.

Ideally, prior to initiating treatment, the viral load and the CD4 cell count should be checked and the viral load test then repeated after approximately four weeks of treatment. If the patient is beginning a regimen that includes two to three drugs for which the patient's virus does not appear to be resistant, it is expected that the amount of virus should decrease by at least 100-fold during this interval. The ultimate goal is for the viral load to decrease to undetectable levels which should occur by approximately 24 weeks. Those that are not having an appropriate response to therapy need to be questioned to make sure that they are taking their medications correctly, and if not, why. If the viral load is not going to undetectable levels and the patient is taking the medications correctly, then it is likely that there is a resistant virus to some of the medications. Drug-resistance testing then should be performed and the patient managed as described in the next section

Viral load increasing while on HIV therapy

If the patient does suppress their virus to undetectable levels on antiviral therapy but then develops detectable virus, several things should be considered. First, it must be established that the patient is taking the medications correctly. If they are missing doses, then every effort must be made to understand why this is happening and correct the situation, if possible. If the poor adherence is a result of drug side effects, efforts should be directed toward managing the side effects or changing to a better-tolerated regimen. If poor adherence is occurring because of the medication schedule of dosing, new strategies should be discussed such as placing medications in a pillbox, associating the dosing with certain daily activities such as tooth brushing or possibly changing the regimen. Finally, if the reason for poor adherence is depression, substance abuse, or another personal issue, these issues need to be addressed and managed.

It is important to remember that sometimes, for reasons not entirely understood, the viral load can briefly increase. Unexpected increases, therefore, necessitate repeated testing of the viral load before any clinical decisions are made. If, however, the viral load is continually detected despite proper adherence to the prescribed therapy, serious consideration must be given to the possibility that the virus has become resistant to one or more of the medications being given. There is now an abundance of data showing that the use of drug resistance tests can improve the response to a follow-up regimen. Testing can be used to determine if an individual's HIV has become resistant to one or more of the drugs that are being taken. There are currently two main types of resistance tests available in the clinic: one that is called a genotype and the other a phenotype assay. The former looks for mutations in the virus and the latter the actual amount of drug it takes to block infection by the patient's virus. The genotype test is very helpful in those being screened for the presence of resistant virus prior to initiating treatment and those experiencing viral rebound on one of their first treatment regimens. The phenotype test is particularly useful in those who are highly treatment-experienced and have substantial amounts of drug resistance. The information derived from these tests, along with a tropism test will ultimately tell the provider which of the many approved drugs are likely to be fully active against the specific patient's virus. Using this information, the goal is to include at least two and ideally three fully active drugs in the next regimen in order to optimize the chances of suppressing the viral load to undetectable levels.

Missing doses or stopping antiviral therapy

It is strongly advised that individuals on an antiviral regimen not miss any doses of their medications. Unfortunately, life is such that doses often are missed. Reasons for missing doses range from just forgetting to take the medication, leaving town without the medication, or because of a medical emergency, such as the need for urgent surgery. For example, after an appendectomy for acute appendicitis, a patient may not be able to take oral medication for up to several days. When a dose is missed, the patient should contact his or her physician without delay to discuss the course of action. The options in this situation are to take the missed doses immediately or simply resume the drugs with the next scheduled dose.

Although every missed dose increases the chance that the virus will develop resistance to the drugs, a single missed dose should not be cause for alarm. On the contrary, it is an opportunity to learn from the experience and determine why it happened, if it is likely to happen again, and what can be done to minimize missing future doses. Furthermore, if a patient cannot resume medication for a limited time, such as in a medical emergency, there still is no cause for alarm. In this circumstance, the patient should work with their HIV provider to restart therapy as soon as is feasible. Stopping antivirals is associated with some risks of developing drug resistance, and those who wish to stop therapy for any one of a number of reasons should discuss this with their health-care provider in advance to establish the best strategy for safely accomplishing this.

