A WORLD WITHOUT AIDS: Still a Distant DreamNovember 30, 2020
“Ribbons of blue, reminds me of you, ribbons of red, are the way that my heart bled..”, when Boney-M first sang these lines in 1979, there was no special meaning attached to them, other than the obvious references to true love, friendship and solidarity. It was later that red ribbons gained a special meaning as the symbol of solidarity with people living with AIDS. The need for such a solidarity movement was felt as HIV carriers were often treated as outcasts by the society.
Only our collective responsibility to each other can help the world end the AIDS epidemic, said UNAIDS Executive Director Winnie Byanyima, elucidating the theme for the World AIDS Day, 2020: ‘Global Solidarity and Shared Responsibility’. “More than 12 million people are still waiting to get on HIV treatment and 1.7 million people became infected with HIV in 2019 because they could not access essential services,” she said.
The Patient in Ward 86
It was at San Francisco General Hospital that the world’s first dedicated outpatient AIDS clinic opened on 1 January 1983. Opened in collaboration with University of California, it employed only those who were passionate about treating people with AIDS. Over time, ‘Ward 86’, which was dedicated exclusively for AIDS patients, gave rise to the ‘San Francisco Model of Care’ that became the standard for treating patients with AIDS. This was despite the stigma associated with AIDS as a disease which supposedly showed the immoral side of one’s personal life. But, from 1983 onwards, there has been a change in social perception about AIDS, at least among the medical staff, and a rising awareness that HIV infected patients must be treated with compassion and respect. The ‘San Francisco Model’ also became the gold standard for the accessibility of immediate medical care by providing an array of health and social services under one roof by close collaboration with the local health department and community organizations. This is still considered an achievement and a wonder, because at the time, AIDS was just starting to make an appearance in medical records. The name was not there in any hospital record even two years earlier.
There is another memorable day in the fight against AIDS, at least from an academic point of view. That is 5 June 1981. It was on this day that US Center for Disease Control (CDC) published an article in its ‘Morbidity and Mortality Weekly Report’, describing cases of a rare lung infection caused by Pneumocystis carinii. It was called PCP in medical literature, short for ‘Pneumocystis Carinii Pneumonia’, and affected five young, white, gay men from Los Angeles who were previously healthy. Dr Michael Gottlieb, an immunologist, Dr Wayne Shandera from CDC and their colleagues reported that all the men have other unusual infections as well, indicating that their immune systems were not working. Two of the patients were already dead by the time the report was out in the press and the others were in a critical condition. This report, however, marked the first official reporting of the most notorious acronym and epidemic of the present century and the next: AIDS, or Acquired Immunodeficiency Syndrome.
The Fear Factor in Gay Sex
The day’s excitement was not over. On the same day, Dr Alvin Friedman-Kien, a dermatologist from New York, telephoned CDC Head Quarters to report a cluster of cases of a rare and unusually aggressive cancer, Kaposi’s Sarcoma, among gay men in New York and California. Like ‘Pneumocystis Carinii Pneumonia’, Kaposi’s Sarcoma was seen to be associated with people who have weakened immune systems. The next day, many newspapers, including The Los Angeles Times and San Francisco Chronicle, made exclusive reports on this ‘strange illness’ sweeping across the city. Within days, CDC received a torrent of reports from all over the US, describing similar cases and other opportunistic infections among gay men. In response to these reports, CDC established a Task Force on Kaposi’s Sarcoma and other opportunistic infections to identify the risk factors so that a case definition for the ‘yet-unnamed syndrome’ can be made. On July 2, a weekly newspaper for the gay and lesbian community in San Francisco coined the term ‘Gay Men’s Pneumonia’ and urged gay men experiencing progressive shortness of brath to see their physicians at the earliest.
On 3 July 1981, the New York Times published an article entitled ‘Rare Cancer in 41 Homosexuals’, helping enter the term ‘Gay Cancer’ into popular vocabulary. It was more than a year later that CDC came up with the term ‘Acquired Immune Deficiency Syndrome- AIDS’ and released the first case definition for it: “A disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known cause for diminished resistance to that disease.” Even then, little progress was made on the therapeutic front to manage the disease until June 1983, when ‘Ward 86’ was isolated to include AIDS patients at San Francisco General Hospital. Within 55 days, another ward, ‘Ward 5B’ was opened in the same hospital, making it the first dedicated in-patient AIDS ward in the U.S. Within days, its 12 beds became fully occupied. News spread all over America that a new deadly disease is killing young people, and President Ronald Reagan couldn’t remain silent anymore. On 17 September 1983, he made a statement about AIDS publicly for the first time, calling it ‘a top priority’ in health care.
HIV on the Stage
The search for the cause of the novel disease could not attain pace due to various reasons.
