Download 3. Honigsbaum, Naomi. HIV, AIDS and children : a cause for

The HIV Epidemic:
An Outcry for Help
By
Luis Gonzalez – Patient
David Carrillo – Clinician
Monica I. Portillo – Epidemiologist
Aldo Gallegos – Researcher
Ysela Virgen – Medical Ethicist
Eric Dominguez – Public Health Officer
April 21, 2004
The HIV Epidemic: An Outcry for Help
When the HIV infection first arose no one had any idea of what it was going to lead to.
What it has led to is a worldwide epidemic claiming millions of lives worldwide. More than 21.8
million people around the world have died of AIDS and more than 40 million people are now
living with HIV, and most of these will most probably die over the next decade. Immediate
action needs to be taken so that there is less transmission of the disease and people living with
HIV or AIDS can be provided with the most effective care.
The patient Luis Gonzalez had symptoms of chicken pox and thrush, which forced him to
seek medical attention. It was revealed through serological tests that he produced the antibodies
against HIV (signifying a positive result). Also, it was revealed that CD4 count less than 400,
meaning that he has a late stage of the HIV infection. Steps to identify epidemiologically where
he contracted the virus revealed that he was sexually promiscuous bi-sexual male.
HIV/AIDS treatment has entered a new era of optimism as well as a period of daunting
complexity. For the first time "eradication" of HIV is being seriously discussed. Almost a dozen
anti-HIV drugs are available and many more are in development. People infected with HIV face
a significant challenge in making decisions about multiple drug combinations, interpreting viral
load tests, as well as issues about how their choices today will effect treatment options
tomorrow. If treatment questions seem complex, add to the mix the task of negotiating a rapidly
changing U.S. health care system.
Epidemiological statistics for HIV and AIDS in the United States and other parts in the
world is very important because we need to remember that these statistics represent the
cumulative experience with HIV infection since the beginning of the epidemic. The distribution
of HIV infection in the populations at risk changes with time as HIV infection moves through
different populations at different rates. The worldwide nature of HIV infection makes it a very
important public health problem. No continent or countries are safe from infection and the virus
can spread rapidly once it enters a group engaging in high risk behavior.
An effective strategy against the progression of the HIV virus is knowledge of oneself,
the progression of one’s HIV and the current treatments available, knowledge of drug resistance
and how it affects the patients’ HIV progression, and an overall understanding on how the virus
in the patient is reacting to current medications being administered to the patient.
Since the HIV epidemic has had such an enormous impact on health care provision, it is
important that a patient with HIV/AIDS be treated with the utmost ethical care. Clinical trails are
essential to scientifically prove the safety and efficacy of new therapies. This is why there is an
ethical criterion that needs to be followed when performing HIV/AIDS research. By developing
and applying strong ethical policies towards treatment of the HIV/AIDS patient and in the aspect
of research, we can help the patient cope with this devastating disease.
It is the objective of the public health officer to figure out the problems that HIV/AIDS
have affected the population in the United States and throughout the world. This deadly
epidemic may not seem like a huge problem in the U.S. but it is throughout the world.
HIV Patient
By Luis Gonzalez
I am Luis Gonzalez, and I have been diagnosed with HIV. I am a 30 year old male who
has had a history of promiscuous sexual activity with both men and women. I would engage in
sexual activity without the use of a condom.
I decided to go to the doctor since I have a reoccurrence of the chicken pox (Herpes
Zoster), characterized by red sores around my body, along with a fever and a headache. This is
strange since I had chicken pox when I younger and thought it wouldn’t reoccur. Also, in
addition to this I also had white patches in mouth, gums, and tongue. The symptoms I had been
experience was an altered sense of taste and burning sensation in my mouth. The doctor said that
it was a fungus called thrush (Candida albicans). I tested positive for HIV since I produce the
antibodies specific for the virus. Also, the doctor said I have a CD4 count less than 400
cells/mm3, signifying a late stage of HIV (almost full blown AIDS). This means that I have had
HIV for a number of years now.
For a few years, prior to this HIV confirmation, I have been getting occasional diarrhea
(varies from day to day). Also, I had been getting flu-like symptoms (fever, headache, sore
throat) for the past few years that comes and goes, which is peculiar in that I am not known for
getting sick. There had been a decrease in activity, since I have felt fatigued. Also, I have had a
slight decrease in weight, which seemed unfamiliar since I have an endomorph body type (this
means it is hard for me to lose weight based on my body type).
