HIV/AIDS: Still a world threat three decades later

Those infected in the West have an almost-normal life expectancy; in sub-Saharan Africa, it is death sentence.

By JUDY SIEGEL-ITZKOVICH
ETHIOPIAN, Hadassah HEALTH officers (photo credit: Hadassah Medical Organization)
ETHIOPIAN, Hadassah HEALTH officers
(photo credit: Hadassah Medical Organization)
Young people could be forgiven for thinking that acquired immune deficiency syndrome (AIDS) has existed as long as polio or tetanus – and even that it is only a chronic disease easily managed with drugs. But in fact, the virus – which in the 1950s jumped in West Africa from chimpanzees to man – was diagnosed for the first time only three decades ago.
Although carriers of the human immunodeficiency virus (HIV), if properly cared for, have a near-normal life expectancy, AIDS remains a fatal disease for tens of millions of victims in much of the developing world, especially sub-Saharan Africa. In Botswana, which is perched on top of South Africa, estimates are that by 2020, there will be more residents infected with HIV than those who are not.
Yet the Western world is far from immune: In the US alone, it is estimated that more than one million people are living with HIV, and more than half a million have died of full-blown AIDS.
Although AIDS used to be front-page news in the Israeli media – at least on World AIDS Day every December 1 – in recent years, the Health Ministry has treated it in a low-key manner. Instead of speaking to the public with press conferences and publicity campaigns, it has only issued press releases and used voluntary organizations that target the homosexual, drug-user and migrant populations, and has worked quietly among immigrants from countries where AIDS is endemic.
Although many countries require all pregnant woman and newborns to be tested for HIV, the ministry does not regard this as mandatory, arguing that it is an “unnecessary expense.”
In its statement for World AIDS Day some four months ago, the ministry focused on homosexual men. It noted that among the 420 newly diagnosed Israeli HIV cases in 2010, 148 of them were homosexual men and that a fifth of the 2,000 gay men who participated in a study admitted to not using condoms during the previous six months, making the rate of condom use in this group four times higher than the figures of HIV-infected men in 2000.
The fact that HIV/AIDS is increasingly regarded as a chronic rather than a fatal disease has produced laxity in protection among high-risk groups, the ministry said. Only a minority of Israeli carriers die of AIDS, due to the more effective AIDS “cocktail” of drugs provided at government expense. Heterosexuals are also among the infected, as are drug users and people who originated in countries where AIDS is endemic. Since 1981, a total of 6,579 cases of HIV and full-blown AIDS have been diagnosed; of those, 1,330 died or left the country. Thus, more than 5,300 HIV carriers and AIDS patients live in Israel today – although it is widely acknowledged that there are about as many undiagnosed carriers still unaware of their condition.
There have been needle-exchange programs for drug addicts for the last half-dozen years, while more advanced testing kits shorten the window of time between infection and when the virus shows up in the blood to less than two months. People who identify themselves can receive free HIV testing not only in the major hospitals’ AIDS centers, but also from the four public health funds; people who refuse to identify themselves are able to get tested in the ministry’s sex clinics, as well as those run by the Israel AIDS Task Force in Tel Aviv and the Open House in Jerusalem.
The AIDS Center at the Hadassah University Medical Center in Jerusalem’s Ein Kerem neighborhood held a clinical conference for the hospital staff last month to update them on HIV/AIDS and report on what the center staff has been doing. The hospital’s new auditorium was filled with over 150 doctors, nurses and medical students who took time off from a busy day to listen.
Internal medicine and infectious disease specialist Prof. Shlomo Maayan, who established Hadassah’s AIDS clinic in 1990 and has directed its AIDS Center since 1997, hosted the event.
There are 33 million known HIV carriers, mostly in Africa, said Maayan, and three million new cases each year. “About two million die of AIDS in an average year, with the result that 15 million children have been orphaned.
“We heard in 1981 about a strange infectious disease. It was published that between October 1980 and May 1981, five young men, all active homosexuals, were treated for Pneumocystic carinii pneumonia at three different hospitals in Los Angeles. Two died. But until 1985, we didn’t even know what it was,” recalled the Hadassah physician.
“Then, in 1985, a retrovirus was discovered that caused a fatal disease that was spread largely by sexual contact,” he continued.
“Sixty million people around the world have been infected, and half of them have died.”
Scientists despaired, thinking AIDS would be the new Black Death, but in the mid-’90s, with the development of a “cocktail” of anti-retroviral drugs (protease inhibitors), the spread of HIV slowed.
“The spread of the pandemic reached a plateau in 2007,” he said, “but the disease will continue for many years until it is defeated – if at all.”
Five years ago, generic anti-retrovirals reached Africa and brought some hope of survival to infected residents, half of whom are women.
