The scientific breakthroughs of the past couple years have renewed hopes that a cure may soon be found for those already infected with HIV, and an effective preventative found for those who are not. Yet, despite the understandable optimism about new drug treatments, there is neither a cure nor a prevention for Acquired Immunodeficiency Syndrome (AIDS). Even though scientists have made significant progress in understanding the human immunodeficiency virus (HIV), the virus that causes AIDS, it is still, in many ways, a mysterious disease.
The ongoing crisis has also spawned increased racial and sexual bigotry directed against groups at high risk of HIV infection. Threats of mandatory testing for HIV and possible quarantine of anyone testing positive are made with alarming--and increasing--frequency, often less out of fear of the virus than out of hatred for those affected. The pandemic is reaching into minority populations lacking adequate health care resources, and there is no consistent plan to counter its movement. These marginal populations are also the least likely to gain access to the new drugs, as well as to have the medical attention required for the success of these complicated pharmacological regimens. The increase in managed care practices, coupled to the decrease in funding of health care for the nation's poorest, guarantees that new treatments will not soon reach the populations most in need. Finally, as the popular press loses interest in AIDS treatments and turns its attention to AIDS vaccine development, there is a very real chance that those already infected may be ignored entirely.
It is our belief, as scientists and health care professionals, that any individual's degree of risk for HIV and AIDS can be substantially reduced even now, before a cure or effective prevention is available. It is also our belief, as gay men and lesbians, that the hysterical bigotry surrounding this epidemic must be confronted and exposed for what it is. The key to prevention of HIV infection and successful treatment of those already infected, as well as to stemming the tide of hatred is education.
As members of the National Organization of Gay and Lesbian Scientists and Technical Professionals (NOGLSTP), we feel it is our obligation to make available to any interested party reliable information about the issues pertaining to HIV and AIDS. Nine y ears have passed since the first pamphlet we released on this subject. It is our hope that by providing this updated information we can contribute in some way to the control, and ultimate defeat, of the plague ravaging both our community and the world.
There is no single disease that can be equated with AIDS. "AIDS" actually refers to a syndrome of different opportunistic infections (OI's) and symptoms that occur as a result of the loss of the normal function of the immune system. Despite the media attention given to alternate theories, scientific evidence demonstrates that AIDS is the direct result of infection with the HIV virus. Though it is not entirely understood how HIV causes the collapse of the immune system ("immunopathogenesis"), the current data overwhelmingly demonstrate that HIV is necessary and sufficient to cause AIDS.
This does not mean that other infectious agents or environmental stresses are unimportant in the development of AIDS. Cytomegalovirus, Pneumocystis carinii (the cause of PCP pneumonia), Mycobacteria avian intracellularae (MAI), and other microorganisms play well-documented roles in the development of AIDS-defining OI's. In addition, there are likely to be other as-yet-unidentified agents involved. But the destruction of the normal surveillance capabilities of the immune system, which allows these agent s to flourish, is a direct result of infection by HIV. This is recognized indirectly by the redefinition of AIDS by the Centers for Disease Control (CDC) in 1993, which includes a low T cell count in addition to the AIDS-defining OI's.
HIV preferentially infects a subset of white blood cells known as "CD4+ T cells," a type of immune cell integral to normal immune function, as well as other specialized immune system cells. This is what makes it so successful, and so deadly. By infecting the cells that normally function to rid the body of foreign invaders, HIV is able to effectively destroy the body's normal resistance. Furthermore, the virus redirects the normal cellular machinery to make copies of itself, spreading the infection.
Previously it was believed that viral replication occurred only at low levels for a period of years after initial infection, a so called "clinical latency" period. But recent research has uncovered a daily life-and-death struggle between the virus and the immune system, with billions of virions and infected CD4+ T cells turning over every day in the blood of infected individuals. This results in the eventual exhaustion - and collapse - of the immune system. There are a small percentage of infected individuals who do not appear to progress to clinical AIDS for very long periods of time, the so-called "long-term non-progressors". It has become clear that no one trait, either infection with a "weak" virus, a better immune response, or inherent genetic resistance to infection can explain all nonprogressors. For example, recent studies suggest that about one percent of people of western European descent carry a mutation in a gene that encodes a T-cell protein used by HIV to enter the cell, a discovery may lead to a novel form of prevention for others. However, much more research in this area is necessary, and it would be money well spent.