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Should patients with the "flu-like" or "mono-like" illness of primary HIV infection be treated?

There are theoretical reasons why patients identified with HIV around the time they are first infected (primary, acute infection) may benefit from the immediate initiation of potent antiviral therapy. Preliminary evidence suggests that unique aspects of the body's immune response to the virus may be preserved by this strategy. It is thought that treatment during the primary infection may be an opportunity to help the body's natural defense system to work against HIV. Thus, patients may gain improved control of their infection while on therapy and perhaps even after therapy is stopped. At one time, the hope was that if therapy was started very early in the course of the infection HIV could be eradicated. Most evidence today however suggests that this is not the case. Consequently, early treatment is not likely to result in a cure, although other benefits may still exist. The current recommendation is that patients with primary infection should be referred to clinical studies where the potential role of therapy can be discussed and further explored. If emotional or social situations make adherence to such treatment questionable, however, the patients are clearly better off delaying therapy.

What about treatment for HIV during pregnancy?

One of the greatest advances in the management of HIV infection has been in pregnant women. Prior to antiviral therapy, the risk of HIV transmission from an infected mother to her newborn was approximately 25%-35%. The first major advance in this area came with studies giving ZDV after the first trimester of pregnancy, then intravenously during the delivery process, and then after delivery to the newborn for six weeks. This treatment showed a reduction in the risk of transmission to less than 10%. Although less data are available with more potent drug combinations, clinical experience suggests that the risk of transmission may be reduced to less than 5%. Current recommendations are to advise HIV-infected pregnant women regarding both the unknown side effects of antiviral therapy on the fetus and the promising clinical experience with potent therapy in preventing transmission. In the final analysis, however, pregnant women with HIV should be treated essentially the same as nonpregnant women with HIV. Exceptions would be during the first trimester, where therapy remains controversial, and avoiding certain drugs that may cause greater concern for fetal toxicity, such as EFV.

All HIV-infected pregnant women should be managed by an obstetrician with experience in dealing with HIV-infected women. Maximal obstetric precautions to minimize transmission of the HIV virus, such as avoiding scalp monitors and minimizing labor after rupture of the uterine membranes, should be observed. In addition, the potential use of an elective Caesarean section (C-section) should be discussed, particularly in those women without good viral control of their HIV infection where the risk of transmission may be increased. Breastfeeding should be avoided if alternative nutrition for the infant is available since HIV transmission can occur by this route.
What about treating non-HIV-infected people exposed to the blood or genital secretions of an HIV-infected person?

Recently, a great deal of interest has focused on preventing transmission to uninfected people who are inadvertently exposed by the early administration of antiviral therapy. Because the risk of infection after most isolated exposures is relatively small and the number of patients needed for study would be great, formal studies are difficult to perform. Animal studies and some human experience, however, suggest that post-exposure treatment may be effective. In fact, the current recommendation is that health-care workers who experience a needle stick from an infected person take antiviral medication for four weeks in order to reduce the risk of infection. Guidelines now recommend similar preventive treatment for people with sexual exposures to HIV. Those individuals considering this type of preventative treatment, however, must be aware that post-exposure treatment cannot be relied upon to prevent HIV infection. Moreover, such treatment is not always available at the time most needed and is probably best restricted to unusual and unexpected exposures, such as a broken condom during intercourse. Although regimens with two or three drugs generally are recommended for those exposed in the health-care setting, the best therapy for sexual exposure still is unknown and ideally should be initiated within hours of exposure and certainly within the first several days. Updated guidelines are published and available at http://www.hivatis.org.

What can be done for people who have severe immunosuppression?

Although one goal of antiviral therapy is to prevent the development of immune suppression, some individuals are already immunosuppressed when they first seek medical care. In addition, others may progress to that stage as a result of resistance to antiviral drugs. Nevertheless, every effort must be made to optimize antiviral therapy in these patients. In addition, certain specific antibiotics should be initiated, depending on the number of CD4 cells, to prevent the complications (that is, the opportunistic infections) that are associated with HIV immunosuppression. Guidelines for the prevention of opportunistic infections can be found at http://www.hivatis.org.

