“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
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)
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)
Untreated AIDS is a devastating
disease that inevitably leads
to an early death
“Tropical Medicine and Parasitiology” 1997
The virus kills people indirectly, by destroying the immune system
The virus kills people indirectly, by destroying the immune system
With a disabled immune system, other infections take off
As you already know…
HIV and AIDS by the numbers
33 million people worldwide living with HIV
2.1 million people died of AIDS in 2004
--this dropped to 1.8 million in 2009
2.5 million new infections in 2009
UN AIDS press release 11/20/2010
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.
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
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
What is your picture of the average
HIV positive person?
In the developing world, HIV is becoming
a disease of children!
New HIV Infections in 2002 by Age Group
In the developing world, HIV is becoming
an infection of children!
UN AIDS press release 11/20/2010 Global Trends
We can also see these differences
when we return to our comparison of
the US
and Haiti
HIV prevalence in the Caribbean ranges from
0.1% in Cuba to > 3% in the Bahamas and Haiti
UNAIDS 2006 Report on the Global AIDS Epidemic
And BBC November 2003
HIV prevalence in the Caribbean ranges from
0.1% in Cuba to > 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.
UNAIDS 2006 Report on the Global AIDS Epidemic
And BBC November 2003
HIV prevalence in the Caribbean ranges from
0.1% in Cuba to > 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
In contrast, in the US….
AIDS is not on this list!
The development of effective
treatments turned the tide in the US
This becomes even clearer
if we focus in on the key years
40
100
35
Percentage o
USE OF ART
30
25
75
DEATHS
20
50
15
10
25
Deaths per 100 Person-Years
5
0
1995
1996
1997
1998
1999
2000
Percentage of patient-days on ART
Deaths per 100 person-years
Mortality vs. ART utilization
0
2001
Palella F et al. 8th CROI 2001; abstract 268b.
However major
disparities in
AIDS incidence
occur even within
our nation
Top 10 States by AIDS Case Rate
per 100,000 Population, 2004
179.2
District of Columbia
New York
Florida
Maryland
39.7
33.5
26.1
Puerto Rico 23.4
Louisiana 22.4
New Jersey 21.2
Delaware 18.9
Georgia 18.6
Connecticut & Virgin Is. 18.4
Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.
U.S. Rate = 15.0
There are also major disparities
along ethnic lines
(largely but not entirely reflecting poverty)
Percent of
AIDS Diagnoses
70
60
White, non-Hispanic
50
40
African American
30
20
10
Latino
American Indian/
Alaska Native
Asian/Pacific Islander
2004
0
1985
1987
1989
Note: Data are estimates.
Source: CDC, Data Request, 2006.
1991
1993
1995
1997
1999
2001
2003
AIDS Diagnoses Disparities, 2004
AIDS Cases
42,514
28%
U.S. Population
293,655,404
White, non-Hispanic
69%
African American
49%
Latino
20%
<1%
Asian/Pacific Islander
1%
AI/AN
13%
14%
4%
1%
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 Native
Sources: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005; U.S. Census Bureau, Population Estimates Program,
2004 Population Estimates.
As with TB, the impact of AIDS
Is not limited to illness and death
As with TB, the impact of AIDS
Is not limited to illness and death
Worldwide >16 million children have been orphaned by AIDS
Lesotho
Swaziland
UN AIDS press release
11/20/2010 Global Trends
Rwanda
More than 11 million
Of these children are in
Sub-Saharan Africa
Newsweek, Vol. CXXXV, No. 3, 17 January 2000
More than 11 million
Of these children are in
Sub-Saharan Africa
UNICEF 2006
There is some good news
to which we’ll return later
UN AIDS press release 11/20/2007 and UNAIDS/WHO/UNICEF report 4/17/2007
There is some good news
to which we’ll 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.
UN AIDS press release 11/20/2007 and UNAIDS/WHO/UNICEF report 4/17/2007
There is some good news
to which we’ll 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
Let’s return to the impact of
AIDS on Haiti
the US
and Haiti
AIDS and the
fear of AIDS
have had a
major effect on
Haiti since the
dawn of the
epidemic
Let’s go back
in time and
see how
things began
The first H: Homosexuals
1981
Doctors in California and New York note increase in cases of
Kaposi’s sarcoma and Pneumocystis carinii pneumonia in
gay men
A remarkable tribute to epidemiology!
They first noticed the disease based on:
a handful of cases of Pneumocystis pneumonia
And 8 cases of Kaposi’s sarcoma and
Why did they suspect a new disease?
Kaposi’s sarcoma lesions
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.
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
Then came the first reports of similar outbreaks
In those injecting illegal drugs
Then came the first reports of similar outbreaks
In those injecting illegal drugs
The second H = heroin-users
By mid 1982 the third and fourth H’s were added:
By mid 1982 the third and fourth H’s were added:
Haitians and hemophiliacs
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 drugs[heroin];
patients with hemophilia; and sexual partners of individuals at increased risk for AIDS”.
As AIDS emerged
into the public view
discrimination against
the 4H’s skyrocketed
Our nation’s 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
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
This sort of fear devastated the Haitian economy
This sort of fear devastated the Haitian economy
"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
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
This led to a reversal of the official policy
but this was too late for Haiti
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
The popular press and some scientists
fed fears of Haitians by suggesting that
AIDS arose in Haiti
This initial theory was quickly discredited
What is the origin of HIV and how would we
determine this?
Remember this?
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
Mutations accumulate over time
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
We can do something similar with HIV
Staph. aureus
TB bug
E. coli
Genome Research 12, 1080-1090 (2002)
HIV is part of a family of viruses
affecting monkeys, apes and people
Retroviruses. CSHL Press Fig. 12-3
HIV is part of a family of viruses
affecting monkeys, apes and people
People
Chimps
People
Chimps
People
Chimps
Science 28 January 2000:Vol. 287. no. 5453, pp. 607 - 614
HIV came from
non-human
primates
4 times!!
Hemelaar J.Trends Mol Med. 2012 Jan 11.
Tebit DM, Arts EJ. Lancet Infect Dis. 2011 Jan;11(1):45-56.
The greatest diversity of HIV
sequences is seen in Central Africa
Global Distribution of HIV-1
Hemelaar J.Trends Mol Med. 2012 Jan 11.
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)
HIV has been transmitted between
apes and people multiple times
People
Chimps
People
Chimps
People
Chimps
Science 28 January 2000:Vol. 287. no. 5453, pp. 607 - 614
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)
A recent study suggests AIDS may have
Passed through Haiti from Africa to the US
World-wide
West Africa only
West Africa only
Sequence analysis also provides
evidence for timing of emergence of epidemic
There are problems with this analysis
Another problem with this analysis:
Early cases
1969: “Robert R” 15 Year old American from St. Louis.
died of Kaposi’s 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