Since the identification of the viral infection in the early 1980s, an estimated 60 million people have been infected with HIV and 20 million are thought to have died as a result of AIDS.

Low HIV sexual transmission rates (less than 1% of HIV exposures lead to infection) are thought to increase significantly during acute phases of the infection when viral loads are elevated, and one third of infants born to HIV infected mothers acquire the infection.

Virgin and Walker focused upon immunological knowledge and tools for vaccine design, suggesting that in their absence, the route to a successful HIV/AIDS vaccine may be elusive and distant. It remains possible that a viable vaccine could emerge as a surprising success from vaccine trials. Even with success, a viable HIV/AIDS vaccine will likely not be 100% effective; recent promising trials in Thailand suggested a reduction of 31% in HIV acquisition as a result of vaccine use. As such, the likelihood of a successful HIV/AIDS vaccine is remote and a vaccine will be only one of several preventative tools to be used against HIV/AIDS.

Current estimates suggest that over 7,000 new HIV infections occur daily around the world. The heaviest HIV/AIDS disease burden (71%) is in Sub-Saharan Africa, but prevalence continues to rise in many areas of the world including Eastern Europe and Central Asia. In order to effectively challenge HIV/AIDS, interventions must be targeted to particular countries and individuals at greatest risk.

“It’s not enough to simply funnel more funding into current AIDS research efforts” commented the authors. Resonant also was the call to those working in the field of HIV research to learn from others with relevant expertise. The authors suggest that “there is no lack of enthusiasm among scientists outside the HIV field to get involved in HIV/AIDS related research; rather there is merely a lack of a way in”.

US Geological Survey Map

“Acute on chronic affliction…not a terminal illness” was the prognosis for Haitian devastation from Paul Farmer, founding director of Partners in Health (PIH) and United Nations (UN) deputy special envoy to Haiti. In a discussion on how to ‘build (Haiti) back better’, Farmer provided vision and firmly placed the current impact of this recent natural disaster against the background of Haiti’s chronic, long-standing privation. In discussing the quake with a Harvard audience, Farmer attributed “resolve and courage” to PIH associates working in Haiti and praised the resilience, determination and capacity of the Haitian people.

One month after the earthquake, the crisis in Haiti is becoming peripheral news; the 7.0 magnitude earthquake struck 10.2 million Haitians on 12^th January 2010. The Haitian government now estimates there have been some 212,000 deaths and 300,000 injured persons, in addition over 1.2 million people have been displaced and approximately 155,000 homes destroyed or damaged. An entire nation remains overwhelmed with trauma and grief.

Haiti is the poorest country in the Americas; UN data describes 55% Haitians living on less than $1.25 (US) a day, and 72% living on less than $2 (US) a day. Haiti has with the highest childhood mortality rates (80 deaths per 1,000 children under 5 years) and lowest life expectancy (61 years) in the Americas.

With over 10,000 NGOs operating in Haiti prior to the earthquake, each with “different personalities (and) objectives”, PIH physician David Whalton commented that different NGOs “find it hard to get along”. In addition to well-intentioned NGOs and individuals, come others who intend to profit from the devastation, some making human trafficking the source of profit.

NGOs such as PIH, admit to their lack of preparedness for this type of devastation; others claim that they were prepared. Such positive admissions are considered with scepticism by PIH. Robust assessment of achievements may be difficult to collate, but observation of progress made thus far makes positive preparedness claims unlikely. An estimated 188,000 people still do not have the most basic access to clean water, and latrines meet only 5% of the total need. In terms of shelter, there are 400,000 plastic sheets for emergency shelter for distribution; as of 11^th February only 49,000 of these items had been distributed. With the imminent rainy season, it appears likely that many displaced people will have no substantial weatherproof shelter.

