The History of HIV Part II

1. The History of HIVPart II Professor David Watkins September 8th, 2015

2. What was AIDS called in the early days? A) GRID B) PCP plague C) Kaposi’s plague D) None of the above

3. 1996 History The government of Brazil pledged to begin providing free combination antiretroviral treatment by the end of the year. It said it would spend up to $45 million on protease inhibitors over the following twelve months. In October, in Washington D.C., the AIDS Memorial Quilt was displayed in its entirety for the last time, but it was also the first time that a display of the quilt had been visited by an American president. "What it has done always in the past, and will continue to do, is to put a face on this epidemic. It makes this epidemic human." - Anthony Turney In December, the White House announced its first ever AIDS strategy. This called, amongst other things, for sustained research to find a cure and a vaccine; a reduction in new infections; guaranteed access to high quality care for AIDS patients; and fighting AIDS-related discrimination. "None of us can afford to sit by and watch this epidemic continue to take our neighbors, friends and loved ones from us" - President Clinton in a letter accompanying the AIDS plan

4. 1997 History Early in 1997 it was reported that, for the first time since the AIDS epidemic became visible in 1981, the number of deaths from AIDS had dropped substantially across the USA. This was excellent news but: "The decline in deaths leaves more people living with AIDS and HIV infection. We do not want to be a wet blanket here, but we still need programs that assure good access to treatment and care for infected people." - Dr. John Ward In New York City the decline was even more dramatic, with the number of people dying from AIDS falling by about 50 per cent compared to the previous year. The number of babies being born HIV positive had also declined dramatically. By the spring it was clear that although excellent for many people, the antiretroviral drugs did have unpleasant and in some cases serious side effects. Resistance could also occur, even when three drugs were being taken, and adherence was an important issue as many pills needed to be taken each day. A number of treatment guidelines were published, and some doctors, particularly in the UK, disagreed with the more aggressive approach taken by the US guidelines. Some doctors were particularly concerned about the recommendations concerning the beginning of treatment when patients did not have symptoms. The US approach was sometimes referred to as the "hit early, hit hard” approach to treatment.

5. 1997 History In May 1997 President Clinton set a target for the USA to find an AIDS vaccine within ten years, so it could be the "first great triumph" of the 21st century. To help attain this goal Clinton announced that a dedicated HIV vaccine research and development centre would be established at the National Institutes of Health. "With the strides of recent years, it is no longer a question of whether we can develop an AIDS vaccine - it is simply a question of when. And it cannot come a day too soon." - President Clinton

6. 1998 History In June, the company AIDSvax started the first human trial of an AIDS vaccine using 5,000 volunteers from across the USA. "It opened a new era in AIDS research, and led us toward the human trials. It was like being in a room that was partially lit and getting darker and darker, and suddenly the lights went on and you could see the pathway out.” San Francisco started a pioneering Post Exposure Prophylaxis (PEP) program giving HIV drugs to people that might have been exposed to HIV through sexual contact or needle sharing during injecting drug use. The HIV drugs were given to people at the earliest possible time after the risk exposure. "The treatment really is to try, in case they've been exposed to HIV, to stop the replication before it infects the cells and like a brush fire gets out of control.” A study found that the combination of caesarean delivery and AZT reduced the risk of HIV transmission from a mother to her baby to less than 1%. The study also found that women who took AZT but delivered their babies by natural childbirth had a higher risk (6.6%) of transmitting HIV to their babies.

7. 1998 History UNAIDS estimated that during the year a further 5.8 million people became infected with HIV, half of them being under 25. Altman L.K. (1998, 24th November) ' Dismaying experts HIV infections soar', the New York Times Sub-Saharan Africa was home to 70% of people who became infected with HIV during the year. South Africa, which trailed behind some of its neighbouring countries in HIV infection levels at the start of the 1990s was catching up fast. It was estimated that one in seven new HIV infections in Africa were believed to be occurring in South Africa. In Botswana, Namibia, Swaziland and Zimbabwe, the estimates showed that between 20% and 26% of people were living with HIV or AIDS. UNAIDS (1998, December) ' AIDS epidemic update'

8. 1999 History A group of researchers at the University of Alabama claimed to have discovered that a particular type of chimpanzee, once common in West Central Africa, was the source of HIV. The researchers suggested that HIV-1 was introduced into the human population when hunters became exposed to infected blood. Reports started to emerge from South Africa of rape cases involving young girls. It was suggested that a popular myth that sex with a virgin could cure AIDS was the root cause of this increase in child rapes. Later on in the year, the South African President Thabo Mbeki claimed that the anti-HIV drug AZT was toxic and could be a danger to health. __________________________________________________________________________________________ 'The River', a book by Edward Hooper, was published. There was a lot of debate about the role of polio vaccines in the origin of the AIDS epidemic. The Kenyan President Daniel arap Moi declared AIDS a national disaster and ordered a National AIDS Control Council to be set up immediately. "AIDS is not just a serious threat to our social and economic development, it is a real threat to our very existence, and every effort must be made to bring the problem under control." - President Moi However the president also said that his government and Kenya's churches would not advocate the use of condoms as a method of prevention because this would encourage young people to have sex. A research study published in November argued that male circumcision could help to reduce HIV infection rates in Africa and Asia.

