Lecture 24 April 22nd

Todays Outline
AIDS Dementia

Announcements
Exam on Thursday, May 1st 8:40-10 am Not a final exam Covers last 5 lectures

AIDS and society

Success stories

Time bombs

BPO-where are they now

Lecture will finish Early to leave time For questions

HIV Infection of the Nervous System

What is the Central Nervous System?

CNS = The brain and the spinal cord Nerves and muscles are the peripheral nervous system (PNS)

AIDS Dementia Complex (ADC)

Progressive disorder
Confusion, memory loss, difficulty thinking and speaking, balance problems

Called ADC when related to HIV itself rather than other brain infections or drug side effects
Neurologists can use CT scans and MRI to distinguish between neurological symptoms due to Opportunistic infections vs the virus itself

 About 50% of AIDS patients develop mental deterioration due to HIV infection, but ADC is rare if viral load can be kept low Mystery--high/low viral loads not a predictor of ADC
High viral load not a guarantee of developing ADC

However, those who do have ADC do have a high viral load in the cerebrospinal fluid

Does HIV infect brain cells?

Some brain cells contain CD4-like receptors
The original thought was HIV can infect cells

However, HIV does not appear to infect brain cells HIV-infected monocytes (a type of macrophage) migrates to the brain and release HIV
The Trojan Horse!

HIV resides in brain spaces, in the cerbrospinal fluid

 It is believed that molecular products of HIV cause nerve cell death

Viral proteins can directly interact with other human proteins to cause neuronal death

Also infected macrophages secrete chemicals that harm neurons Some believe HIV invades the brain within a few weeks to months after HIV infection
Neuronal cell death due to HIV a slow process?

Problems with HIV in brain tissue

Blood-brain barrier interferes with some drug treatments
Very few protease inhibitors can cross barrier A number of the Reverse transcriptase inhibitors can cross the barrier

Even though Anti-retrovirals have decreased the number of ADC cases in US, cant reverse brain
damage if already present

HIV in the brain can evolve independently from the rest of the body
Drugs effective against HIV in blood may not work in the CNS

Health Care and AIDS

Who needs to know?

What does the public think?

(Should a Doctors HIV status be told to his patients?)

We should know
95% said they should know if a surgeon was infected 94% said all physicians 90% said all health care workers

Would you accept treatment from an HIV+ physician, surgeon? Nurse?

What is the risk?

Heart surgery
Death by surgery is about 2-9%
Death without surgery much higher Worth the risk?

Death by surgery is 2-9%

Death by HIV infection from infected surgeon estimated at about 1 in 100,000 Worth the risk?

Infected Patients
Should the doctor know a patients HIV Status?
96% of HIV infected felt they should tell their healthcare worker Universal precautions should always be in place

It is very difficult for a doctor to fire his patient

The AMA has strict guidelines Americans with Disabilities act

AIDS and Social Issues

Stigma
Individuals do not feel comfortable disclosing their status Increases silent transmission Linkage with immorality If someone is HIV+ Must be gay or A drug user or Had sex with someone they should not have Questionable lifestyle Term innocent victims (syphilis?) Such as newborns, hemophiliacs Does this mean others are not innocent, they are guilty for their behavior?

Blame
AIDS statistics categorize
Are the infected MSM, bi-sexual, ID users What states, countries, ethnic groups are most affected?

Society can rationalize that AIDS belongs to someone else Blaming others leads to persecution
Black death Hitler

Fear Factor
People fear what they do not know and cant control 2011 survey (US)
36% of people are very/somewhat uncomfortable having a roommate who is HIV+ 45% of people are very/somewhat uncomfortable having food prepared by someone who is HIV+

The dilemma of AIDS education

Two opposing views AIDS will kill you (scare us into safety) Abstinence, safe sex or else Hospital precautions AIDS is not very contagious (prevents hysteria) AIDS victims must be cared for What to call a risk? 1 in 300 a high or low risk? Is 1 in 400,00 a high or low risk? Is 1 in 6,000 a high or low risk?