Cases of tetanus, acute respiratory and diarrhoeal diseases are being reported. Current elevated disease risks also reflect the low rates of vaccination (51% in 2006 for children in the first year of life). A vaccination program began on 2^nd February to provide measles/rubella and diphtheria, tetanus and pertussis vaccinations to children under 7 years, and diphtheria and tetanus vaccines for all over 8 years. With significant rates of tuberculosis prior to the quake, this disease also poses a significant threat for Haitians. With the rains will come increased risk of mosquito borne diseases malaria and dengue, and water borne diseases including typhoid and cholera. The rainy season will be succeeded by the hurricane season, which will bring new challenges for Haiti.

The inability of the international aid community to deliver medicines, food, water and shelter to people in need in a timely manner is a major cause for concern as the effort to ‘build back better’ continues. That leaders and innovators in public health, such as PIH appreciate, communicate and offer continued commitment to challenge these incredible difficulties is essential. The combination of factors which have contributed to the poor international aid response leaves me wondering how Haiti, a nation afflicted by poverty and oppression, isolated from equitable economic development and longtime host to substantial NGO and UN (since 1994)  presences, can now ‘build back better’? I want to be hopeful that the earthquake has sincerely brought renewed efforts to move Haiti towards sustainable health and prosperity, but I am sceptical.

However, I am in agreement that while the task is overwhelming, it must be tackled by Haitians and international partners in a collaborative manner which ensures solidarity with the Haitian people. While the immediate goal must be to help Haiti on a path towards shelter and recovery from the immediate devastation, the larger goal must be to furnish Haitians with the ability to build and support strong and sustainable infrastructures.  

‘Under Our Skin’ is punctuated with stories from Lyme disease sufferers describing highly varied and extreme disease symptoms ranging from muscle spasms, epileptic seizures, loss of speech and movement, to extreme, chronic pain and fatigue. In the film, patient after patient attested to the chronic symptoms they suffered in association with a Lyme disease diagnosis. Suffering was often also compounded by the frequent dismissal and misdiagnosis of symptoms. Lyme disease diagnosis remains a difficult, even controversial issue; diagnosis methods are not robust and a diagnosis itself can come with societal ridicule. To be honest, I hadn’t appreciated Lyme disease as the most commonly reported US vector borne disease. Nor had I appreciated the controversy that surrounds it. 

There are thought to have been around 35,000 Lyme disease cases in the US in 2008. Transmission has been documented in temperate forested regions of Europe and East Asia, but  infrequently in the tropics. The disease results from infection with one or more of 3 species of Borrelia bacteria (burgdorferi in USA and Europe, afzelli and garinii in Europe and East Asia) via the bite of an infected deer tick.  In around 70-80% cases a characteristic bullseye rash appears at the bite site within 30 days of the bite; accompanying disease symptoms  include fever, headache, depression and fatigue. For most Lyme disease patients the infection can be resolved with a short dose of antibiotics and symptoms are mild. However, long term symptoms can include damage to the neurological system, the heart and the joints. The full syndrome was recognized in Lyme, Connecticut in 1975, from sentinel cases of a cluster of children with arthritis. The responsible bacteria were definitively identified in the early 1980s.

‘Under Our Skin’ addresses the controversial issue of Lyme disease as a chronic infection which requires long term antibiotic treatment. There was speculation during the film that chronic Lyme disease symptoms could be caused either solely by persistent Borrelia burgdorferi infection, or by  B. burgdorferi along with other tick borne organisms such as Babesia and Anaplasma. Also entertained were highly speculative suggestions that the bacteria can be transmitted sexually. The specific bacterial cause of chronic Lyme disease symptoms appeared to be unclear for the patients documented in this film. Persistent Borrelia and/or other bacterial infections seemed to be unconfirmed, also often unclear or absent were specific prolonged immune responses to the Borrelia bacteria. 