Since the confirmation of HIV, I have been depressed and have been taking Prozac to
battle my depression. My doctor wants me to join a support group and get off of that drug. I
hope that I can. Also, to battle the symptoms associated with thrush the doctor prescribed me a
combination of antifungal drugs, Clotrimazole, Troches, and Nystatin. As for the treatment to
deal with the symptoms, caused by the resurgence of the chicken pox, the doctor prescribed me
oral Acyclovir. For the headache, I am taking over-the-counter 500mg of Tylenol. Also, the
doctor informed me that I had to rethink my lifestyle, due to that fact that I am promiscuous and
bi-sexual. Sometimes a feel guilty about that. He suggested I could talk with my priest, but I
haven’t done that in years. Maybe I will.
Now as the T-cell count continues to drop, clinicians and researchers continue to find
new medications to help inhibit T-cell degeneration in HIV/AIDS patients (like me). On going
studies are being conducted to find a vaccine or eradication of the HIV virus. I am working now
to raise consciousness among the community as a whole.
References
1. HIV Symptoms Online. http://www.aidshivtest.com/symptoms-of-hiv.htm
2. Aranow, Richard and et. al. HIV Resistance Testing Consultation Service: Consultation
Report. December 2001: pp. 1-5.
3. Murray, Patrick, and et. al. Medical Microbiology 4th Edition. 2002
4. Birchall, Martin A. and Siobhan M. Murphy. HIV infection and AIDS . 1992
5. Zaas, David. “Cases from the Osler Medical Service at Johns Hopkins University.” The
American Journal of Medicine, Volume 113, Issue 9, 15 December 2002, Pages 760-762.
.
Clinician (Infectious disease specialist)
David Carrillo
HIV/AIDS treatment has entered a new era of optimism as well as a period of daunting
complexity. For the first time "eradication" of HIV is being seriously discussed. Almost a dozen
anti-HIV drugs are available and many more are in development. People infected with HIV face
a significant challenge in making decisions about multiple drug combinations, interpreting viral
load tests, as well as issues about how their choices today will effect treatment options
tomorrow. If treatment questions seem complex, add to the mix the task of negotiating a rapidly
changing U.S. health care system.
Be As Informed As Possible
Now, more than ever, it is essential to have as much knowledge as possible about HIV treatment
options. Even expert panels of researchers have difficulty in making recommendations in today's
environment of multiple treatment regiment and rapidly evolving research data. A recent review
of AIDS information newsletters demonstrates the range of opinions to be found regarding
treatment choices. For a person newly infected with HIV, one doctor recommended no treatment,
while another recommended a six drug combination. The tremendous value of newsletters lies in
the explanation and discussion of the background issues and the context of each approach. The
six drug combination was used in a research setting, testing a very aggressive approach for
people newly infected with HIV. The "no treatment" approach was discussed by a conservative
doctor working in a urban clinic who wanted more research done and was concerned about
compliance and medical coverage issues.
When treatment strategies are reported on television, in newspapers, or discussed by friends,
often the background information is left out. Reliable treatment newsletters provide information
based on interviews and surveys of leading researchers, reports from scientific journal articles
and analysis by authors experienced in HIV/AIDS treatment issues. The information in this
newsletter is reviewed and cross checked by a number of different people to insure accuracy and
reduce bias.
Treatment journals are an extremely valuable source of state of the art information covering
various options as well as putting these options in perspective. They can provide a lifeline for
people living in small communities or who otherwise have limited access to up to the date
treatment. They also provide information, which can be taken to a doctor to help with treatment
discussions.
Treatment Guidelines
The table below outlines basic treatment guidelines as recommended by health care professionals
who treat a large number of HIV-positive people, recommendations published by the
International AIDS Society, and recommendations made by local and national university-based
AIDS experts. As with any general guidelines, each person's unique situation must be factored
into any treatment plan. Considerations include drug tolerance, drug interactions, and the
person's overall health, including energy level, weight loss, or other symptoms. Another very
important consideration is the rate of change of CD4 cells and viral load. Any treatment plan
should take into consideration future therapy as well.
Two measurements of viral load a couple of weeks apart are recommended for a baseline for all
HIV-positive persons. Viral load should be measured about 4 times per year. Additionally, viral
load measurements should be obtained 4-8 weeks after initiating a new therapy to assess its
efficacy.
Therapy Recommendations
Viral Load Non-detectable, CD4 greater than 500 - OBSERVATION
Viral Load Non-detectable, CD4 200-500 - DOUBLE THERAPY
Viral Load Non-detectable, CD4 less than 200 - TRIPLE THERAPY
Viral Load up to 5-10,000 , OBSERVATION OR DOUBLE/TRIPLE THERAPY
Viral Load up to 5-10,000, CD4 200-500, TRIPLE THERAPY
Viral Load up to 5-10,000, CD4 less than 200, TRIPLE THERAPY
Viral Load greater than 5-10,000, CD4 greater than 500, DOUBLE OR TRIPLE THERAPY
Viral Load greater than 5-10,000, CD4 200-500, TRIPLE THERAPY
Viral Load greater than 5-10,000, CD4 less than 200, TRIPLE THERAPY
Note: Double therapy means a combination of 2 drugs, usually two nucleoside reverse
transcriptase inhibitors (AZT, 3TC, ddI, ddC, and d4T). Triple therapy means a combination of 2
nucleoside reverse transcriptase inhibitors and a protease inhibitor (saquinavir, ritonavir, or
indinavir) or a non-nucleoside reverse transcriptase inhibitor ( delavirdine or nevirapine).