Although it may seem obvious by now, the fact is that many are still ignorant about how HIV is spread. Many people fear casual contact, such as embracing, sharing food, etc. This ignorance contributes to the prejudice encountered by PWAs. Therefore, NOGLSTP wants to state clearly that, to date, there are only three known ways to spread HIV infection: intimate sexual contact, direct injection, or from mother to infant. The best prevention is to avoid behavior that is at high-risk for transmission of the virus. In considering all of these means of transmission, it must be remembered that HIV is an infectious agent, not a moral agent, and is subject only to the laws of biology.
HIV is spread by intimate heterosexual or homosexual contact, via
mucosal membranes (e.g. vagina and rectum). Anal or vaginal intercourse
without a condom is the most effective sexual way to spread HIV infection.
Despite natural defense mechanisms, unprotected oral/genital sex must also
be considered risky, though the degree of risk, while not zero, is still
significantly lower than penetrative sex.
The risk of HIV infection by sexual contact can be minimized, although not eliminated, by the practice of "safer sex" techniques. These involve the consistent and proper use of condoms, dental dams, and similar barriers during genital, anal, or oral/genital intercourse, or the practice of safer sexual techniques such as mutual masturbation. It is true that the "safest" sex is abstention, but it just as true that people can be sexually active and at the same time minimize their risk of infection.
As a blood-born agent, HIV is most efficiently spread by direct
injection into the bloodstream. This accounts for both the infection of
many hemophiliacs early in the epidemic and the current high infection
rate among intravenous drug users (IDU's) who share injection needles.
With regards to the latter group, more than a half dozen well designed
studies have demonstrated that needle exchange programs significantly curtail
HIV spread among drug users. As scientists, we realize that the use of
IV drugs is contrary to the physical well- being of the user. We also know
that drug addiction is a powerful, all-consuming force in many lives. Therefore,
we believe aggressive educational intervention, including the distribution
of sterile needles and instructions on how to clean needles, is necessary.
Although this is a politically difficult question, we believe the demonstrated
efficacy of needle exchange should outweigh political beliefs in governmental
funding of such programs.
Many people have also been infected by transfusion of HIV-containing blood, though advances in screening blood products have minimized that risk substantially. Minimizing contact with potentially infected blood and blood products reduces the risk of HI V infection by this means. Blood banks have taken more stringent steps in the past few years to insure a safe supply of blood and blood products. While we believe it is wrong to universally prevent gay men and lesbians from donating blood, it is important that gay men and lesbians who know they are at risk of infection to refrain from donation.
Between 20 and 30 percent of infants born to HIV-infected mothers
will be infected themselves. The majority of these acquire the infection
either late in pregnancy or during the birth process, though some may acquire
the virus during subsequent breast- feeding. Scientists are studying the
mechanisms by which this occurs in hopes of finding effective prevention,
although recent studies indicate that aggressive antiviral treatment prior
to, during, and after birth reduce transmission dramatically. However ,
the best way currently to prevent maternal-to- infant transmission is to
protect women from initial infection.
Perhaps nothing is more frustrating about the AIDS pandemic than the lack of effective vaccines to prevent HIV infection. However, recent advances in antiviral drugs for those already infected raise the hope of turning infected individuals into the functional equivalent of long-term nonprogressors. Furthermore, most of the OI's associated with AIDS can be at least temporarily managed by either single drugs or a combination of drugs.
There has been a great deal of publicity for possible HIV-preventive vaccines. Unfortunately, the publicity has so far outperformed the vaccine candidates. And even though there are a number of variations on a few vaccine concepts in small clinical trials, the "pipeline" for vaccine candidates is essentially empty. Many biotechnology companies have dropped their vaccine research programs, citing liability problems, regulatory burdens, and cost constraints. Thus the burden for developing an effective vaccine has fallen almost entirely on the federal government, via the NIH, which has yet to produce positive results in this area. Although several candidates are in the "pipeline," none is promising enough to be in wide use anytime soon.