The nuanced narrative of ’Under Our Skin’ describes the noble sufferers and ‘Lyme warrior’ medical practitioners, in opposition to the villainous officials of the Infectious Disease Society of America (IDSA) and health insurance companies. The financial affiliations and proprietary interests of IDSA Lyme disease advisory panel members were justifiably raised to indicate potential serious bias. However, there was also inappropiate comment that scientific references cited by IDSA Lyme disease advisory panel members included too many of their own previously peer reviewed articles. (As scientific experts tend to collaborate and produce articles with other scientists, this argument would justify exclusion of much relevant scientific literature!)

Lyme disease symptoms can be prolonged, chronic and varied. There is no specific recommended long-term anti-bacterial treatment for sufferers. Randomised controlled clinical trials have been conducted and reported no prolonged benefits of long-term antibiotic use for chronic Lyme disease symptoms. But there is discussion on how far these results can be extrapolated and suggestions from uncontrolled trials that long-term antibiotic treatment could be beneficial. Prolonged antibiotic treatment seemed to have worked well for the many sufferers chronicled in ‘Under Our Skin’, but no objective measures were presented. Perhaps it’s time for at least one more controlled and comprehensive trial…?

Doxycycline is one of several recommended short term (4 weeks) antibiotic therapies which can be used to treat Lyme disease. Others include oral amoxicillin and intravenous penicillin.  Doxycycline has broad application and can be used to resolve respiratory and urinary tract infections, as well as infections with a number of organisms including E. coli, Streptococcus, Chlamydia and Yersinia pestis (plague) amongst others. In addition, this anti-bacterial agent can be used as a prophylaxis (and treatment) for malaria and anthrax. Using long-term antibiotic treatment for chronic Lyme disease symptoms could reduce the effectiveness of doxycyline and other medications against Borrelia bacteria and other organisms.

‘Under Our Skin’s apparently unfettered support for use of long-term antibiotic treatments was troubling to me. It may be true that the Borrelia bacteria are at such low numbers as to be poorly detected, or that they are hidden somewhere… But, it’s also equally plausible that untreated or ineffectively treated acute Borrelia infections can have chronic, debilitating autoimmune consequences - without bacteria being persistently present.

Clear examples of the negative impact of imprudent antibiotic use are not difficult to find. The emergence and spread of drug resistant organisms including multi-drug resistant tuberculosis and methicillin-resistant Staphylococcus aureus (MRSA) are just two of these (doxycycline is currently used to treat MRSA). While many scientific issues where speculated upon in ‘Under Our Skin’, the consequences of long-term, non-specific antibiotic treatment were concerns which this film failed to raise.

‘Under Our Skin’ is an enlightening and engaging Oscar nominated documentary film. The film explores what it means suffer chronic Lyme disease symptoms in America today, keeping at it’s core the unheard narratives of these sufferers.

Maybe an unexpected highlight, but I’m impressed at these findings… A recent study proved that application of azithromycin (Zithromax) to treat trachoma saved sight in Ethiopia and saved lives too. Chlamydia trachomatis is the leading cause of preventable blindness. Left untreated, chronic and repeated trachoma infections in children can lead to irreversible adult blindness; there are an estimated 8 million irreversible visual impairments attributed to trachoma.  Surgery, Antibiotics, Facial cleanliness and Environmental improvement (SAFE)  can all play a role in reducing the risk of disease, as well as treating and resolving infections.

The study published in September was conducted in Ethiopia, where 119 of every 1000 children die before 5 years of age. After azithromycin treatment for trachoma, the overall mortality rate among children who had taken the drug was half that of those who had not. One of the study leaders, Dr Tom Lietman, from the University of California at San Fransico, commented that “For years, people in trachoma-affected communities have reported that the antibiotic helped address other health problems”.

This study validates those reports, particularly so in the wider context that azithromycin is used to effectively treat many other infections. Diarrhoeal diseases and malaria are common causes of death for children under 5 in sub-Saharan Africa, causing an estimated combined 2.5 million childhood deaths annually. In the study setting, it’s likely that broad use of azithromycin may have treated a host of the neglected diarrhoeal and respiratory diseases as well as malaria, resulting in a significant reduction in childhood mortality.