Alternatively, an effective combination of 2 drugs may be 2 protease inhibitors, such as
saquinavir and ritonavir. (STEP Perspective 1996; Vol. 8, No. 2 for a complete discussion of
combination therapy.) Resistance makes this more complicated.
Guidelines for Prevention of Opportunistic Infections
Following is a list of common Opportunistic Infections (OI's) and whether or not preventative
therapy is recommended:
Pneumocystis pneumonia (PCP), BENEFICIAL IF CD4 less than 200
Toxoplasmosis, MAY BE BENEFICIAL IF CD4 less than 100 AND Toxo Antibody Positive
CMV, BENEFICIAL IF CD4 less than 50
Cryptococcus, MAY BE BENEFICIAL IF CD4 less than 100
Mycobacterium Avium Complex, BENEFICIAL IF CD4 less than 100
Note: Preventative therapy (prophylaxis) for PCP is of benefit to all HIV-positive persons with
CD4 values below 200, and some health care providers recommend preventative therapy even in
some people with slightly higher CD4 counts. While some studies have shown a benefit for
preventative therapy for the other infections in the table above, problems with side-effects, drug
interactions, and resistance have resulted in selective use of drugs to prevent these infections. An
HIV-infected person with low CD4 counts, (less than 100), should discuss the use of drug
therapy to prevent these infections with their health care provider on an individual basis. CMV
infection in the eye can cause permanent, irreversible vision loss, even when treated. Therefore,
many health care providers recommend that all HIV-infected persons with CD4 counts below
100 be examined regularly for evidence of early CMV infection in the eye (retinitis). Early
treatment may prevent vision loss. Screening cannot be done by a quick look into the eye, but
requires drops to dilate the eye and a careful examination by a trained professional (fundoscopy).
Prophylactic therapy for opportunistic infections should not be discontinued if low CD4 counts
increase significantly on antiretroviral therapy. Apparently, the risk of an OI is not significantly
decreased when CD4 cell counts increase on antiretroviral therapy.
Self-Advocacy
In a perfect world, all health care providers would be well-informed and the best and most
effective treatment would be offered to all persons who are HIV-positive. However, this is not
always the case, and clients must take action and insist that their health care provider and health
plan provide them with the opportunity to receive the best possible care. Survival may depend
upon it! Sometimes, health care providers are not well-informed about the latest developments
concerning protease inhibitors or viral load testing. Other times, the health care plan or health
maintenance organization (HMO) may not allow health care providers access to the newest, or
best drug, or laboratory tests that he or she wants to prescribe. In either case, each person must
become an activist and a treatment advocate on their own behalf.
References
1. Topics in HIV Medicine, Volume 8, Issue 5: August 2000. IAS-USA
2. Deeks SG, Smith M, Holodniy M, et al. HIV-1 protease inhibitors: A review for clinicians.
JAMA. 1997;277:145-153.
3. Lucas GM, Chaisson RE, Moore RD. Highly active antiretroviral therapy in a large urban
clinic: risk factors for virologic failure and adverse drug reactions. Ann Intern Med.
1999;131:81-87.
4. Valdez H, Lederman MM, Woolley I, et al. Human immunodeficiency virus 1 protease
inhibitors in clinical practice: predictors of virological outcome. Arch Intern Med.
1999;159(15):1771-1776.
5. Centers for Disease Control and Prevention, Division of HIV AIDS Prevention. New attitudes
and strategies: a comprehensive approach to preventing blood-borne infections among IDUs.
Available at: http://www.cdc.gov/hiv/projects/idu-ta. Accessed June 20, 2000.
6. Bamberger JD, Unick J, Klein P, et al. Helping the urban poor stay with antiretroviral HIV
drug therapy. Am J Public Health. 2000;90(5):699-701.
7. Ledergerber B, Egger M, Opravil M, et al. Clinical progression and virological failure on
highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study. Lancet.
1999;353:863-868.
