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The changing face of AIDS.

In the wake of medical and social advances domestically, the worst may be yet to come on a global scale.

October 1, 1990--A talented young architect from Hershey, Pennsylvania succumbs to AIDS-related cancer. His name is Patrick and he is 33 years old.

December 2, 1997--Following World AIDS Day, the Los Angeles Times publishes a story about 33-year-old Michael, a young man suddenly resurrected from illness by the use of bold new combined-drug therapies. After years of living with AIDS, he is reentering the work force.

Although AIDS remains the leading cause of death among 25- to 44-year-olds, and a United Nations World AIDS Day report revealed a worldwide toll of 30.6 million victims (nearly double that of earlier estimates), a well-spring of hope from the scientific community indicates the tide may be turning against the epidemic. As we approach the new millennium, there are cautious hints of optimism from even the most skeptical corners.

Education and Epidemic Patterns

After more than a decade of research and frustration, the world community of AIDS researchers and health care providers began to see signs of progress in the last half of 1996. At the 11th Annual Conference on AIDS held July 9, 1996, in Vancouver, Canada, the Atlanta-based Centers for Disease Control and Prevention (CDC) reported a 12% decrease in the rate of new HIV cases, and a reduction in the number of AIDS-related deaths (22,000) in the first half of 1996. The smallest recorded increase in both statistics was seen in 1995, and in 1996 came the first report of a decrease anywhere in the world. Reports from other developed nations were corroborating these findings. Western Europe, New Zealand and Australia were also beginning to report decreases in new HIV cases.

The good news did not stop there. At the same conference, David Ho, M.D., director of the Aaron Diamond AIDS Research Center in New York City and the 1996 Time Man of the Year, revealed a bold new strategy utilizing protease-inhibitors in combination with standard antiviral medications, a therapy used by more and more doctors with increasing success. In trials begun the previous summer, Ho administered this "combination therapy" to patients within the first few weeks of infection rather than waiting for full-blown AIDS to take hold. The results were startling. The HIV in his patients' blood was so low it could not be measured.

As the world AIDS community entered 1997 with new optimism, increasing research and investment dollars into refining combined-drug therapies, other patterns began to emerge. In April of 1997, the World Health Organization reported a decline in new cases in Thailand, once the center of Asia's AIDS epidemic. And although Asia continued to report trouble spots in poorer countries like Cambodia, India and Burma, these statistics represented a significant turning point in the world's fight against the disease.

In Washington, D.C., the Clinton administration also stepped up its efforts to keep AIDS in the foreground. President Clinton personally announced his choice to head the Office of National AIDS Policy, the agency charged with coordinating federal policy on AIDS. "In the first four years of my administration, we increased spending by about 60%," he said. "In fiscal year 1997 alone, $167 million will go to state AIDS drug assistance programs that provide access to medication, including protease inhibitors for low-income individuals who don't have prescription drug coverage. We [shortened] the time needed to approve drugs to treat AIDS, leading to the approval of eight new AIDS drugs and 19 for AIDS-related conditions. This has allowed many people simply to go on with their lives, to live with this disease not worry-free, but not in despair either."

To spearhead this drive, Clinton chose Sandy Thurman, the outspoken executive director of AID Atlanta, the oldest and largest AIDS service organization in the south. A committed activist with deep political roots, Thurman assumed the post at a time when a decrease in death rates threatened funding.

"Thurman's experience in running a large community-based organization makes her especially well-equipped to build the partnerships we need throughout our country," Clinton said. "The director of this office must be an individual with a clear understanding of AIDS as a disease and as a social issue in America--someone who knows the scientific front as well as the human center of AIDS, someone who knows how to cut through the red tape to get the job done."

Armed with this renewed commitment, and with data from the combined-drug therapies, the scientific community has begun taking a closer look at Thailand, now one of the most watched and well-documented countries in the world. Because it was the first country in Asia to see AIDS cases, the lessons to be learned from awareness and prevention efforts are becoming more and more evident.

Awareness and Attitudes

Epidemiologists at Johns Hopkins University have discovered that a decrease in HIV infections among young Thai men from 10.4 and 12.5% in 1991 and 1993 to 6.7% in 1995 is related solely to prevention and awareness efforts. The results of their study, published in the New England Journal of Medicine, clearly show that the fall in HIV prevalence came only after "substantial changes in high-risk sexual behavior." "It is a clear sign that education and awareness programs can be effective--and that there should be more of them," stated Gilles Poumerol, the World Health Organization's regional adviser on sexually transmitted diseases and AIDS, in an April 7, 1997 news report by the Inter Press Service English News Wire.

This strategy is proving extremely difficult to initiate in the most vulnerable area of the world--the Sudan. Not only is there a resistance to prevention efforts by a population mired in civil war since 1983, but data collection and reporting is arduous. These countries alone account for the increase in the revised worldwide infection rates and estimates reported by the United Nations on World AIDS Day.

According to Osman Mohamed Alkhidier, M.D., head of the Health Ministry's National AIDS Committee, based on the rate HIV is believed to be spreading in the Sudan, the number of orphans due to AIDS is expected to jump from 14,000 in 1996 to 90,000 in 1998. Discussion of prevention and protection has been nearly impossible in a culture where nearly all secondary school students believe "AIDS" refers to government and social services. Without change, these children will one day risk infection.

Typical Victim

As traditional prevention and education programs fail miserably in some underdeveloped countries, the rest of the world continues to report a decline in new cases, but only among segments of the population in which cases were first reported. In the United States, for example, statistics reveal a 6% drop in new cases in 1996, a 25% decline in AIDS deaths in 1997, and a current blood supply that is nearly 100% HIV-free. Simultaneously, reports point to a rise in those infected heterosexually, increasing 11% among men and 70% among women. The CDC has reported that between 1991 and 1996 new AIDS cases rose twice as fast among people 50 and over as they did among young adults. While groups who have long perceived themselves to be "at risk" are becoming less a target, those still in denial--or less informed--about the nondiscriminatory nature of this killer are becoming more "at risk."