These important findings are impressive, offering great potential to scale up the antibiotic treatment element of the SAFE programme and save many young lives. But wide-scale application of non-specific drug treatment should be taken with real prudence; such approaches must be integrated with other interventions and considerate of scientific understanding about the development of drug resistance. The rise of drug resistant organisms is no fiction; malaria, tuberculosis, HIV and staphylococcal infections, amongst others, certainly prove the need to proceed with caution!

Number 2, An Effective Malaria Vaccine Coming Soon?

In 2009, phase 3 human clinical trials began with the most promising malaria vaccine to date. The vaccine known as RTS,S/AS02 (aka RTS,S or Mosquirix) can be used safely, generating specific immunity to malaria and most importantly seeming to provide significant reductions in severe malaria (49%) and clinical disease (35%) in African children. The RTS,S vaccine was developed by Glaxo SmithKline (GSK) in the mid 1980s with support from the Walter Reed Medical Centre; since 1991 the vaccine effort has been a public-private partnership between GSK and the PATH Malaria Vaccine Initiative.  Designed primarily for use in Africa and first tested on humans in the early 1990s, this is the most promising malaria vaccine to date.

The start of the largest ever malaria vaccine trials was announced this year; seven African countries, including 11 medical research institutes, will participate. The vaccine will be administered to up to 16,000 infants and children younger than 17 months in Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique and Tanzania. Results of this trial are expected in 2012. With the already encouraging results shown so far, the first malaria vaccine may be available for wide-scale use by 2015.

Number 1, Swine Flu Fever Takes Over The World & Everything!

H1N1 virus

Swine flu happened to the whole world in a big way in 2009, overshadowing all other public health/infectious disease news. By mid 2009, WHO had declared H1N1 (swine flu) a global pandemic, and some measure of panic, or perhaps I should say elevated concern, set in for a good while. There were masks in public places, and (hopefully!) much practice of good hand-washing hygiene. The H1N1 virus spreads rapidly (just like seasonal influenza), and is a new virus which causes a highly infectious disease. While thousands of deaths have occured, H1N1 is not highly pathogenic, and has not caused the feared high rates of illness and death.

1976 H1N1 vaccination

Vaccines have proven highly controversial and aroused much suspicion regarding safety and efficacy. There is no reliable evidence to show that current vaccines are either unsafe or ineffective; rather there is increasing peer reviewed evidence to the contrary ^{1 2}. However, in the US, nasal and pediatric syringe-filled H1N1 vaccines have recently been recalled due to dosage concerns. 

Most countries have stopped recording the numbers of new infections, and millions are thought to have been infected with the H1N1 virus without serious symptoms. The number of deaths continues to rise; to date at least 12,220 deaths have been attributed to H1N1 globally.

Swine flu will undoubtedly continue to inspire research, debate and discussion in this new decade, as will other pressing infectious diseases and public health happenings. So stay tuned for more global pandemics news in 2010.

To Good Health and a Happy New Year!

1. Greenberg ME, Lai MH, Hartel GF, Wichems CH, Gittleson C, Bennet J, Dawson G, Hu W, Leggio C, Washington D, Basser RL. Response to a monovalent 2009 influenza A (H1N1) vaccine. N Engl J Med 2009; 361 (25) 2405-13 http://nejm.highwire.org/cgi/reprint/NEJMoa0907413.pdf

2. Nolan T, McVernon J, Skeljo M, Richmond P, Wadia U, Lambert S, Nissen M, Marshall H, Booy R, Heron L, Hartel G, Lai M, Basser R, Gittleson C, Greenberg M. Immunogenicity of a Monovalent 2009 Influenza A(H1N1) Vaccine in Infants and Children: A Randomized Trial. Jama 2009;   http://jama.ama-assn.org/cgi/reprint/2009.1911v1

2009 began with Ebola in Democratic Republic of Congo (DRC); cases were recorded on 2^nd January. The outbreak came to an end in February, after causing 32 cases and 15 deaths.