Public Health Officer
By Eric Dominguez
As a public health officer its my objective to figure out the problems that HIV/AIDS have
affected the population in the United States and throughout the world. HIV infections have been
reported from over 173 countries and in all populations. By mid-1993, more than 11 million
people worldwide were infected with HIV. The number of persons infected since the start of the
pandemic is 14 million. HIV is spreading much more rapidly in developing countries than in
industrialized countries. It is estimated that more than 90 percent of new HIV infections are
occurring in developing countries. More than 60 percent of the world’s total HIV infections have
occurred in Africa, but Asia’s extremely rapid rate of HIV spread will surpass that of Africa
within the decade. HIV/AIDS is increasing dramatically in Asia. India is leading the world in
absolute numbers of HIV infection, estimated at 3-5 million. China too has a growing HIV/AIDS
problem, with the number of infections estimated at 10 million. Given its huge population size
and the current rate of HIV infection in the region, Asia is set to overtake sub-Saharan Africa in
absolute numbers before 2010. It can therefore be said that by the year 2020 Asia will be the
epicenter of the HIV/AIDS pandemic. HIV is huge health problem with profound social and
economic implications. The spread of different HIV clades, or subtypes, in different geographic
areas and within different populations is just beginning. Given the presence of multiple clades in
Thailand and their clustering in certain risk groups, studies connecting the multiple markers with
spread within the population are critical. They estimate that around 42 million individuals are
living with HIV/AIDS. If this number is put in broader perspective it becomes clear that AIDS is
affecting well over 160 million people worldwide. Health care systems in countries with high
infection rates are literally being overwhelmed. Food security is also being affected in rural areas
of Africa as the loss of adults is leading to labor shortages in the fields. Education is also being
affected. The HIV epidemic is measurably slowing the population growth of the world before
our eyes.
About 20 years since its discovery the HIV disease remains a hidden epidemic in many
rural areas. The relatively small number of AIDS cases reported from rural communities creates
the impression that only urban residents are at risk for the disease. Although a closer look at rural
HIV/AIDS statistics reveals some disturbing trends. During the first 13 years of the epidemic the
Centers for Disease Control and Prevention (CDC) received reports of 18, 000 rural residents
who had been diagnosed with AIDS. At the end of 1997, an estimated 17, 000 people with
AIDS were living in rural areas of the United States and an additional 41,000 to 57,000 rural
residents were living with asymptomatic or symptomatic HIV infection.
Through December 2003 there were approximately 520, 000 persons living with the HIV
infection or AIDS. These reports only include persons diagnosed with HIV/AIDS infection in
states with integrated HIV/AIDS surveillance systems (30 out of 50 states). In 2000, CDC
estimated that 800,000 to 900,000 persons in the U.S. were living with HIV or AIDS. The
difference in these values is due to several factors, including the fact that; reporting of persons
diagnosed with HIV has not yet been implemented in all states and territories. It is also due to the
fact that anonymous tests are excluded from case reports and many people are unaware of their
HIV status. HIV is a big problem in the United States that many people are unaware of or don’t
care about it. Compared to other countries around the world the U.S. ranks below other countries
but this could be due to the fact that several are not reported.
Education of the public on HIV/AIDS is essential in slowing the progression of this
disease. Treatment programs for IV-drug abusers should be available to allow persons seeking
assistance to enter promptly and be encouraged to alter the behavior that places them and others
at risk for HIV infection. Outreach programs for IV-drug abusers should be undertaken to
increase their knowledge of AIDS and of ways to prevent HIV infection, to encourage them to
obtain counseling and testing for HIV antibody, and to persuade them to be treated for substance
abuse. The ability of health departments, hospitals, and other health-care providers and
institutions to assure confidentiality of patient information and the public’s confidence in that
ability are crucial to efforts to increase the number of persons being counseled and tested for
HIV infection. Public health prevention policy reduction of the transmission of HIV infection
can be furthered by an expanded program of counseling and testing for HIV antibody, but the
extent to which these programs are successful depends on the level of participation. Priorities for
public health counseling and testing should be based upon providing ready access to persons who
are most likely to be infected or who practice high risk behaviors, thereby helping to reduce
further spread of infection. Sexual partners and those who share needles with HIV-infected
persons are at risk for HIV infection and should be routinely counseled and tested for HIV
antibody. There should implement routine HIV testing in medical care settings serving HIVprevalence populations. There should be rapid HIV testing in non-clinical settings, such as
homeless shelters, drug treatment programs, and social events. There should be available for
people living with HIV who have multiple complex problems. There should be education
available for the persons in this country who have no idea of how they have contracted HIV.
These preventable methods will go a long way in reducing the effects of this deadly epidemic
that has been wreaking havoc for 2 plus decades.
References
1. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV,
MWWR, July 18, 2003, www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm
2. The World Bank, HIV/AIDS and Rural Development: An Action Plan,
www.worldbank. .org/AIDS-econ/toolkit/rural.html
3. Honigsbaum, Naomi. HIV, AIDS and children : a cause for concern / by Naomi
Honigsbaum. London : National Children's Bureau, c1991.
