Advances in AIDS Study Foreshadow Long Battle
Acquired Immune Deficiency Syndrome, or AIDS, is no longer the obscure mystery disease that it was a short time ago. But three days of intense discussions this last week by some of the world’s leading experts on the usually fatal illness revealed that a long and costly battle has only just begun.
The International Conference on AIDS, sponsored by the United States and the World Health Organization, made it clear that new challenges now face not only scientists and health workers, but all of society.
“We are at a turning point in the epidemic,” declared Dr. Dean F. Echenberg of the University of California, San Francisco, Medical School.
Most of the varied viewpoints represented at the conference seemed to agree that despite new problems, much has been accomplished in less than four years since the first cases of AIDS were identified.
Virus Linked to AIDS
A virus that is generally regarded to be the cause of AIDS has been discovered, and a great deal has been learned about how it is transmitted. In addition, there is now a test that is intended to let an individual know if he or she has been infected by the virus. Groundwork for a vaccine is under way, and preliminary studies on at least six new drugs indicate that they may become effective treatments against the disease.
Still, AIDS shows no sign of being abated anytime soon.
Dr. James Curran of the Centers for Disease Control now estimates that between 500,000 and 1 million Americans already are infected by the AIDS virus and that perhaps 10% of that number will develop the disease.
This means that the number of AIDS cases in the United States will grow from the 9,608 reported this week, to 50,000 to 100,000 within the next several years. This influx of new cases is expected to result in enormous medical and psychosocial problems for patients and financial problems for all of society. Half of the AIDS sufferers reported to date have died.
The chief reason for the exponential rise in the number of expected cases is the long incubation period--up to five years--for the virus before symptoms appear. This means that an individual can be infected with the virus for as long as five years and not know it.
Backlog of Cases
Further, the long incubation period means that most likely there are thousands of people unknowingly spreading the infection to others, causing an even greater increase in the backlog of cases yet to appear.
One of the major challenges faced by public health authorities is to find ways to convincingly educate people in the high-risk groups of the hazards they face, as well as ways in which they can protect themselves and prevent the spread to others.
One way, authorities say, is by taking the blood test.
Recently licensed by the federal government as a tool to protect the nation’s blood supply by identifying virus-contaminated blood donations, the test has triggered controversies over its efficacy and over who--in addition to blood donors--should be encouraged to take it.
In general, public health experts believe that everyone in the high-risk groups should be tested. But many gay organizations have advised homosexuals to avoid the test because they fear that confidentiality will not be respected.
Millions of Americans already are members of the three high-risk groups that have been identified--male homosexuals and bisexuals, intravenous drug abusers and hemophiliacs. Respectively they represent 73%, 17% and 1% of the total cases reported to date in the United States.
New Risk Group
But as researchers from San Francisco, New York and the U.S. Army told the conference, a new risk group is making its appearance within the heterosexual population. AIDS was most likely introduced to this group by bisexual males and female prostitutes who are intravenous drug abusers.
In the Army, according to Dr. Robert R. Redfield of the Walter Reed Medical Center, heterosexuals are the largest single group among the 41 AIDS or similar cases reported to date at that facility.
He said that the ease with which the virus can be transmitted from male to female or female to male is “disturbing.” Among seven of the male or female soldier-patients who were married, five of their spouses have developed symptoms, Redfield said.
He said the pattern of spread among heterosexuals probably will follow a demographic route similar to that already seen among the other high-risk groups--appearing first in large numbers in population centers like San Francisco, New York and Los Angeles.
Already in New York, a study by Dr. Charles Rabkin of the city Health Department revealed that 3.4% of the heterosexuals attending a clinic for sexually transmitted diseases showed a positive test for the presence of the AIDS virus.
“That is one-tenth the rate for the (male gays and drug users) but 15 times the rate for healthy blood donors,” Rabkin said. Nearly all of the group had engaged in sex with a number of different partners.
Problem of Public Education
The growing risk to heterosexuals complicates the problem of public education, according to Echenberg of UC San Francisco, because heterosexuals who have multiple sex partners are not yet sufficiently aware of their risk to pay attention to the mass education programs that are aimed primarily at gays and drug abusers.
He said San Francisco authorities are considering programs in which heterosexuals who test positive have individual counseling to impress upon them the possibility of their spreading the disease to others.
The urgency of launching more preventive public education programs was also stressed by several other health workers at the conference.
“The principal lesson I heard is that health education is the most powerful weapon to control the spread of AIDS,” Dr. Alvin Novick, a Yale University biologist and ethicist, said in an interview.
“Many lives can be saved at once without waiting for a vaccine or new drugs. The cost is trivial compared to caring for thousands of patients.”
The obstacle to establishing such programs, Novick said, is that society finds it difficult and embarrassing to aim helpful programs at elements of the population that it considers to be engaged in illicit behavior.
“But it must be done because we cannot allow thousands to die because their personal lives are not ones we choose for ourselves,” Novick said.
Still another challenge, speakers told the conference, is for the creation of programs to provide aid and counseling for the depression, anger, anxiety and guilt experienced by most AIDS patients.
A high incidence of dementia and brain atrophy has been a recent observation among AIDS patients, according to several investigators. Dr. Jimmie C. B. Holland, a psychiatrist at Memorial Sloan Kettering Cancer Center in New York, said dementia is the most common psychiatric diagnosis in AIDS patients.
The possible explanation for this observation is another finding that the AIDS virus, in addition to attacking cells in the immune system, has a strong attraction for brain cells.
Destruction of brain cells by the virus is suspected of being the cause of the dementia and other neurological problems that impair 30% to 40% of all AIDS patients, according to a National Institutes of Health team headed by Dr. D. C. Gadjusek, a Nobel Prize winner.
Dr. Leon G. Epstein, a member of that team, said studies of chimpanzees who had been inoculated with tissues from AIDS patients indicated that the brain is the most heavily infected of any body tissue.
Even children, who developed AIDS before birth from their mothers who have the disease, experienced brain damage as early as 4 months of age, said Dr. Anthony B. Minnefor, a physician at St. Joseph’s Medical Center in Patterson, N.J., who studied the babies of drug abusers.
Caring for such patients is putting a tremendous strain on the health care budget in this country, speakers also noted.
Some estimated that it could cost as much as $5 billion just to provide medical care for the cases expected to occur in the near future in the United States.
Looked at globally, the cost of both treating existing cases and funding prevention programs is rising monthly as more countries become aware that they have an AIDS problem.
Even those patients who show some symptoms of AIDS but who do not meet all the criteria for the disease are causing funding dilemmas for cities and counties in the United States, said Dr. James M. Olesky of the New Jersey Medical School in Newark.
He noted that Medicare and Medicaid will not pay for the so-called AIDS-related cases, although often they are as complex to care for as true AIDS cases. The large bills that these patients run up have to be picked up by counties or cities that run public hospitals.
While 80% of all reported cases worldwide are in the United States, data presented by Dr. Jean Baptiste Brunet of the World Health Organization Collaborating Center in Paris indicated that the stage of the epidemic in Europe and Latin America is only two to three years behind the United States. In the United States, the epidemic is recognized to have begun about 1978, although the first cases were not reported until June, 1981.
Many experts believe an important factor in controlling the disease in all countries will be to use the blood test as part of a program to give people with AIDS the motivation not to spread it to others.
Although U.S. Health and Human Services Secretary Margaret M. Heckler told the conference that the American-developed test will be made available to other countries, many experts worry about how developing countries will be able to afford it as well as the educational programs.
Nevertheless, said Dr. Fakhry Assaad of the World Health Organization, “it is a worldwide problem that will require worldwide attention.”