Cholera: pumphandle bringing death in 19th century

From February to April, meningococcal disease outbreaks occurred first in Nigeria, then in ‘the African belt’, and finally in Chad; there were around 1600 deaths.

Notable also were cholera outbreaks in Zimbabwe between January and March. This disease of unclean water emphasized the dismal levels of sanitation inflicted upon Zimbabweans and caused 4762 deaths.  

Mosquitoes brought yellow fever to Sierra Leone and Guinea in January, to DRC in April, to Liberia in May, to Cameroon in Oct, and to the Central African Republic in December; there was one confirmed death in each country except Sierra Leone.  

Polio broke out in parts of Nigeria in July. There were 258 cases as a result of a wild polio virus. An additional 108 more cases resulted from a vaccine-derived polio strain.

Polio, and Kala azar (leishmaniasis) amongst other diseases, struck the already crippled South Sudan during 2009.

A pneumonic plague outbreak in China resulted in quarantine of 10,000 people for several days in August; there were12 infections and 3 deaths.

Mosquitoes bit back in October and November, this time carrying dengue fever to Cape Verdians.

Throughout the year, bird flu emerged occasionally in varied countries including China, Viet Nam, Indonesia, Cambodia and Egypt. Unlike ‘Swine flu’, bird flu is highly pathogenic, on average causing death for 60% of those infected. Bird flu doesn’t spread easily; in 2009, 72 infections and 32 deaths were confirmed.

Number 4, New Tools to Prevent HIV/AIDS; Good or bad news first?

In HIV/AIDS news, the first successful ‘proof of principle’ wide-scale human vaccination strategy was announced  in 2009. Phase 3 HIV trials in Thailand using a ‘prime then boost’ combination of two vaccines, ALVAC and AIDSVAC, showed promise for ongoing vaccine development. The combination vaccines were tested on 16,000 uninfected volunteers, all at moderate risk of acquiring HIV. Volunteers were followed up for 3 years in the largest HIV vaccine trial to date. While the numbers of people who became HIV positive during the trial were small (74 people in placebo group, 51 in vaccine group), the risk of HIV infection was 31% lower for people who had been vaccinated compared with those who hadn’t. The news is both welcome and encouraging, but the positive results of this trial are also limited. The number of HIV positive individuals was small and although trends were maintained, differences were no longer quite statistically significant when the data were analysed ‘per protocol’. 

In other HIV/AIDS news, there were disappointing trial failures of the vaginal microbicide ‘Pro 2000′. Pro 2000 proved ineffective after large scale trials in some 9,500 women in 4 African countries.

Estimated number of new TB cases, 2008

Two billion people, or one third of the world’s population, are estimated to be infected with Mycobacterium tuberculosis, the bacteria which cause tuberculosis (TB). According to WHO’s Global Tuberculosis Control 2009 update report, in 2008 there were approximately 1.3 million TB deaths, and an additional 520,000 TB deaths among HIV positive individuals ¹.

TB is an airborne pathogen, transmitted after prolonged, close contact with coughing and sneezing infectious individuals. (It would be highly unlikely to pick up TB on the bus or train!)². After inhalation of airborne droplets containing the bacteria, M. tuberculosis generally moves to rest within the lungs, though infection of other parts of the body can also occur ³. 

With WHO’s Stop TB campaign, there appears to be global co-operation to dramatically reduce the world’s TB burden. Reaching 2015 milestones is amongst the Millennium Development Goals (MDG) (Target 6.c) to target HIV/AIDS, malaria and other diseases, including TB. Compiled with data from 198 countries and covering more than 99% of the global population, the 2009 TB report update provides evidence that deaths from TB are on track to be halved by 2015 (in comparison with 1990 rates), and will likely meet MDG targets. During the past 15 years, 36 million people are thought to have been cured of TB and 8 million deaths averted. In the past 12 months, 2.3 million people, around 87% of those treated, have been cured of TB and the global 2008 target for cure of TB has been exceeded by 2% ¹. While directly observed treatment, short-course (DOTS) program costs ranged from $100 to $5000 in different areas of the world, WHO considers this program the ‘most cost-effective approach in the fight against tuberculosis’.

