30 Years with AIDS: Observations and Evaluations by Professionals (Answers to journalists’ questions)

Over the past 30 years we have witnessed a remarkable scientific progress in fighting HIV/AIDS. The following is a discussion I had with reporters on HIV /AIDS situation in Lithuania and around the world, epidemiology and prevention, professional expectations and achievements.

This year marks 30-year anniversary of the world living with HIV / AIDS. How did it start? Who were the first to receive the infection?

30 years ago ( in1981) the U.S issued an official report which soon travelled around the world -five young men, all of them previously in good health, died from pneumonia which, as emerged later, developed due to a damage it caused to immune system. When it was found that all the dead ones were gay, the name first proposed to describe the illness was GRID or gay-related immunodeficiency. This marked the beginning of extensive research and observations. It quickly became clear that the unusual damage caused by a virus that specifically violates the human immunity, which in turn causes the further development of AIDS, was so called acquired immunodeficiency syndrome. At that time it was decided to call the virus HIV or  human immunodeficiency virus.

When and how the news about the first AIDS case reached Lithuania?

The first HIV-infected person  in Lithuania was a sailor from Klaipeda, who was given treatment for a serious health condition at Kaunas Clinics in 1989. Suspected of having HIV the patient’s blood sample was sent to the Virology Research Institute in Moscow, where at that time I was doing my a postgraduate studies. The suspected diagnosis was confirmed. At that time it was clear that the virus was imported from abroad and it could have been introduced only by those who had sex with foreign nationals. As you know, the   first wave of HIV peaked in gay community in Lithuania. The second wave affected the sailors who brought back this “souvenir” having received it from the port prostitutes in different African countries.  Subsequently, HIV began to spread among drug users.

The first predictions/ information on HIV – did they bear any similarity to the reality you faced later on?

Let’s put it this way – it was hard to imagine then the enormity of the challenge ahead of us.

Were there any assumptions or predictions that had nothing to do with what was actually happening then and now?

It was expected that HIV would spread more rapidly than it is spreading right now. At the beginning the focus globally was on sexual transmission of the infection that overshadowed another problem – transmission via injecting drug use.

What has been done in 30 years?

Over the past 30 years we have seen remarkable scientific developments in the field of HIV / AIDS.  Among the achievements in the field of research the most significant was the discovery of HIV as the original cause of AIDS; the development of  HIV diagnostics; the understanding of the nature of viral transmission and the mechanism of viral functioning; the clear understanding of the nature of the immune response to HIV and the subsequent chain of events leading to the development of AIDS; the development of more than 30 antiretroviral drugs (ARV’s ). Equally important was the fast-growing number of approved HIV prevention methods. However, research in the field is still facing enormous scientific challenges. Given the preventive tools we currently have at hand, the profound changes can bring about the successful development of safe and effective vaccine to prevent HIV infection.

What are the current trends in global HIV/AIDS epidemics?

The global HIV epidemics reached its peak in 1999. Since that year HIV incidence over the decade has decreased by 19 percent. However, since its discovery HIV/AIDS has killed 30 million people worldwide.  Around 34 million people in the world are presently living with HIV. More than 50 percent of all living with HIV are women and young girls. The highest HIV prevalence rate in the world (25.9 percent) in adult population was identified in Swaziland (African country). We see the reduction of AIDS related deaths not only among adults but among children alike.  The mother-to-child transmission during pregnancy, childbirth or breast-feeding is now on the decrease as well. With the development of the effective HIV drugs, which do not kill the virus in the body per se, but inhibits its proliferation thus increasing life expectancy of HIV-positive people, the number of people living with HIV has also increased. However, we see the increasing numbers of orphans (0-17 years) whose parents died of AIDS.

What is the predominant mode of HIV transmission in Europe?

Europe is diverse and trends are very different. For example, in Western and Central Europe, the predominant mode of HIV transmission is unprotected sex, especially among men who have sex with men (Germany, Spain, Holland, and UK), whereas in Eastern European region, which includes Lithuania, the predominant mode of HIV transmission remains the injecting drug use.  Injecting  drug use accounts for more than 65 percent of new HIV cases in Lithuania each year. The understanding of  a close relationship between HIV and drug use came at relatively early stage in the country; however, drug prevention and control still remains one of the most important tasks in the entire chain of HIV prevention, and not only in Lithuania but also abroad.

Three decades have passed since HIV was first identified. Does the world have a hope?

Over the past 30 years we managed to completely change the lives of those who are living with HIV. This was possible due to emergence of some treatment methods which have changed HIV diagnosis from a nearly one hundred percent death sentence to that of a chronic but controllable disease. Yes, the available scientific recourses give us a hope. Drugs able to kill the virus in the body have not been developed yet and the future is in the hands of well-known and new biological prevention methods and HIV vaccine research.