It was almost three years later that the International Committee on the Taxonomy of Viruses announced that the virus leading to AIDS would be officially known as ‘Human Immunodeficiency Virus-HIV’. The real scenario became apparent very soon, with dossiers and reports claiming that the human body can’t get rid of HIV and no effective cure for HIV existed. The virus attacks cells that help the body to fight infection, making a person more vulnerable to other infections and diseases. It is spread by contact with certain body fluids of a person with HIV, most commonly during unprotected sex or through sharing injection equipment. If left untreated, HIV can lead to the disease of AIDS. Once you happen to have HIV, you have it for life. On 1 December 1988: World AIDS Day was observed for the first time. The date was designated by the World Health Organization and supported by the United Nations. The theme for the observance was “Join the Worldwide Effort”. But such efforts yielded few benefits in the early days. By 1992, AIDS became the number one cause of death for US men aged between 25 to 44.
On 30 September 2015, The World Health Organization introduced a revised guideline recommending ART or antiretroviral therapy should be initiated in everyone living with HIV at any CD4 cell count.. Through ART, people with HIV can live long and prevent transmitting HIV to their sexual partners. In addition, there are effective methods to prevent getting HIV through sex or drug use, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). WHO recommends that daily oral PrEP can be an additional prevention choice for those at substantial risk for contracting HIV. It has expressed a belief that through new health policies and shared responsibility, nations can avert more than 21 million deaths and 28 million new infections by 2020. Several organizations are moving towards the aim of developing the first functional cure for the disease, one that leaves people living with HIV healthy and medication-free without necessarily wiping the virus completely.
The Berlin Patient
AIDS research and antiretroviral therapy has come a long way since the disease was discovered in the 1980s. Ten years ago, an HIV patient was cured of the disease for the first time. The ‘Berlin patient’, as he was called, was Timothy Ray Brown. He received a bone marrow transplant from a donor who was naturally resistant to HIV. However, attempts to replicate the ‘Berlin patient case’ have not been successful and bone marrow transplants still carry high risks for HIV-positive patients. There have been improvements in antiretroviral drugs. HIV vaccines too are underway, but an HIV cure is still a distant dream. One of the most promising treatment strategies against HIV is to try to inhibit the virus’ ability to replicate its genetic material. This can prevent the virus from making copies of itself. The French company Abivax has shown in clinical trials that this approach has the potential to become a functional cure for HIV.
A key aspect of the drug is that it can target the reservoir of HIV viruses that are remaining inactive within our cells. Current ART-therapies suppress the virus in circulation by inhibiting the formation of new viruses, but they won’t catch the viruses hiding in reservoirs. As a result, when ART-therapy is stopped, the virus comes back in 10 to 14 days. On the other hand, the drug developed by Abivax binds to a specific sequence of the viral RNA, inhibiting its replication. Ehrlich highlighted that a key factor in its drug can target the reservoir of HIV hiding in blood cells, and it can also find the latent viruses hiding in the intestine of the patient, which is the largest reservoir of HIV. Another approach of a similar kind is to use latency-reversing agents. These can activate the dormant HIV reservoir and kill the viruses. In 2016, a group of researchers from universities in the UK reported promising results from one patient treated with this method. But the researchers themselves stated that those were only preliminary results. Similar results are now being published by Zion Medical, the Israeli pharma company.
Immunotherapy, the Last Hope
Immunotherapy involves ‘recharging’ the immune system to fight HIV. But it is not as simple and straightforward as it sounds. Researchers in Oxford and Barcelona reported a new kind of immunotherapy that could prime the immune system against the virus. Their approach towards developing a functional HIV cure combines a drug to activate the hidden HIV reservoir and a vaccine that can trigger an immune response that is a thousand times stronger than normal. Bill Gates, who strongly believes that only immunotherapy could help AIDS patients, has made a huge investment in Immunocore, a company in Oxford. Immunocore has designed T-cell receptors that can seek and bind HIV and instruct immune T-cells to kill any HIV-infected cells. This process can be initiated even when the levels of HIV are very low in the body, as in the case of the HIV-reservoirs. This mode of treatment has shown promising results in human tissue samples, but human trials involving people living with HIV are still waiting to be carried out.
French pharmaceutical company InnaVirVax has come with a vaccine that can stimulate the production of antibodies against HIV protein 3S, enabling T-cells to attack the virus. The drug can also promote a total recovery of the immune system. Besides these efforts, a lot of attention has been focused on a group of people who carry a mutation on the gene that encodes CCR5, a protein on the surface of white blood cells. Because of the mutation, these people can’t produce the protein. It is this protein that allows HIV to enter the cells. Scientists at US-based Sangamo Therapeutics are now trying to silence this gene so that there will be a permanent wiping-out of HIV infections and AIDS. In 2016, the company succeeded in extracting patients’ immune cells and editing the DNA to make them resistant to HIV. In the future, this kind of ‘gene editing’ would be more easy using CRISPR-Cas9, a gene-editing tool. But there is a lot of ethical controversy around CRISPR gene editing, particularly over fears that the technology can be used to create ‘designer babies’.