4. United States. General Accounting Office. Global health [electronic resource] : Global
Fund to fight AIDS, TB and malaria has advanced in key areas, but difficult challenges
remain. Washington D.C. U.S. General Accounting Office, 2003
5. Way, Peter O. The impact of HIV/AIDS on world population / by Peter O. Way and
Karen A. Stanecki. U.S. Dept. of Commerce, Economics and Statistics Administration,
Bureau of the Census : [Supt. of Docs., U.S. G.P.O., distributor, 1994]
Epidemiology and AIDS
By Monica I. Portillo, Epidemiologist
Epidemiology is the study of the patterns of disease occurrence in populations and of the
factors affecting them. This field is of great importance to the understanding of human diseases,
and epidemiological studies can be used to address many questions. It is important to keep in
mind that epidemiological studies involve large populations of individuals since they draw on the
total experience and behavior of large numbers of individuals. It is important to avoid making an
ecological fallacy: explaining behavior of an individual based on observations of an entire group.
Another example of an improper conclusion is identifying certain characteristics of a group as
causing a disease. For example, epidemiological studies have identified male homosexuals as
one of the groups at high risk for AIDS. This does not imply that simply being homosexual
causes AIDS, as some people have claimed. Instead, certain sexual behaviors by some gay men
link them to AIDS.
Epidemiology has played a central role in the fight against AIDS right from the beginning
and this will continue. The initial identification of AIDS as a new syndrome in 1981 was made
through epidemiological studies. These studies reported the unusually high occurrence of
individuals with rare diseases associated with immunological defects. The initial epidemiological
studies showed a high frequency of the new disease in sexually active male homosexuals.
Furthermore, the pattern of occurrence suggested that AIDS might be caused by an infectious
agent that could be transmitted by sexual means. The appearance of AIDS cases among
recipients of blood transfusions or blood products as well as injection drug users suggested that
AIDS could be transmitted through contaminated blood. The study of individuals afflicted with
AIDS and also of groups of high risk individuals led to the isolation in 1984 of HIV, the virus
that causes AIDS. As soon as HIV was isolated the virus was used to develop the test for HIV
antibodies. The availability of the HIV antibody test allowed much more accurate
epidemiological studies because evidence of infection could also be detected in healthy
asymptomatic individuals. This led to the realization that an alarming number of individuals have
been infected with HIV in many parts of the world. Epidemiological studies of high risk groups
have identified the underlying high risk behaviors such as unprotected sexual encounters, and
sharing IV needles. This in turn has led to development of public health measures and safe sex
guidelines which are our only weapons in AIDS prevention today. Finally epidemiological
studies provided the proof that azidothymidine (AZT) is an effective therapeutic drug for AIDS.
The two basic kinds of epidemiological studies are descriptive and analytical. The goal of
the first is to describe the occurrence of disease in populations. Analytical studies seek to identify
and explain the cause of diseases. Descriptive epidemiological studies measure the appearance of
disease by categories of person, place, and time. Analytical epidemiology studies are generally
more focused than are descriptive studies. They investigate the causes of a particular disease and
they often involve assigning a numerical value to a potential risk factor.
Epidemiology has been extremely important in this epidemic. Here are some conclusions
that can be drawn by such studies. The total number of AIDS cases that have been reported in the
United States for the years 1978 to 1997. By the end of 1997, a total of 641,086 cases had been
reported, of which 390,084 had died. Current estimates are that between 650,000 and 900,000
people in the United States are infected with HIV; many of these people may develop AIDS and
ultimately die if the new therapies are not completely effective. The distribution of AIDS cases
according to risk groups. Homosexual and bisexual men make up the largest percentage of cases,
followed by injection drug users, hemophiliacs, and recipients of blood transfusions, sexual
partners of HIV-infected individuals, and children of HIV-infected mothers. Women make up
16.5 percent of American AIDS cases. This low percentage is because the largest number of
cases occurs in homosexual and bisexual men. Women make up about half of the AIDS cases for
the AIDS cases for the other risk groups. The frequency of AIDS cases among African
Americans and Hispanics is about three to five times higher than that of the general population.
Epidemiological studies regarding HIV transmission are presented here to illustrate how these
studies allow us to draw conclusions about the relative risks of different activities for HIV
transmission. One study implicates an activity (anal sex) in HIV transmission and other studies
show that casual contact does not cause HIV transmission. This one epidemiological study
looked at the relative risks of different sexual activities. This study was part of the San Francisco
Men’s Health Study, which is an ongoing study of single men in an area of that city. This
particular area has been especially hard hit by the AIDS epidemic. The study involved 1,034
single men, who were monitored for HIV antibody status and asked about their sexual practices;
forty eight percent were seropositive at the beginning. The homosexual men in the study were
divided according to whether or not they practiced anal intercourse. Those who were the
receptive partner or who were both receptive and insertive showed significantly higher
frequencies of HIV infection than those who did not engage in anal sex. This shows that anal
intercourse is a high risk mode of HIV infection. Other studies of heterosexual sexual couples
who engage in vaginal as well as anal intercourse clearly show that insertive intercourse can
result in HIV transmission to the man. The most likely situation is that anal receptive intercourse
is a very high risk sexual activity, and insertive intercourse is somewhat lower, although
significant in risk.