Recently you became a member of the Global Virus Response Network, so you have the opportunity to learn firsthand from the most famous scientists in the world why the development of vaccine against HIV is such a challenge?

The spread of the infection cannot be completely curbed without developing a vaccine. Experts do not forecast any rapid changes here. Their hopes are well grounded – there are so many vaccines under clinical trial at the moment. One thing is clear – the current vaccines under clinical trial induce an immune response that stimulates antibody production. However, many questions and uncertainties remain: whether the number of antibodies will be sufficient to prevent the transmission of the immunodeficiency virus after the exposure. The possible dangers are still unknown; how will a vaccinated person feel in ten or more years the. Finally, who should be vaccinated? All newborns? The young ?  Society as a whole?  Gay people?  Drug users? Biological, medical aspects are intertwined with social, ethical and economical ones. One  thing that seems to be clear is that this problem  is to stay for quite a while, and the best vaccine against HIV so far is HIV prevention.

What are the new HIV prevention measures that world scientist are talking about right now?

Only integrated measures have proved to be effective so far. What I mean is behavior change interventions and new biological prevention methods. However, what works for one group of people or culture may not work for another. For example, recently published research results on biological approaches to HIV prevention clearly demonstrated that circumcision of adult males can significantly reduce HIV transmission the risk during heterosexual intercourse. This measure is successfully used in some African countries, but it is hardly imaginable in our region. Another example is antiviral agents with microbicide gel for women that can be used locally prior to sexual activity. They also reduce the risk of HIV transmission. Pre-exposure prophylaxis that involves special courses of antiretroviral therapy for men who have sex with men is also a new science-based HIV prevention measure, but it is not accessible in some countries due to high costs.

Why has the statement “HIV prevention is the drug against HIV” been promoted in recent years?

The breaking point was reached in 1996 with the development of a new group of HIV drugs. They gave a new hope. Since then, the treatment has been much more successful, and HIV  from inevitably fatal infection has transformed to a relatively well-controlled chronic disease. Furthermore, the latest study in 2011 revealed that HIV drugs that inhibit virus replication reduce viral loads in human fluids and thus minimize the risk of HIV transmission during sex up to 96 percent. Extraordinary effects of the drugs on viral reproduction in the body led experts to combining prevention resources. Antiviral  treatment for HIV is given to 6.6 million people worldwide currently. However, overall of 14.2 million people need it. Only 47 percent of world demand for treatment is satisfied presently. About  200 people in Lithuania receive HIV treatment, which costs from 25 to 32 thousand Litas  one person a year on the average. The treatment is fully covered by National Health Insurance Fund. Speaking about future prognosis – demand for drugs is going to grow, as more and more people every year need the treatment. The  World AIDS Conference 2008 provided explicit figures – to one HIV-positive person who is given antiretroviral treatment every year, there are two newly infected with HIV.

How does Lithuania look like in the global HIV epidemic context? Are we any different?

The country is small, but we had Lithuanian AIDS Centre which functioned for 20 years (1989-2009) and was well known as a medical facility offering comprehensive and methodical preventive services, especially in Europe. We learned a lot from the experience of the finest institutions in Western Europe and North America. Over 20 years, the Lithuanian AIDS Centre was visited by great number of many colleagues from various European countries specializing in HIV; cooperation was established and experiences shared. Comprehensive preventive response to HIV; the integration of personal and public health services has slowed the pace of the spread of HIV in due course of time. Throughout the entire HIV incidence registration period until 30 November there were 1867 HIV cases of infection registered, most of which (1546) occurred in men and 321 in women. Most of HIV cases occurred in 25-34 year age group. Most HIV positive persons (1322) were identified among injecting drug users, including the Klaipeda County (510). homosexual intercourse accounted for 111 cases; whereas heterosexual relationship accounted for 268 cases; there were 2 cases of mother to child transmission and 164 cases of unknown origin. Internationally, Lithuania received a positive assessment due to high HIV testing coverage for pregnant women. Almost 96 percent of all pregnant women are tested for HIV, which allows early detection of HIV infection and use of preventive therapy as well as other measures that allow protecting the newborns from HIV transmission.  Only 10 European countries conduct such responsible prenatal HIV care.

In  2009, AIDS incidence rate in Lithuania was 1.1 cases per 100 thousand population, corresponding to an average indicator for all other countries in the region. The most common AIDS marker in Lithuania is pulmonary tuberculosis as is in other Eastern European countries.

What further HIV-relating challenges ahead of us do you see?

A growing demand for antiviral drugs and its burden on the state budget, especially in terms of ensuring the access to treatment in prisons. National Health Insurance Fund experts estimate that in order to ensure a state covered treatment of HIV infection for a HIV positive person, two people have to work all year round, stay healthy, and pay taxes. We need to fight drug addiction, which is one of the leading HIV risk factors; educate young people about HIV and other sexually transmitted infections.