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Notes And Quotes

Twenty years and counting, where will we be in 2021?

Susman, Ed

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On 5 June 1981, the US Centers for Disease Control’s Morbidity and Mortality Weekly Report ran a short notice about the occurrence of Pneumocystis carinii in five men, a report now generally cited as the beginning of the written history of the AIDS epidemic. Of course, we now know that AIDS had been around for at least a generation before that and maybe a lot longer, but the 20th anniversary of the MMWR article gave researchers in the field a chance to reflect on an extraordinary two-decade journey in fighting a disease that will rival the Black Death in history, and to predict how we may fare in the next 20 years.

“For the next 20 years to be a time of success, not continued failure, our approach to AIDS must change radically,” wrote editor Robert Steinbrook, MD, and deputy editor Jeffrey Drazen, MD, in an editorial in the New England Journal of Medicine. “The United States and other rich nations must contribute the billions of dollars needed for treatment and prevention in poor countries … Treating and preventing infection must be viewed in terms of simple morality and humanity, not as an endeavor that is burdened by national and sexual politics, misinformation, stigma and blame,” they said in the journal issue dedicated to discussion of the epidemic.

Prevention, relief goals

Michael Gottlieb, MD, of Pasadena, California, who penned the first lead article about AIDS in the journal in December 1981, outlined some of the necessary steps that will be required to control the epidemic:

“We physicians must continue to advocate aggressive programs for prevention – especially among intravenous drug users and gay men and in Hispanic and black communities – and we must ensure easy access to care and medication for people who are HIV-positive.

We must convince the pharmaceutical industry, foundations and the government that there is a moral imperative to provide humanitarian relief in poor countries.

We must hope that the clock will not be turned back to the time when ‘AIDS’ and ‘HIV’ did not find a place in the presidential vocabulary.”

And in another retrospective look at the epidemic in the journal, Kent Sepkowitz, MD, of Memorial-Sloan Kettering Cancer Center, New York, said that spin-offs from the fight against AIDS have included a streamlined ability of the US Food and Drug administration to approve new medications; a blueprint of activism that has been adopted by proponents of care for more than 150 different disease states; fast-paced efforts to protect the blood supply against contaminants such as bovine spongiform encephalopathy. On top of that, for fortunate members of the world’s society, AIDS itself appears to have morphed from “a predictably fatal infection to a chronic condition requiring daily medication and occasional visits to the doctor’s office.” Despite these gains, however, the epidemic threatens to spin completely out of control in many of the world’s poorest nations.

Noted Steinbrook and Drazen in their editorial: “In 2021, undoubtedly there will still be an AIDS epidemic. But in 2001, the medical community and world leaders have a unique opportunity to begin the long and difficult process of bringing the epidemic under control. The next 20 years can be different but only if we act now.” (Vol. 344, No. 23).

UN General Assembly

In a special 3 day special session on HIV/AIDS, the United Nations General Assembly in late June adopted a “Declaration of Commitment” – a blueprint for mobilizing an accelerated response to the pandemic. The 16-page declaration, “Global Crisis – Global Action”, addresses a wide range of issues, and stated: “The HIV/AIDS challenge cannot be met without new, additional and sustained resources.”

The declaration seeks to achieve by 2005, a target of $7–10 billion annual expenditure on the epidemic in low and middle-income countries and those experiencing or at risk of rapid expansion. The declaration calls for the adoption of national strategies and financing plans for fighting HIV/AIDS by 2003. Among those goals were:

reducing HIV prevalence rate among people aged 15–24 years by 25 percent by 2005;

ensuring that by 2005, “a wide range of prevention programs which take account of local circumstances, ethics and cultural values, is available in all countries, particularly the most affected countries.” Those should include education encouraging responsible sexual behavior, including abstinence and fidelity, as well as expanded access to essential commodities, including condoms and sterile injecting equipment;

providing access by 2005 to education and services so that all young men and women aged 15–24 years can develop “the life skills required to reduce their vulnerability to HIV infection”;