9. 2000 History Early in the year the South African government made a decision to invite a panel of experts to pursue debate on questions relating to HIV/AIDS. In March it was reported that South African President Thabo Mbeki had consulted two American 'dissident' researchers to discuss their claim that HIV was not the cause of AIDS. In April, President Mbeki sent a letter to world leaders explaining his views on HIV/AIDS. In this letter Mbeki argued, amongst other things, that since HIV is spread mostly through heterosexual contact in Africa, the continent's problems are unique. "Accordingly, as Africans, we have to deal with this uniquely African catastrophe... It is obvious that whatever lessons we have to and may draw from the West about the grave issue of HIV-AIDS, a simple superimposition of Western experience on African reality would be absurd and illogical.” In Botswana, as many as one in four adults and four of every ten pregnant women were estimated to be infected with HIV. The president of Botswana, Festus Mogae, announced that new contributions from donors including $50 million donated by the Bill and Melinda Gates Foundation would allow his country to provide antiretroviral therapy to all HIV-infected pregnant women and children born with the virus.

10. 2000 History In July, the 13th International AIDS Conference was held in Durban, South Africa. This was the first time that such a conference was held in a developing country or in Africa. Nkosi Johnson, an eleven year old HIV-positive boy, gave a speech in the opening ceremony of the conference and called for the government to give AZT to pregnant HIV-positive women. Mbeki used his opening address at the conference to stress the role of poverty in explaining the problems faced by Africa and compared the campaign against AIDS with the struggle against apartheid. "As I listened and heard the whole story told about our own country, it seemed to me you could not blame everything on a single virus.” To counter the comments made by president Mbeki, over 5,000 scientists around the world signed the 'Durban Declaration' affirming that HIV is the cause of AIDS. Nelson Mandela, South Africa's former president, closed the AIDS conference with a call for action to combine efforts and save people. "History will judge us harshly if we fail to do so now, and right now.”

11. 2000 History In September, the first phase of a new vaccine trial was launched in Oxford. The trials were sponsored by the International AIDS Vaccine Initiative. The research into an AIDS vaccine was criticised by the World Bank for focusing on a vaccine that could be marketed in western countries, despite the fact that more than 90% of HIV infections were in the developing world. It was reported that the number of people living with HIV in Brazil was less than half that once predicted by health experts, and the number of AIDS deaths had plummeted by as much as fifty per cent since the introduction of combination antiretroviral therapy in 1996. The country's HIV prevention and treatment programmes were seen as a model for other resource-poor countries to emulate. "It makes a lot of sense to look at what Brazil is doing... Something they're doing is working." - Mbulelo Rakwena, South Africa's ambassador to Brazil Treatment provision remained non-existent in South Africa, and President Mbeki stated in an interview with the Time Magazine that he did not think that HIV alone caused AIDS. "Clearly there is such a thing as acquired immune deficiency. The question you have to ask is what produces this deficiency. A whole variety of things can cause the immune system to collapse… But the notion that immune deficiency is only acquired from a single virus cannot be sustained. Once you say immune deficiency is acquired from that virus your response will be antiviral drugs. But if you accept that there can be a variety of reasons, including poverty and the many diseases that afflict Africans, then you can have a more comprehensive treatment response.” In October, President Mbeki announced his withdrawal from the scientific and public debate on the causes of AIDS after admitting that he had created confusion in South Africa.

12. 2000 History There has been a lot of confusion about what Mbeki said and did not say during the year. It is clear that over a period of some months, particularly in April and in September, Mbeki led many people to think that either 1) he does not believe that HIV causes AIDS or 2) he does not believe that HIV causes AIDS on its own. It would seem that Mbeki may have believed that immune deficiency is caused by a collection of factors such as poverty, nutrition and contaminated water as well as HIV, rather than just HIV on its own: "You cannot attribute immune deficiency solely and exclusively to a virus.” It is true that poverty related factors such as malnutrition will hasten the onset of AIDS in people who are HIV-positive. Therefore, it is also true that provision of food will slow down the progression of HIV. However improved nutrition is not enough in itself to permanently keep people healthy. History provides evidence of this.

13. 2001 History The U.S. Government threatened Brazil with legal action over its production of generic HIV drugs. The complaint was dropped later in the year and Brazil promised to give the USA advance warning before changing its patent law for drugs. Thirty-nine pharmaceutical companies withdrew their case against the South African government's efforts to lower drug prices. This victory was, however, overshadowed by a statement by the health minister Manto Tshabalala-Msimang, who said that the government already offered adequate treatment to AIDS patients and that proposals to buy antiretroviral drugs were still being considered. The South African government released its annual HIV/AIDS figures estimating that 4.7 million people were infected with HIV/AIDS and that 24.5% of pregnant women were HIV-positive in 2000.

