Are you unaware that vast numbers of your fellow men

1
Are you unaware that vast numbers of your fellow
men suffer or perish from need of the things that
you have to excess, and that you required the
explicit and unanimous consent of the whole human
race for you to appropriate from the common
subsistence anything besides that required for
your own? Jean-Jacques Rousseau, 1775
2
As you now know, in the developing world
treatable infectious diseases remain big killers
Leading causes of death in Sub-Saharan Africa,
South Asia, and Southeast Asia for persons age
0-44 (World Health Organization)
3
HIV/AIDS and AIDS related illnesses are among the
largest killers
Leading causes of death in Sub-Saharan Africa,
South Asia, and Southeast Asia for persons age
0-44 (World Health Organization)
4
Untreated AIDS is a devastating disease that
inevitably leads to an early death
Tropical Medicine and Parasitiology 1997
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The virus kills people indirectly, by destroying
the immune system
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The virus kills people indirectly, by destroying
the immune system
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With a disabled immune system, other infections
take off
8
As you already know
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HIV and AIDS by the numbers
33 million people worldwide living with HIV
2.5 million new infections in 2007
2.1 million people died of AIDS
UN AIDS press release 11/20/2007
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Once again, AIDS and the deaths it causes are not
evenly distributed around the world
It is estimated that 5 million individuals were
newly infected with HIV during 2001.
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Sub-Saharan Africa is the epicentre 68 of
HIV-infected people live there 1/3 in just 8
countries
UN AIDS press release 11/20/2007
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This has had dramatic effects on the life
expectancy of those in sub-Saharan Africa
2005 Economic report to the US President, Council
of Economic Advisors
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What is your picture of the average HIV positive
person?
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In the developing world, HIV is becoming a
disease of children!
New HIV Infections in 2002 by Age Group
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We can also see these differences when we return
to our comparison of
the US
and Haiti
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HIV prevalence in the Caribbean ranges from 0.1
in Cuba to gt 3 in the Bahamas and Haiti
One in 20 Haitians has the disease, and it is
the main cause of death among women of
reproductive age.
Region-wide, fewer than one in four people
needing antiretroviral drugs received them
UNAIDS 2006 Report on the Global AIDS
Epidemic And BBC November 2003
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In contrast, in the US.
AIDS is not on this list!
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The development of effective treatments turned
the tide in the US
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This becomes even clearerif we focus in on the
key years
Mortality vs. ART utilization
100
40
Percentage of Patient-days on HAART
35
USE OF ART
30
75
25
DEATHS
Percentage of patient-days on ART
20
50
Deaths per 100 person-years
15
10
25
Deaths per 100 Person-Years
5
0
0
1995
1996
1997
1998
1999
2000
2001
Palella F et al. 8th CROI 2001 abstract 268b.
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However major disparities in AIDS incidence occur
even within our nation
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Top 10 States by AIDS Case Rate per 100,000
Population, 2004
U.S. Rate 15.0
Source CDC, HIV/AIDS Surveillance Report, Vol.
16, 2005.
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There are also major disparitiesalong ethnic
lines (largely but not entirely reflecting
poverty)
Percent of AIDS Diagnoses
White, non-Hispanic
African American
Latino
American Indian/ Alaska Native
Asian/Pacific Islander
2004
Note Data are estimates. Source CDC, Data
Request, 2006.
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AIDS Diagnoses Disparities, 2004
AIDS Cases
U.S. Population
42,514
293,655,404
White, non-Hispanic
28
69
African American
49
13
Latino
14
4
20
Asian/Pacific Islander
1
1
lt1
AI/AN
Notes U.S. Population estimates do not include
U.S. dependencies, possessions, and associated
nations persons who reported more than one race
were included in multiple categories. May not
total 100 due to rounding. Total AIDS diagnoses
in 2004 include persons of unknown race or
multiple races. AI/AN American Indian/Alaskan
NativeSources CDC, HIV/AIDS Surveillance
Report, Vol. 16, 2005 U.S. Census Bureau,
Population Estimates Program, 2004 Population
Estimates.
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As with TB, the impact of AIDS Is not limited to
illness and death
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As with TB, the impact of AIDS Is not limited to
illness and death
Worldwide gt15 million children have been orphaned
by AIDS
Lesotho
Swaziland
Rwanda
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More than 11 million Of these children are in
Sub-Saharan Africa
Newsweek, Vol. CXXXV, No. 3, 17 January 2000
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More than 11 million Of these children are in
Sub-Saharan Africa
UNICEF 2006
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There is some good news to which well return
later
Global HIV prevalence of people living with
HIV leveled off in 2007 and and number of new
infections has fallen In part as a result of the
impact of HIV programs.
Access to retroviral therapy increased sharply in
2006 From 1.3 million to 2 million, a 54
increase in one year However, this is still only
28 of those in need of treatment
UN AIDS press release 11/20/2007 and
UNAIDS/WHO/UNICEF report 4/17/2007
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Lets return to the impact of AIDS on Haiti
the US
and Haiti
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AIDS and the fear of AIDS have had a major
effect on Haiti since the dawn of the epidemic
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Lets go back in time and see how things began
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The first H Homosexuals

• Doctors in California and New York note
  increase in cases of
• Kaposis sarcoma and Pneumocystis carinii
  pneumonia in gay men