The most hopeful breakthroughs have come in the area of antiviral therapy, particularly the development and approval of drugs that target the HIV protease enzyme, or the so-called protease inhibitors (ritonavir, saquinavir and indinavir), and the approval of a new class of drugs that inhibit the viral replication enzyme reverse transcriptase (RT), the nonnucleoside RTInhibitors (nevirapine, delavirdine, and several others). These join the nucleoside analogue RTIs (AZT, ddI, ddC, d4t and 3TC), thus in creasing the potency and choices of drug regimens. Dramatic effects have been achieved in using combinations or "cocktails" of these drugs. A majority of patients who get these cocktails show drops in the amount of virus detectable in their blood (and a few to undetectable levels), leading to hopes that infected individuals can be made the functional equivalent of long-term nonprogressors, or even have the virus eradicated from their body (although this is only speculation at this time). Other drugs are being developed that are aimed at other HIV enzymes, as well as next generation protease inhibitors and RT inhibitors, with the goal of further increasing the arsenal of weapons that can be brought to bear against HIV.
However, there are several caveats. Not everyone is helped by the new drug regimens, either because they are unable to tolerate the side effects of the new drugs, are unwilling to follow the strict dosing regimen required to take multiple drugs, or have already developed strains of HIV resistant to the drugs. Thus, NOGLSTP supports not only ongoing identification and testing of new antiviral agents, but also expanded basic research. We believe that any real breakthrough in anti-HIV therapy will come only from a thorough understanding of the biology of the virus itself, and its interaction with its human host. While recognizing that AIDS research gets a seemingly disproportionate share of the federal health research budget, we believe that the potential destruction threatened by the epidemic requires even greater commitment of resources.
A more difficult therapeutic question is posed by so-called "alternative" medicine, including such things as hyperthermia (the superheating of blood), holistic approaches, and untested drug regimens. While not discounting the possibility that these may be effective to some degree in limited circumstances, there is also not enough scientific evidence to warrant wholehearted support. In some cases there is evidence contrary to the claims of proponents. Though there are many examples of "magic bullets" scattered through the past 14 years, the outright dismissal of potential new therapies by health officials and physicians is also unwarranted. Those who support an untested therapy must be more scientifically rigorous and honest about reporting its success, and those in official positions (FDA and NIH officials, researchers, etc.) must be willing to expand testing of promising candidates. NOGLSTP believes that the urgency of the AIDS pandemic demands that scientists and clinicians be open to testing non-traditional ideas. However, proponents of non-traditional ideas should not overstate their case, which could lead some people to forsake moderately effective treatments for totally ineffective ones.
AIDS is not a single epidemic, but is multiple concurrent epidemics. Once stigmatized in the United States as a "gay disease", it is now spreading most quickly among women and people of color, especially in the inner cities of this country, while continuing to decimate the gay community. The unifying thread of these different epidemics is that HIV is destroying marginalized communities. As scientists and technical professionals, we know that the hatred and fear engendered by this virus are unfounded. I t is important that we use the resources we have been given to further basic and clinical research, and to dispel the medical and social myths surrounding this epidemic.
To that end, we also believe that knowledge is power, and individuals at risk should take responsibility for their personal safety, should be willing to know their HIV status, and should take appropriate steps to maintain their health and well-being whether infected or not. The fact that the infection rate is increasing again among young gay men is disturbing. HIV is not an inevitability, as many believe, nor is it a judgment, as many others believe. It is a virus, and as such, its threat can be minimized until science gives us the tools to destroy it.
Copyright December 1996, NOGLSTP Inc. Authored by Fintan R. Steele, Ph.D.
This pamphlet may be reproduced and distributed in its entirety including
this section. Any reproduction and distribution without attribution to
the author and NOGLSTP will be considered plagiarism and will be prosecuted.
This topic is available as a pamphlet from the NOGLSTP office. Send a self-addressed
stamped envelope with your request to NOGLSTP, PO Box 91803, Pasadena CA
91109.