14. 2003 History At the time, Botswana officially had the highest global HIV prevalence of 38.8 percent. However, in early January, Swaziland's Prime Minister Sibusiso Dlamini said that HIV prevalence had risen to 38.6 percent from 34.2 percent in January 2002. Although prevalence in Swaziland remained slightly lower than Botswana, reports in January suggested that HIV prevalence in Swaziland was unofficially the world's highest, as the figures released were considered to be already out of date. Botswana was struggling to expand its antiretroviral treatment program, largely because of a shortage of health workers. The government had hoped to provide drugs to 19,000 people by the end of 2002, but had enrolled only 3,200 by the end of January 2003. Jerry Thacker, a controversial Christian extremist chosen by the White House to sit on a presidential AIDS advisory panel and who once described the virus as the 'gay plague', was forced to withdraw his name after protests from gay rights groups. ____________________________________________________________________________________ Vaxgen announced that their AIDS vaccine had failed to reduce overall HIV infection rates among those who were vaccinated. The vaccine showed a reduction in certain ethnic groups, indicating that black and Asian volunteers may have produced higher levels of antibodies against HIV than white and Hispanic volunteers. However, many outside observers were skeptical of the ethnic group part of the study. In November, the AIDS vaccine also failed in a clinical trial in Thailand. "The outcome of this trial is one more reminder of how difficult it is to combat HIV and how important it is for the international public health community to redouble the effort to develop an effective vaccine.”- Donald P. Francis, Vaxgen President

15. 2004 History In January Brazil's government reached a deal with pharmaceutical companies to reduce the price of HIV/AIDS drugs by around a third. It was believed that the deal saved the government about $100 million in 2004 and cut the average treatment cost per patient to a new low of $1,200. Also, 10 million free condoms were given out to people in Brazil during the carnival season as part of an AIDS-prevention campaign. In parts of Russia and Eastern Europe, HIV was spreading faster than anywhere else in the world. ____________________________________________________________________________________ President Bush's $15 billion initiative to combat the global AIDS pandemic, by now known as PEPFAR (President's Emergency Plan For AIDS Relief), began full implementation in June, having received its first funding in January. PEPFAR was to concentrate on fifteen focus countries, all of them in Africa except Guyana, Haiti and Vietnam (which was a late addition to the list). The initiative set a goal of providing AIDS treatment to 200,000 people living in the focus countries by June 2005.

16. 2005 History Brazil turned down $40 million offered by PEPFAR because it refused to agree to a declaration condemning prostitution. The director of Brazil's HIV/AIDS program said the government had taken the decision "in order to preserve its autonomy on issues related to national policies on HIV/AIDS as well as ethical and human rights principles".

17. 2006 History The Vatican sparked excitement among AIDS campaigners when it suggested it was planning a review of its stance on condom use as a method of HIV prevention. However, it soon became clear that a major change in policy was unlikely, and that the Catholic Church would probably continue to oppose condom use in all circumstances. ________________________________________________________________________________________________ In August, attention turned to the XVI International AIDS Conference in Toronto. One major talking point was how to accelerate the expansion of antiretroviral therapy worldwide, and in particular how to alleviate dire shortages of healthcare workers in the most needy countries. Delegates also discussed the pros and cons of routine HIV testing, whereby everyone attending medical settings is offered an HIV test, regardless of symptoms. The WHO and others suggested that wider use of this approach would increase take-up of treatment and help to counter stigma. The conference provided a platform for critics of the South African government’s response to AIDS. Activists protested at the country’s exhibition stand, which was dominated by unproven nutritional remedies, with almost no reference to effective medication. Conference co-chair Mark Wainberg said it was “unconscionable” that South Africa’s leaders would not talk openly about AIDS. Stephen Lewis (UN Special Envoy for HIV/AIDS in Africa) went further in his closing speech: “South Africa is the unkindest cut of all. It is the only country in Africa … whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state... The government has a lot to atone for. I'm of the opinion that they can never achieve redemption.” Shortly after the conference, more than 80 prominent international scientists wrote an open letter to South African President Thabo Mbeki calling on him to sack health minister Manto Tshabalala-Msimang, whom they blamed for “disastrous, pseudo-scientific policies” on HIV/AIDS. Instead, the South African government set up a new inter-ministerial committee to take charge of the national AIDS response, to be headed by the deputy president, thus seeming to sideline the controversial health minister.

18. 2011 History A more positive development was announced in May. Hailed as a ground-breaking development for the field of HIV prevention, results from the HPTN 052 trial found that antiretroviral treatment could reduce the risk of transmission among discordant couples by 96 percent. Known as ' Treatment as Prevention', this prevention method involves the HIV-positive partner adhering to a regime of ARVs after diagnosis rather than waiting for their CD4 count to become low.

19. 2012 History The US’ Food and Drug Administration (FDA) announced their approval of using an antiretroviral drug combination for pre-exposure prophylaxis (PrEP), to reduce the chances of the sexual transmission of HIV. Whilst mirroring the UNAIDS guidelines released in April, FDA advice went further by also recommending that HIV-negative people, with an increased risk of becoming infected with HIV – such as, people in serodiscordant relationships, or people classed as high risk for HIV infection, e.g. MSM - should begin taking HIV treatment for prevention.