It is important to consider control of HIV/AIDS in the global perspective for two reasons.
First HIV infected people in all areas of the world develop the same immunodeficiency that is
seen in developed countries. Second it is in the self interest of developed countries to combat
infections such as HIV wherever they occur worldwide. In this age of rapid transportation an
infectious disease is only an airplane ride away from any place in the world. Any HIV in the
world is a threat to those of us in the United States. It is in our own self interest to combat the
spread of HIV on any continent.
References
1. Cox, Frank D., AIDS, 6th edition. McGRaw Companies, Inc., 2000.
2. Department of Health and Human Services. Condoms and Sexually Transmitted
Diseases…Especially AIDS, 1991 Publication FDA 90 4239.
3. Hatcher, Robert A., Contraceptive Technology, New York: Irvintong Publishers, 1996.
4. Shilts, Randy., AIDS epidemic and relation to the gay community. New York: St. Martin
Press, 1987.
5. Taylor, Gary., AIDS and Society, New York: Atheneum Press, 1994.
Research on HIV
By Aldo Gallegos, Researcher
HIV Background
The Human Immunodeficiency Virus (HIV) is categorized into a group of organisms
referred to as retroviruses. These viruses are a type of virus that, when not infecting a cell, stores
its genetic information on a single-stranded RNA molecule instead of the more usual doublestranded DNA. After a retrovirus penetrates a cell, constructs a DNA version of its genes using a
special enzyme called reverse transcriptase. This DNA then becomes part of the host cell’s
genetic material. Since such organisms like the HIV virus lack essential organelles such as
ribosomes, mitochondria, etc., the virus uses the components of the host cell to carry out its RNA
to DNA synthesis which then is proceeded to mass virus duplication once such synthesis is
undergone. For example during initial infection with HIV when the virus comes in contact with
the host, it then proceeds to find susceptible T cells, this is the first site at which there is massive
production of the virus in the lymphoid tissue. This event yields inevitable bursts of viruses
throughout the site of infection causing viremia and wide decimation of the lymphatic tissues and
organs. When ever this occurs great efforts by the immune system are underwent, however in
lure of such efforts some viruses are still able to get away therefore causing infection.
Eventually this results in a high viral turnover that leads to the overall destruction of the immune
system. Therefore this leads to the overall, however gradual, deterioration of the immune
system. During course of infection, crucial immune cells, called CD4+ T cells (the backbone for
the cascade effect of immune response) are disabled and killed and their numbers are greatly
declined. With such catastrophic damage to the immune system the body’s ability to effectively
attack even the simplest organisms, which before caused only asymptotic problems, is now
susceptible to infection without a way to suppress organism pathogenicity. The body is now
immunocompromised against all pathogens.
Countermeasures Against HIV Progression
Many efforts have been made in attempt to control the further progression of the HIV
virus. The main focus on how to combat the virus is by the development of new drugs in heavy
and extensive doses. One example on drug development is the research done on the virus’
ability to effectively use the enzyme reverse transcriptase (RT) to convert its RNA genetic
material to DNA by using host components. One such drug development is a nucleoside reverse
transcriptase inhibitor (NRTI). This drug is antiretroviral drug whose chemical structure
resembles a modified version of a natural nucleoside. This compound suppresses replication of
retroviruses by interfering with the RT enzyme. However all NRTI’s require phosphorylation of
in the host’s cells prior to their incorporation into the viral DNA. One example of an NRTI is
that of Ziovudine which was approved by the FDA in 1987 and used with other antiretroviral
drugs to help combat the HIV virus. However alike many other organisms the HIV virus has
become resistant to many of the drugs produced in the 80’s and early 90’s. In this effort, in case
of drug resistant, many new drugs have been approved or are under clinical trials. Such drugs
include Amdoxovir (DAPD) and Alovudine (MIV-310) both are in Phase II (phases of FDA
approval range from I-III) and are expected to launch in 2006, these two drugs can be used in
countermeasures to drug resistant against NRTI’s.
Another factor at which drug development is aimed at is that of protease inhibitors.
These drugs act by inhibiting the virus protease enzyme, which prevent viral replication.