Although a great deal of money and effort have been invested in developing an HIV vaccine to prevent infection, they have not been successful so far because of the many mutations in the “envelope surrounding the virus,” Maayan explained.
“Recently, monoclonal antibodies were synthesized by reverse-engineering that manage to penetrate the natural protective layer and neutralize the virus at a number of sites on the envelope,” he said. “Maybe someday this discovery will lead to an effective vaccine, but we don’t really know if it would work.”
Hadassah University Medical Center treats some 350 HIV carriers and AIDS patients, he continued, 41 percent of them women. “Half are immigrants from countries where AIDS is endemic; 30% are homosexuals; 10% are foreign migrant workers and another 10% addicts who inject drugs.”
His Ein Kerem center employs four physicians, two social workers, a nurse, a pharmacist and a technician, as well as four advisers in the testing center, and two coordinators for Ethiopian immigrants who come from the community itself. In the last six years, the characteristics of immigrants and non-immigrants have become very similar, he said.
The center’s activities put a special focus on gynecology/obstetrics for both the Jerusalem region and the Palestinian Authority. In addition to carrying out HIV testing, it also follows up at-risk pregnancies, has a national clinic to produce safe pregnancies for male carriers and healthy women; and conducts research and counseling internationally, especially with Ethiopia.
The center’s Dr. Karen Olshtein-Pops noted in her lecture that the drug zidothymidine (AZT) was initially thought to have much potential in treating AIDS. But as it was used alone (a monotherapy), doctors quickly became disappointed. Then a two-drug therapy of anti-retrovirals was developed in 1994; it worked much better. In 1997, a third drug appeared, to which carriers reacted even better.
The drug cocktail with combinations of five main drugs followed. There still are side effects, but patients no longer have to swallow dozens of pills a day, as several medications have been combined into one pill.
There had been a dispute among AIDS experts regarding when HIV carriers should start taking the drug cocktail; today, it is decided according to the levels of CD4 immune cells in the blood.
“Some said to wait until it reached 200,” said Olshtein-Pops, “but today it is done already when the level falls between 500 and 350.”
She noted that a 46-year-old man named Timothy Brown, an HIV carrier who underwent a bone marrow transplant two decades ago because he also developed leukemia, is today free of the virus and essentially cured.
The transplant transferred a genetic variation that made his system resistant to HIV.
“Bone marrow transplants could be good,” said the Hadassah doctor, “but it’s almost impossible to find a suitable donor.
Researchers are thinking of utilizing genetic engineering to create lymphocytes without a certain receptor using HIV patients’ own cells. There is some optimism, but the research is at an early stage.”
Following Israeli research and recommendations, the World Health Organization has endorsed circumcision in sub-Saharan Africa as a prophylactic to reduce the infection risk significantly.
As life expectancy for HIV carriers has lengthened, Olshstein-Pops runs a fertility program at Hadassah to allow healthy women to have babies fathered by infected men. At the AIDS Center, 48% of couples treated there include one healthy member and one carrier. If the woman is free of HIV, the man’s semen can be “rinsed” to remove the HIV virus; the virus is not able to penetrate the sperm itself, but is found mostly in the leukocytes. The would-be father must undergo drug treatment for at least six months and then give a semen donation that is rinsed.
So far, said Olshtein-Pops, 58 couples – most of them married and in their 30s – have registered. The participants include 32 native-born Israelis, seven Israeli Arabs, 10 born in Eastern Europe and nine in Ethiopia.
Of 22 women who have undergone artificial insemination with rinsed sperm, 16 got pregnant by artificial insemination. Three women miscarried, but two couples are now on their second pregnancy. Two births involved twins.
There wasn’t a single case of a healthy woman who was infected with HIV from her partner, she concluded with pride.
Nurse Michelle Bashan spoke about how to prevent women with HIV from infecting their infants. There are 10 cases annually in Israel of pregnant HIV carriers. They receive AZT during pregnancy to reduce the presence of the virus, and the baby is delivered by cesarean if it is high and vaginal delivery if it is not. The women are not allowed to breastfeed, as the breast milk of carriers can transmit the virus to the baby. These methods have prevented the transfer of the virus to the infant in nearly all cases, she said.
Bashan urged the Health Ministry to issue a directive to test all pregnant women for HIV.
“It is done in the US and elsewhere, but not here. It is advisable so we have no surprises,” she said.
Maayan – who has traveled to Africa many times – summed up by noting that “Hadassah has spearheaded much international cooperation on AIDS. We have conducted joint research, such as on drug resistance in Addis Ababa, and dozens of doctors and nurses have come here for advanced training. There is also a medical student exchange program.
“As AIDS involves not only medical but also social and economic influences, it has to be dealt with holistically, and this is what we have done in the Third World. We have a lot to give.”