In underdeveloped countries where education and funds are nearly nonexistent, or where the epidemic is in its early stages, the picture remains tragic. "As this epidemic has matured, the makeup of its victims has changed," says Brian Atwood, administrator for the United States Agency for International Development. "The most common victim of HIV infection over the next year will be a young woman in her 20s living in sub-Saharan Africa. She will be married. She will have two or three children and will be infected by her husband." Atwood predicts nearly 42 million children will be orphaned by AIDS by the year 2010 in just 23 countries.

"I think we knew this epidemic was moving faster than we could capture, but I had no idea the numbers would be as large as they are," says Thurman.

Key Challenges

Today the prime objections to the daring strategy proposed by Ho in 1996 remain the lack of funds and the false sense of security that could erroneously be spread among those who would attempt to use these treatments as a "morning after" remedy. With little scientific data currently available from drug trials--and knowing that the HIV virus that causes AIDS can hide indefinitely--reverting to unprotected and risky behavior would be a mistake. Hence, the scientific community continues its quest for the only sure-fire way to completely eradicate this deadly disease--a vaccine.

Thurman concurs. "I offer the community my personal commitment to the efforts to develop vaccines, find a cure, and not just create a bureaucracy to provide services and care," he says. "Beyond our borders, millions of people struggle against the odds to live long enough to reap the benefits of a cure."

Given the lengthy incubation period of the disease, and based on the experiences of the developed nations, the number of AIDS cases usually peaks some 10 to 15 years after the first HIV cases are detected. "Unfortunately, we may not have seen the worst in Asia," adds Poumerol. "Since the earliest cases in many Asia-Pacific countries emerged in the early '90s, the epidemic will peak in those places around the year 2000."

The key challenges facing the developed world are intimidating. The United States' role on the world stage as the only remaining super-power with sufficient economic clout to fund preventive programs is expanding. However, future economic consequences are in question. Contributing to poverty-stricken countries with staggering population numbers and rates of infection provides challenges not yet fully recognized. The CDC continues to report a need to find additional resources for the services, treatment and care of AIDS patients who are now living longer and more productive lives, as well as a desire not to lose sight of prevention as the most cost-effective way to save lives. In the coming years, the competition for scarce resources will be a key issue in the fight against this epidemic.

For more than 10 years, AIDS has provided the world with some stunning and unforgettable images--Princess Diana shaking the hand of an AIDS victim; the premature retirement of basketball great Magic Johnson; the public deaths of some of our finest and brightest, including Arthur Ashe, Elizabeth Glaser and young innocents like Ryan White. And, closer to home, few of us can escape the memory of the needless death of a beloved son, brother, child, mother or friend.

In Memory of Patrick (1957-1990)


* Cumulative total of AIDS deaths worldwide: 11,700,000

* Percent of adults living with AIDS worldwide: 1%

* Worldwide, children will be among the hardest hit in years to come. Total new infections per year for 1996 and 1997 were 3,000,000 and 5,800,000, respectively. Reported deaths were 1,500,000 and 2,300,000, respectively. Of those deaths, nearly 20% were children ages 18 and under.


Published in a December, 1997 United Nations report.
REGION                         TOTAL REPORTED CASES

Sub-Saharan Africa                      20,800,000
Southeast Asia                           6,000,000
Latin America                            1,300,000
North America                              860,000
Western Europe                             530,000
East Asia/Pacific                          440,000
Caribbean                                  310,000
North Africa/Middle East                   210,000
Eastern Europe/Central Asia                 15,000
Australia/New Zealand                       12,000
Total World Wide                        30,612,000

RELATED ARTICLE: World AIDS Conference Stresses Prevention

Prevention is the only realistic method to stop the spread of AIDS, according to the findings of the 12th World AIDS Conference as reported in the International Herald Tribune. In previous years there was positive speculation surrounding drugs such as AZT and protease inhibitors, but this year the conclusion was clear--drugs are not the answer. Most of the 13,775 participants representing 177 countries agreed preventive steps, such as sex education, needle exchange programs and condom distribution, still prove most effective in combating the spread of HIV.

Doctors are now less inclined to believe in drug treatments as the solution for the AIDS epidemic. AZT and protease inhibitors are costly (up to $15,000 a year for one infected person), and their efficacy is in question. The miracle pharmaceutical "cocktails" have proven less effective than doctors and scientists had hoped.

Conference speakers stated preventive measures could be the key to saving millions of lives, but need to be more aggressively pursued. "We know prevention works, but we don't do enough of it," said W. Silntrai, M.D. Some worry strategies such as passing out condoms or needles send a message that may lead to promiscuity or drug use. Speakers said this is not true. Silntrai explained older generations, many of which may not be personally affected by the disease, oppose these preventive methods because they are unable to relate to the issues at hand. "They forget the craziness of those boiling hormones and how much sex occupied their thoughts," he said.

Also addressed at the conference was the status of the epidemic in underdeveloped countries. Most developing countries are unable to afford care for those infected. Additionally, early detection is less prevalent in poorer countries. A more advanced screening test is currently available, but it is expensive and, therefore, not accessible to developing countries.

The harsh reality of AIDS continues. With more than 30 million people now infected worldwide, doctors say a medical cure is still in the distant future. The conference re-stated what doctors have known since the early stages of this disease--the only solution is prevention.
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Title Annotation:includes related article on prevention
Author:Wallace-Johnson, Suzanne
Publication:American Fitness
Date:Sep 1, 1998
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