Science and the Media

Mainstream reporting
Scientific consensus
Does every opposing view have equal rights (as in a political campaign) All scientists are human Science needs the media to educate

Tabloid reporting
Extremes of hope and fear Supports what the public already believes rather than changing that belief

What do we believe?
7% of white Americans believe an HIV vaccine exists (is being kept secret?)
24% of African Americans 16% of Hispanics

33% believe that vaccines in study could cause HIV infections (old datanow??) 42% did not know that vaccines require testing 40% believe spending more money on prevention wont make much difference in the epidemics progress

Some Success Stories

Uganda
In early 1990s, 15% of adults living with HIV In 2001, 5% of adults living with HIV Attributed to strong political leadership, open communication, grassroots organizations, condom distribution, HIV testing, and treatment of sexually transmitted infections

 Cuba (0.1% prevalence)

1986 had routine screening Initially, indefinite quarantine. 1993 allow a choice Good medical care Data base of all HIV+ and partner Mother-to-child almost unheard of

 Thailand
Condom distribution to sex workers
Clamp down on those who failed to use them

Rights of women promoted Anti-AIDS messages broadcast 1991, annual diagnoses 143,000 2003, annual diagnoses 19,000

Reasons for Success

Open communication Combated stigma and discrimination People will continue their behavior, lets help them do it more safely Community involvement
Done with them, not to them

Are they still successful

In all countries, a small, but significant rise in new HIV infections (but the numbers are still good!) Why
Better treatments so less worry? Fatigue in keeping up with the prevention campaigns?

HIV/AIDS Time bombs

Africa
Sub-saharan Africa highest rates of people living with AIDS Life expectancy < 40 in 9 countries Conditions similar to bubonic plague
Loss of skilled workers, teachers, health care workers Need to constantly retrain

Burial economics issues

Cremation, bankrupt families, coffin industry only reliable source of income

Asia
India
2nd highest number of HIV+ people Transmission by sex workers/truck drivers, IDU 80% of people living in country may never have heard of AIDS
Approximately 60% of HIV infected live in rural areas

Funding lags Treatment access for poor limited

 China
80% of AIDS cases are IDUs and prostitutes For new infections, 48% from sexual contact, 50% IDU, 2% mother-to-child Ads for condoms made legal in 2002

2006-2008
Routine testing, free medical care, some education now in place

 Russia
66% of HIV/AIDS cases in Eastern Europe Major route of transmission is IDU and sex workers Former president Putin referred to the issue for the first time in 2007 Now, government pledges money for many HIV/AIDS related services

The Band Played On

Where are They Now?

Don Francis
Retired from the US Public Health Service in 1992. Joined Genentech to help develop an AIDS vaccine. Left in 2004 to co-found Global Solutions for Infectious Disease. (trying to make identifying and treating disease affordable)

Luc Montagnier
--won the Nobel Prize in Physiology or medicine in 2008. Shared with Francoise Barr-Sinoussi (for their discovery of the AIDS virus) and Harald zur Hausen (for showing human papilloma viruses lead to cervical cancer)

Robert Gallo
still working on AIDS research (among other things). Did not share the Nobel Prize 2002 Gallo and Montagnier publish together in Science

James Curran --remained director of AIDS and HIV epidemiology and prevention at the CDC until 1995. Became Dean of the School of Public Health at Emory University Selma Dritz --Den mother of the gays. Assistant Director of the bureau of communicable disease control in SF. Died Sept. 2008, 91 years old Mary Guinan --currently working as the acting Nevada State Health Officer Harold Jaffe --worked at the CDC until 1995. Currently the director of the National center for HIV, STD, and TB prevention

Marcus Conant --chief medical officer for Presidio pharmaceuticals. Focused on developing treatments for HIV and other chronic viral infections. Recipient of numerous leadership awards William Darrow --Professor of public health at Florida International University. Still working on AIDS research Matilde Krim --Currently at Columbia University school of Public Health

Cleve Jones
Diagnosed HIV+late 1980s Begins treatment in 1994 Still active in Gay community, AIDS awareness advocate
http://www.pbs.org/wgbh/pag es/frontline/aids/interviews/jo nes.html

Larry Kramer
Continues to write and call attention to gay issues and AIDS Diagnosed HIV+ in late 1980s Liver transplant 1991

David Sencer --Became a consultant for international health until 1993. Retired. Serves on a variety of ethics committees at Emory University and teaches freshman medical students Mervyn Silverman --actively involved in amfAR from 1986 until present. Involved in numerous public health causes. (amfAR is the foundation for AIDS research, non-profit)

The Red Ribbon

Designed by Manhattan painter, Frank Moore II, in 1991 Died in 2002 from AIDS-related complications Red--because the disease was known as blood-born Shape--signifies the connectedness of all of us with or without the disease He wanted to make a visual support for those infected with HIV or had AIDS