reducing by 2005, the HIV prevalence rate among infants by 20 percent;

strengthening health care systems and addressing the affordability of HIV-related drugs, including antiretrovirals, by 2003;

eliminating, by 2003, all forms of discrimination against people living with HIV/AIDS and members of vulnerable groups;

creating new national strategies, by 2003, to help those at greatest risk to new infection, “as indicated by such factors as the local history of the epidemic, poverty, sexual practices, drug using behavior, livelihood, institutional location, disrupted social structures and population movements”;

improving services for children orphaned and affected by HIV/AIDS, including counseling, school enrollment, access to food, shelter and social services, and protection from abuse;

increasing investment in the search for an AIDS vaccine. “With no cure for HIV/AIDS yet found, further research and development is crucial,” the declaration stated;

asking for national periodic reviews of progress towards achieving the commitments set out in the declaration, as well as an annual full day or discussions on such progress by the General Assembly;

“We recognize and express our appreciation to those who have led the effort to raise awareness of the HIV/AIDS epidemic and to deal with its complex challenges,” stated the Declaration. “We look forward to strong leadership by governments, and concerted efforts with full and active participation of the United Nations, the entire multilateral system, civil society, the business community and private sector.”

Another reservoir for HIV

Researchers at the Mount Sinai School of Medicine in New York City reported in the New England Journal of Medicine (Vol. 344, No. 26) that HIV appears to enter kidney cells of the kidney and can reside there without being impacted by effective therapy.

“Our results suggest that renal epithelial cells may be a persistent reservoir of HIV-1 RNA transcription and that any interruption in therapy could lead to rapid formation of infectious virions,” reported Jonathan Winston, MD, clinical associate professor in the division of nephrology at Mt. Sinai.

Winston and colleagues determined after biopsy in one patient who had well-controlled viremia on highly active antiretroviral therapy that the virus was still active in the kidney cells.

Dr. Winston has previously published work connecting HIV-infection and kidney function (Journal of the American Society of Nephrology 1996, 7:1–7). Others who have also looked at HIV with infection of the kidney include: Dr. Vivette. D’Agati, MD, a pathologist at Columbia Presbyterian Medical Center, New York (J Am Soc Nephrol 1997, 8:138–152); Dr. Arthur Cohen, MD, professor of medicine at Cedars-Sinai Medical Center, Los Angeles (Modern Pathology 1988, 1:87–97); Jeffrey Kopp, MD, senior investigator at the National Institutes of Health, Bethesda, MD (Proceedings of the National Academy of Sciences, USA 1992, 89:1577–1581]; and Leslie Bruggeman, Ph.D., assistant professor of medicine at the Mount Sinai School of Medicine (J Am Soc Nephrol 2000, 11:2079–2087).

On a personal note

The last time I saw Nkosi Johnson, the then 11-year-old South African child was speaking at the United States Conference on AIDS in Atlanta. He had been to New York, San Francisco and had just finished a luncheon talk at the conference, describing the heartache of living with HIV in South Africa, and the wonder of being a worldwide emissary, promoting understanding of the epidemic as well as pleading for prevention and treatment for the millions of people with the disease. “I do this for the sake of other children out there who are suffering,” said Nkosi, his voice low but strong. His tour of the US was nearly over, and Nkosi was anxious to return to Johannesburg. “I miss my sister” he admitted. His fervent wish, he said, would be “that everybody knows about the AIDS virus. And then I would teach them so that then they could help the people.”

He said he was tired from his travels but was happy to have the opportunity to awaken people to the need to fight the disease that has killed so many mothers and fathers and children throughout the world. We shook good-bye, his tiny hand almost swallowed by mine, but his grip was solid. Only a few weeks later we learned that Nkosi had again been felled by complications of the disease. Somehow he held on through his 12th birthday in February. He died on 1 June.

I had heard Nkosi speak in Durban and in Atlanta. His passing is another reminder that this terrible epidemic continues to darken the brightest lights of our time.

Ed Susman

© 2001 Lippincott Williams & Wilkins, Inc.