Protease inhibitors block the protease enzyme from breaking apart long strands of viral protein to
make the smaller, active HIV proteins that comprise the virion. If the larger HIV proteins are
not broken, they cannot assemble themselves into new functional HIV particles. All protease
inhibitors are based on amino acid sequences recognized and cleaved in HIV proteins. Most
protease inhibitors contain synthetic analogue of the phenylalanine-proline sequences at
positions 167 and 168 of the gag-pol polyprotein that is cleaved by the protease. Therefore
protease inhibitors prevent cleavage of gag and gag-pol protein precursors, this in turn arrests
maturation and blocking the infection of more virions. Some examples of protease inhibitors
include Saquinavir (Fortovase), and Ritonavir (Norvir). If drug resistance occurs one drug that is
on the verge of FDA approval is Tipranavir which is scheduled for launch in 2005. This drug is
greatly beneficial because it is taken in small dosages, reduces the use of the daily pill burden
and if taken with Ritonavir will greatly reduce the viral load by an increase of .8-1.3 log.
An effective strategy against the progression of the HIV virus is knowledge of oneself, the
progression of one’s HIV and the current treatments available, knowledge of drug resistance and
how it affects the patients’ HIV progression, and an overall understanding on how the virus in
the patient is reacting to current medications being administered to the patient.
Reference Page
1. Clavel, Francois, MD. Mechanisms of HIV Drug Resistance: A Primer. 2002.
2. www.pubmed.com
3. www.prn.com
4. Where’s My Pipline?. Vicissitudes of Medicine and Marketing Take Toll on Me-Too
Line Up.
5. Camp.Rob. TAGline. Treatment Action Group (TAG) vol. 11, issue 4. April 2004.
The Ethics behind the HIV Epidemic
By Ysela Virgen, Medical Ethicist
The human immunodeficiency virus (HIV) epidemic is a growing alarm all over the
world. The acquired immunodeficiency syndrome (AIDS), caused by HIV, already kills more
than 2 million people every year, and this number will grow as people who have harbored and
spread HIV for up to 10 years develop full blown AIDS. There are many issues involved when
dealing with this epidemic. One of these issues involves the development of policies and
research that are strong not only legally but morally as well, when dealing with the treatment of a
patient with HIV/AIDS.
First of all, ethics can be defined as the discipline of dealing with what is good and bad,
and with moral duty and obligation. Medical ethics is a discipline/methodology for considering
the implications of medical technology/treatment and what ought to be. Since the HIV epidemic
has had such an enormous impact on health care provision, it is important that a patient with
HIV/AIDS be treated with the utmost ethical care. The Texas Medical Association explains that
with regards to the HIV/AIDS issues, that a physician should accept the responsibility for the
care and treatment of a patient with AIDS, HIV, antibodies to HIV, infection with any other
probable causative agent or AIDS, or if the patient has a medical condition that is within the
physician’s area of specialty or expertise. Also, the physician can refer the patient to another
“appropriate” physician who will accept the responsibility for the care and treatment of the
patient if this patient falls outside of the original physician’s expertise. This is only if the original
physician would have done the same thing for another patient, without HIV/AIDS, who fell
beyond their medical expertise. This policy is important so that a patient with HIV/AIDS is
allowed the deserved medical treatment necessary without being discriminated against and
passed from one physician to another. There is no room within the medical profession for
prejudice for people with HIV/AIDS. The physician knows that he/she is supposed to be
dedicated to providing competent medical services with compassion and respect for human
dignity. All too often, this policy is ignored by many physicians and it is the patient who suffers
tremendously from this. This policy needs to be greatly enforced. I suggest that physicians
receive stricter evaluations not only by their medical peers, but by their patients. If they do not
comply, their medical license should be revoked. A physician who does not have the compassion
and the respect for human dignity should not be treating people who are in such a crucial stage in
their life, not only physically but emotionally, as well.
Physicians are ethically obligated to respect the rights of privacy and of confidentiality of
HIV/AIDS patients. AIDS is a reportable diagnosis in the 50 states of the United States, but
unfortunately HIV positivity without the diagnosis of AIDS is not reportable in all states.
However, Texas State Law requires the physician to report to the Texas Department of Health
cases of any AIDS and HIV infections. Currently, 30 out of 50 states require the reporting of a
positive test. It is important for this law to undergo change so that HIV positivity will become
reportable in all 50 states. This will be of great use when dealing with issues like, tracking the
disease and limiting transmission of the disease. I do believe that this policy will undergo change
due to the fact that 30 out of 50 states have already accepted this policy. Confidentiality is a great
issue when dealing with this information, but this is crucial information that aids in the
prevention and treatment of a disease that has and is claiming so many lives. However, these
policies apply to the United States, but the whole world is suffering from this epidemic. People
all over the world need to be thoroughly educated about this disease. Other countries and
provinces need to be aware that they need to also implement strict policies that will help aid in
limiting the transmission of this disease. These countries need to find the way to provide their
people with the tools necessary for the prevention of HIV/AIDS. This includes medical centers
that provide education and counseling, condoms, adequate health professionals, adequate
treatment, etc.