In summary, patients with a CD4 cell count of less than 200 should receive preventative treatment against Pneumocystis jiroveci with trimethoprim/sulfamethoxazole (Bactrim, Septra), given once daily or three times weekly. If they are intolerant to that drug, patients can be treated with an alternative drug such as dapsone or atovaquone (Mepron). Those patients with a CD4 cell count of less than 100 cells per mm3 who also have evidence of past infection with Toxoplasma gondii, which is usually determined by the presence of toxoplasma antibodies in the blood, should receive trimethoprim/sulfamethoxazole. Toxoplasmosis is an opportunistic parasitic disease that affects the brain and liver. If a person is using dapsone to prevent Pneumocystis jiroveci, pyrimethamine and leucovorin can be added once a week to dapsone to prevent toxoplasmosis. Finally, patients with a CD4 cell count of less than 50 cells per mm3 should receive preventive treatment for Mycobacterium avium complex (MAC) infection with weekly azithromycin (Zithromax), or as an alternative, twice daily clarithromycin (Biaxin) or rifabutin (Mycobutin). MAC is an opportunistic bacterium that causes infection throughout the body.
What is in the future for HIV-infected individuals and for those at risk to contract HIV?

Trends continue toward simplifying drug regimens to improve adherence and decrease side effects. In addition, the availability of multiple new drugs in new classes have made it possible to suppress viral load to undetectable levels even in the most treatment-experienced patients. With such great success in treatment, it has been disappointing that there has been much less progress in research related to prevention and establishing a cure. Research is attempting to find ways to enhance the body's natural defenses against HIV in order to control viral growth on and off therapy. Similarly, innovative studies are under way to purge or eliminate the HIV from the body. Although all of this research is exciting, it has been met with little success and for at least the near future, patients will need to remain on antiviral therapy.

The good news is that the development of antiviral therapy has led to marked declines in AIDS-related deaths in many parts of the world. The majority of infected individuals, however, do not have access to the expensive antiviral medications. Accordingly, the best hope for limiting the current epidemic of HIV around the world remains an effective vaccine. Unfortunately, despite increasing research in this area, the development of a vaccine continues to lag far behind the progress that has been made in antiviral therapy.
HIV At A Glance

* The human immunodeficiency virus (HIV) is a type of virus called a retrovirus, which infects humans when it comes in contact with tissues such as those that line the vagina, anal area, mouth, or eyes, or through a break in the skin.
* HIV infection is generally a slowly progressive disease in which the virus is present throughout the body at all stages of the disease.
* Three stages of HIV infection have been described.
1. The initial stage of infection (primary infection), which occurs within weeks of acquiring the virus, and often is characterized by a "flu-" or "mono-"like illness that generally resolves within weeks.
2. The stage of chronic asymptomatic infection (meaning a long duration of infection without symptoms) lasts an average of eight to 10 years.
3. The stage of symptomatic infection, in which the body's immune (or defense) system has been suppressed and complications have developed, is called the acquired immunodeficiency syndrome (AIDS). The symptoms are caused by the complications of AIDS, which include one or more unusual infections or cancers, severe loss of weight, and intellectual deterioration (called dementia).
* When HIV grows (that is, by reproducing itself), it acquires the ability to change (mutate) its own structure. This mutation enables the virus to become resistant to previously effective drug therapy.
* The goals of drug therapy are to prevent damage to the immune system by the HIV virus and to halt or delay the progress of the infection to symptomatic disease.
* Therapy for HIV includes combinations of drugs that decrease the growth of the virus to such an extent that the treatment prevents or markedly delays the development of viral resistance to the drugs.
* The best combination of drugs for HIV has not yet been defined, but one of the most important factors is that the combination be well tolerated so that it can be followed consistently without missing doses.