In 2008, 9.4 million active TB cases were estimated to have occurred (up by 100,000 from 2007) and new TB case reporting rates (61%) fell 10% short of MDG targets. The majority of new cases occurred in Asia (55%), followed by Africa (30%), the Eastern Mediterranean (7%), European (5%) and American (3%) regions. In particular, India and China had the highest number of new cases (2 and 1.3 million), while approximately 450,000 new cases were each recorded in South Africa, Nigeria and Indonesia ¹.

Tuberculosis phases of infection, 2005 (Rook, Dheda, Zumla)

Of the 2 billion individuals infected with M. tuberculosis, between 5 and 10% become sick with disease. Previously known as consumption, symptoms including persistent cough, coughing up blood or sputum, chest pain, weakness, fatigue, weight loss, lack of appetite, nausea and fever characterise TB. The remaining 90% infected individuals show no disease symptoms and do not transmit the bacteria. For these individuals M. tuberculosis is not actively growing and dividing and the infection is referred to as latent. Distinctions between active and latent TB infections are both helpful and commonly used, but there is also evidence that these distinctions may not be so clear cut. Replicating bacteria are likely to persist during latent TB infections as are non-replicating bacteria during active infections ⁴.

During latency ‘infection is controlled, but the risk of disease is not eliminated’ commented Prof Douglas Young of the Tuberculosis research group at Imperial College, London. ‘We need to reduce the chances that someone exposed to TB progresses to active disease’. The ability to easily identify people facing an elevated risk of disease is limited. Better understanding of the biology and immunology of latent TB could not only provide opportunity to target individuals at greater risk of disease, but could also enable the development of treatments with which to better and more rapidly target the latent bacteria. In this way, rather than aiming to treat 2 billion TB infected individuals, Prof Young suggests that a ‘feasible treatment may be applied to a reasonably sized population’.

One major challenge to combatting TB is the development of bacteria which cannot be effectively treated with anti-TB drugs. Multidrug-resistant TB (MDR-TB) is resistant to at least two of the best, and universally used first line anti-TB drugs, isoniazid and rifampicin, and accounts for at least 11% of all active TB cases worldwide. In 2007, there were 131,000 MDR-TB cases reported in India, 112,000 in China, 43,000 in Russia, 16,000 in South Africa and 15,000 in Bangladesh ¹. Laboratory capacity to measure resistance must be enhanced in order to detect drug resistant TB. Extensively drug resistant TB (XDR TB) is a more extreme and rare type of drug resistant TB. It is resistant to first line treatment, plus fluoroquinolone and at least one of three second line drugs (i.e., amikacin, kanamycin, or capreomycin). Both drug resistant TB types require longer and more intensive treatment and have higher mortality rates than drug sensitive TB.

It’s not difficult to understand why there is poor adherence to TB drugs. ‘Once treatment has started, people normally become non-infectious after about two weeks and begin to feel better after two to four weeks, but at least six months treatment is required to cure the disease’.  With improper use of, poor adherence to and improper prescription of drug treatments, drug resistant TB will continue to spread, causing the cost and length of TB treatment to increase, and making TB more deadly.

So, there’s good and bad TB news in this update report. Many parts of the world are already meeting the 2015 TB targets. However, while the 2004 global peak TB infection rates are showing sustained decline, drug resistance is increasing and achieving 2015 MDG targets in South East Asia ‘will be challenging’ and ‘appear impossible’ in many African countries.