Also, the law of the State of Texas does not require the physician to notify a spouse of a
positive test result for HIV and AIDS. This crucial information is left at the physician’s
discretion. I believe this information should not be left at the physician’s discretion, but should
be a mandated law. I believe that the spouse, only the spouse, of the patient with HIV/AIDS
should also be notified of the results. Confidentiality and privacy are important, but when
someone engages into marriage they should be aware that they now have a moral responsibility
towards their spouse. It is not fair for the spouse of an HIV/AIDS patient to run the risk of
becoming infected unnecessary due to the fact that, in essence, life or death information was
withheld from them. The physician should also be required to counsel and attempt, by all means
possible, to persuade the infected patient not to endanger other parties. I would even take this
further and when dealing with AIDS/HIV patients, have a psychiatrist work alongside with the
physician to help the infected patient deal with their disease and be guided to make the correct
choices. This cooperative treatment would hopefully involve the prevention of HIV/AIDS spread
from this individual. However, the setback to this kind of medical cooperative treatment is that it
would probably be costly to the individual because they would add on an extra professional. If
the patient has insurance, most likely the insurance company will not want to cover this kind of
treatment. Maybe health representatives could target insurance companies and inform them of
the tragic consequences this epidemic is bringing with it and try to work something out. Also, if
the patient does not have insurance, the doctors and psychiatrists, as educated health
professionals, could come to some financial agreement.
Another important ethical issue that arises from HIV/AIDS is that of governing research.
This is very important in all types of research, especially involving clinical trials. Clinical trails
are essential to scientifically prove the safety and efficacy of new therapies. There is an ethical
criterion that needs to be followed when performing HIV/AIDS research. First and above all,
concern for the interests of the subject must always prevail over the interest of science and
society. Also, the physician must be free to use a new diagnostic and therapeutic measure, if in
his/her judgment it offers a hope of saving life, re-establishing health or alleviating therapeutic
methods. Another criteria is that for all phase I, II, and III clinical trials, a compassionate access
program must be in place, so that participants who choose to be part of a clinical trial do so of
their own free will and not because they are forced into this kind of trial because they have no
other treatment option. Finally, another ethical criterion is that people who do not qualify for a
clinical trial and who have an urgent clinical need to access that new therapy, must be given
access through a compassionate access program. These ethical criteria should be implemented
worldwide in order to avoid unethical research in regards to HIV/AIDS. I believe that the United
Nations, as a whole, should come together and enforce these ethical research policies to all of
those in need around the world. These are very good criteria when dealing with human lives as
research tools because as mentioned earlier, there needs to be compassion and respect for human
dignity. An example of an unethical research practice has been unfortunately observed in many
HIV/AIDS cases where placebo-controlled trials have taken place and great controversy has
followed, due to the fact that many individuals in the control group were being treated differently
than those in the control group of developed nations. This is why I suggest that the United
Nations work together and implement the essential ethical criteria described above. However,
these possibilities do not look very prosperous due to the financial resources of certain nations.
For example, 90% of the approximate 30 million or more HIV-infected individuals do not have
access to therapy due to the fact that drugs used for treatment are costly and available only in
developed countries. Funding from non-government sources, such as that recently provided by
the Bill and Melinda Gates Foundation, are crucial in the developing world.
Patients with HIV need to accept moral responsibility for their sexuality. Knowingly
transmitting an incurable infection is inexcusable. While physicians do not and should not
monitor patients’ sex lives, they do have an obligation to encourage as strongly as possible
proper moral living to prevent the spread of AIDS.
To conclude, the issue of medical ethics is crucial and necessary when treating a patient
with HIV/AIDS and in governing research. Unfortunately, an ever growing HIV and AIDS
epidemic is not inevitable, but with the right approaches, applied quickly enough, we can all
work to lower HIV infection rates and less suffering for those affected by this epidemic. By
developing and applying strong ethical policies towards treatment of the HIV/AIDS patient and
in the aspect of research, we can help the patient cope with this devastating disease.
References
1. American Psychological Association. (2001). Ethics in HIV-related Psychotherapy:
Clinical Decision-making in Complex Cases. Anderson, J.R. & Barret, R.L. (Eds).
2. Glaxo Wellcome Inc. (1997). Be Smart About HIV: Living with HIV Information Kit
[Brochure]. U.S.
3. Hamblin, J. (1992). People Living With HIV: The Law, Ethics and Discrimination.
Retrieved April 19, 2004, from the United Nations Development Programme Web site:
http://www.undp.org/hiv/publications/index.htm
4. Madigan, M.T., Martinko, J.M., & Parker, J. (2000). Brock Biology of Microorganisms (9th
ed.). Upper Saddle River, NJ: Prentice Hall.
5. Whittaker, B. (1997). Compassionate Access Programs & HIV Antiretroviral Treatments.
Retrieved April 18, 2004, from the National Association of People Living with HIV/AIDS
Web site: http://www.napwa.org.au/