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A remarkable tribute to epidemiology!
They first noticed the disease based on a
handful of cases of Pneumocystis pneumonia And 8
cases of Kaposis sarcoma and Why did they
suspect a new disease?
Kaposis sarcoma lesions
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A remarkable tribute to epidemiology!
Because you NEVER see these diseases in patients
who are not immune-compromised.
Their hypothesis A new sexually transmitted
disease.
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In July 1981 Dr Jim Curran of the CDC summarized
what we knew
"Dr. Curran said there was no apparent danger to
non homosexuals from contagion. 'The best
evidence against contagion', he said, 'is that
no cases have been reported to date outside the
homosexual community or in women'" - The New
York Times
http//www.avert.org/his81_86.htm
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Then came the first reports of similar
outbreaks In those injecting illegal drugs
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Then came the first reports of similar
outbreaks In those injecting illegal drugs
The second H heroin-users
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By mid 1982 the third and fourth Hs were added
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By mid 1982 the third and fourth Hs were
added Haitians and hemophiliacs
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In March 1983 this was formalized by the CDC
"persons who may be considered at increased risk
of AIDS include those with symptoms and signs
suggestive of AIDS sexual partners of AIDS
patients sexually active homosexual or bisexual
men with multiple partners Haitian entrants to
the United States present or past abusers of IV
drugsheroin patients with hemophilia and
sexual partners of individuals at increased risk
for AIDS.
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As AIDS emerged into the public
view discrimination against the 4Hs skyrocketed
45
Our nations leaders did not help
"It is true that some medical sources had said
that (AIDS) cannot be communicated in any way
other than the ones we already know and which
would not involve a child being in the school.
And yet medicine has not come forth unequivocally
and said, 'This we know for a fact, that it is
safe.' And until they do, I think we just have
to do the best we can with this problem. I can
understand both sides of it." - Ronald W. Reagan
Sept. 17, 1985
http//www.avert.org/his81_86.htm
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This was despite strong scientific evidence to
the contrary
"The cause of AIDS is unknown, but it seems most
likely to be caused by an agent transmitted by
intimate sexual contact, through contaminated
needles, or, less commonly, by percutaneous
inoculation of infectious blood or blood
products. No evidence suggests transmission of
AIDS by airborne spread. The failure to identify
cases among friends relatives, and co-workers of
AIDS patients provides further evidence that
casual contact offers little or no risk MMWR
Weekly (1983) 'Current Trends Acquired
Immunodeficiency Syndrome (AIDS) Update - United
States', June 24, 32 (24) 309-11
http//www.avert.org/his81_86.htm
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This sort of fear devastated the Haitian economy
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This sort of fear devastated the Haitian economy
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"It killed tourism in Haiti," says Dr. Jean Pape,
who has been treating AIDS in Haiti since the
beginning and who founded the Haitian Study
Group on Opportunistic Infection and Kaposi's
Sarcoma Tourism formed the backbone of the
Haitian economy. "... Within a year the tourism
industry decreased by 80 percent, Goods
manufactured in Haiti could not be sold in the
U.S."
PBS Frontline
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The number of American visitors, who make up
more than two-thirds of Haiti's tourists, fell
from 70,000 in the winter of 1981-82 to 10,000
in 1983, including travelers on business,
according to the Haitian Government
PBS Frontline
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This led to a reversal of the official policy but
this was too late for Haiti
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The popular press and some scientists fed fears
of Haitians by suggesting that AIDS arose in Haiti
this may be an epidemic Haitian virus that was
brought back To the homosexual population in the
United States Dr. Bruce Chabner, National Cancer
Institute Dec. 1983
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The popular press and some scientists fed fears
of Haitians by suggesting that AIDS arose in Haiti
54
This initial theory was quickly discredited
55
What is the origin of HIV and how would we
determine this?
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Remember this?
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
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Mutations accumulate over time
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
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We can do something similar with HIV
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
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HIV is part of a family of viruses affecting
monkeys, apes and people
Retroviruses. CSHL Press Fig. 12-3
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HIV is part of a family of viruses affecting
monkeys, apes and people
People
Chimps
People
Chimps
People
Chimps
Science 28 January 2000Vol. 287. no. 5453, pp.
607 - 614
61
Since mutations accumulate over time more
variants suggest HIV has been in West Africa for
a longer time
World-wide
West Africa only
West Africa only
Nature Reviews Genetics 5, 52-61 (January 2004)
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HIV has been transmitted between apes and people
multiple times
People
Chimps
People
Chimps
People
Chimps
Science 28 January 2000Vol. 287. no. 5453, pp.
607 - 614
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The greatest diversity of HIV sequences is seen
in West Africa
World-wide (especially subtype B)
West Africa only
West Africa only
Nature Reviews Genetics 5, 52-61 (January 2004)
64
A recent study suggests AIDS may have Passed
through Haiti from Africa to the US
World-wide
West Africa only
West Africa only
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Sequence analysis also provides evidence for
timing of emergence of epidemic
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There are problems with this analysis
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Another problem with this analysis Early cases
1969 Robert R 15 Year old American from St.
Louis. died of Kaposis sarcoma--Later tests
reveal HIV-1 in tissue
1969 Norwegian sailor Arvid Noe. He, his wife
and daughter die of AIDS in 1976 Later tests
reveal HIV-1 subtype O in tissue
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