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Notes & Quotes

Susman, Ed

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To the AIDS Readership:

You will note in the issues of AIDS 2001 that the cover design has been changed. We have also added this feature ‘Notes and Quotes’ which will cover key issues in HIV/AIDS throughout the world. This section of AIDS will inform you of new observations, new ideas, and new hypotheses that are related to efforts to control and, eventually eliminate the HIV epidemic. We hope you appreciate these new features of AIDS.


The Editors of AIDS

US intelligence paints a gloomy picture of how AIDS will impact Africa

It's not often that the United States Central Intelligence Agency – yes, the controversial CIA – shares its crystal ball with the world, but its project Global Trends 2015 was intended to be publicized.

`Grappling with the future is necessarily a work in progress,’ said George Tenet, director of the CIA, ‘that should constantly seek new insights while testing and revising old judgments.’ The project gathered information from academia, private think-tanks and the corporate world, and tackled numerous worldwide dilemmas, including the health consequences of the international AIDS epidemic.

The CIA report on the impact of AIDS in Africa is devastating. ‘In the absence of a major medical breakthrough, the relentless progression of AIDS and other diseases will decimate the economically productive adult population, sharply accentuate the continent's youth bulge, and generate a huge cohort of orphaned children. This condition will strain the ability of the extended family system to cope and will contribute to higher levels of dissatisfaction, crime and political volatility,’ the report predicted.

Dire forecasts

The report predicts:

•AIDS will reduce economic growth by up to 1 percent of gross domestic product per year and consume more than 50 % of health budgets in the hardest-hit countries.

•AIDS and associated diseases such as tuberculosis will have a destructive impact on families and societies, as the diseases together will account for the majority of deaths in most developing countries.

•The diseases in some African countries will result in average life spans being reduced by 30 to 40 years.

•The disease will create in Africa 40 million orphans.

•AIDS, other disease and health problems will hurt prospects for transition to democratic regimes as they undermine civil society, hamper the evolution of sound political and economic institutions, and intensify the struggle for power and resources.

•Some countries in Africa with high rates of AIDS will experience reduced population growth or even declining populations despite relatively high birth rates. In South Africa, for example, the population is projected to drop from 43.4 million in 2000 to 38.7 million in 2015.

`There will be exceptions to this bleak overall outlook,’ Tenet said, but the report suggested the quality of governance, rather than resource endowments, will be the key determinant of development among African states.

An example of a successful program in Africa

One of those successes was a program at the University of Zimbabwe that exceeded its goals of reaching adolescents and young adults in hopes of getting them to change sexual attitudes and activities. With sponsorship from the World Bank, the University of Zimbabwe had supported 34 partners in the region, to implement 64 projects in reproductive and sexual health interventions in South Africa, Zimbabwe, Zambia and Malawi.

Wendy Roseberry, a senior technical analyst at the World Bank reported that during 1999, projects in Zimbabwe and South Africa trained 955 peer educators, held 85,297 outreach meetings, reached 1,093,583 men and 895,241 women, and distributed 8,298,431 condoms.

That program resulted in major changes in conduct. For example in Kriel, South Africa, planners hoped to reduce sexually transmitted infections by 33 percent in three years - a target surpassed by the Kriel pilot project's achievement of a 38 percent decline in sexually transmitted infections during the first 18 months. Similarly, the project sought to achieve 70 percent condom use outside primary relationships. Within the first 18 months, the Kriel project has achieved 90 percent condom use outside primary relations among men and women. In addition there was a 30 percent decline in boyfriends among women and a 5 percent decline in girlfriends among men.

Nevirapine warning in post-exposure prophylaxis

US government epidemiologists warned doctors and patients to be alert for possible liver abnormalities that can occur among patients who use the non-nucleoside reverse transcriptase inhibitor nevirapine - especially when the drug is used to prevent AIDS infection from needlestick-type injuries.

The Centers for Disease Control and Prevention, Atlanta, has uncovered 22 cases in which people with these injuries were given nevirapine and subsequently suffered liver damage and skin rashes. Two cases involved life-threatening hepatotoxicity.

Although zidovudine has been approved for treatment of post-exposure prophylaxis (PEP), nevirapine's use is relegated to cases in which zidovudine or other drugs have been shown to be ineffective.

However, the National Center for HIV, STD and TB prevention said that the findings in these cases should not deter the use of nevirapine to prevent transmission of the virus from an infected mother to her newborn. That therapy requires just one dose of nevirapine, while PEP can involve several dosings.

The United States Public Health Services does not recommend PEP for all types of occupational exposures to HIV. Since most of these exposures fail to result in HIV infection, government officials are concerned that the risk of serious toxicity from drugs such as nevirapine may be much greater than the risk of infection.

Taking a look at forgiveness quotient

The temptation to take a ‘drug holiday’’ from dozens of anti-HIV pills looms large among people living with HIV/AIDS. But doctors have hammered home the message that missing just a few doses of the drug could jeopardize the effectiveness of the medications -especially protease inhibitors.

Well, that might not be the case all the time, researchers hint. Scientists are scrutinizing the concept of a ‘forgiveness quotient’ for some protease inhibitors - particularly those that can be boosted in potency by addition of subtherapeutic doses of ritonavir.

Eric Furfine, a principal research scientist with GlaxoSmith-Kline in Research Triangle Park, North Carolina, said that patients who add doses of ritonavir to their regimens may be able to maintain a high enough level of active drugs such as amprenavir in the bloodstream so that occasional lapses in drug administration do not create resistant virus.

In laboratory studies, Furfine determined that amprenavir - because of its long half-life which can be boosted with ritonavir – had the highest forgiveness quotient of any of the other protease inhibitors. He took isolates from 28 protease inhibitor experience patients and tested them 12 and 24 hours apart and found they still inhibited the virus.

Ritonavir has shown that it can improve absorption of amprenavir, saquinavir, indinavir and lopinavir.

Furfine said the concept looks good in the laboratory, but no one should attempt to extrapolate his data in practice until well-designed clinical trials can prove that what works in the test tube works in the human body.

Websites of interest

CIA report on Global Trends 2015

World Bank

The Kids Aids site

Elizabeth Glaser Pediatric AIDS Foundation

© 2001 Lippincott Williams & Wilkins, Inc.