Robin Wood, Director of the Desmond Tutu HIV Centre at Cape Town University, South Africa recently commented that ‘TB treatment is failing in South Africa’. High HIV and TB infection rates are common within the population, but the drivers of the TB epidemic remain unclear.

The 2050 target to eliminate TB is ambitious. ‘The current pace of progress is far from sufficient to decisively target our goal of TB elimination’. Dr Mario Raviglione, Director of WHO’s Stop TB Department.

M. tuberculosis is thought to have originated at least 20,000 years ago ⁵. TB has devastated human health for centuries and in the mid 1800s was a leading international killer. Today, sustained investigative and intervention efforts will be essential to meet the challenges posed by TB to global public health.   

1. WHO. Global Tuberculosis Control: A short update to the 2009 report. 2009;    http://www.who.int/tb/publications/global_report/2009/en/

2. TB-Alert. Tuberculosis. Your questions answered. 2009;    http://www.tbalert.org/resources/documents/TBYQADec2007Re-print.pdf

3. CDC. Tuberculosis. Basic TB Facts. 2009;    http://www.cdc.gov/tb/topic/basics/default.htm

4. Gill WP, Harik NS, Whiddon MR, Liao RP, Mittler JE, Sherman DR. A replication clock for Mycobacterium tuberculosis. Nat Med 2009; 15 (2) 211-4 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779834/?tool=pubmed

5. Ernst JD, Trevejo-Nunez G, Banaiee N. Genomics and the evolution, pathogenesis, and diagnosis of tuberculosis. J Clin Invest 2007; 117 (7) 1738-45 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904327/?tool=pmcentrez

As 33.4 million people live with HIV/AIDS globally, there are many representatives from varied groups to act as spokespeople for the variety of lives touched and claimed by the HIV/AIDS pandemic. But HIV/AIDS continues to disproportionately affect the poor and the marginalised. The pandemic disproportionately affects sub-Saharan Africa. 71% of those living with HIV/AIDS live in sub-Saharan Africa, and mostly in Southern Africa. The nine countries with elevated rates (10-30%) of HIV are within Southern African region.

The launch of the 2009 AIDS Epidemic Update report in Shanghai on 24^th November was an occasion to acknowledge the 17% decline in new HIV infections over the past 8 years. Comparing rates between 2001 and 2008, in sub-Saharan Africa the reduction in new HIV infections was 15%, in East Asia 25%, and in South and South East Asia 10%. With this World Health Organisation (WHO) and UNAIDS report came the welcome news that the apparent peak of the pandemic is over. But passing the 1996 peak of 3.5 million new HIV infections does not mean the trend for this pandemic will now be a smooth slide downwards. The 17% decline in new HIV infections is indeed welcome news, and a result of difficult work by a host of varied workers and activists. But there remains much work to be done, and much awareness to be raised before this pandemic, which has spread so rapidly, and with devastating consequence, can really begin to abate.

It is not widely acknowledged that in Eastern and Southern Africa, HIV spread was not through promiscuity, but through a network of long-term concurrent partnerships. Uganda’s 1987-1992 ‘Zero Grazing’ campaign offered a model of grassroots activism with government support which was effective in limiting the spread of the pandemic. Heterosexual transmission of HIV is common. But this pandemic also disproportionately affects men who have sex with men (MSM). Ignoring or stigmatising these individuals will neither serve them nor the wider community. Either approach will mean that MSMs will not acknowledge and limit high risk behaviour, they will not learn their HIV serostatus and they will pass the virus to both homosexual and heterosexual partners. In Eastern Europe, 57% new infections occurred among drug users in 2008, but the focus of investment is has not been on this high risk group in this part of the world.

The WHO/UNAIDS 2009 AIDS Epidemic Update describes that an estimated 2.9 million lives are thought to have been saved as a result of antiretroviral use. In high income countries treatment has been widely available. The number of deaths averted in Western Europe and North America is 1.1 million, and similar to the 1.2 million in sub-Saharan Africa, ‘despite the much larger epidemic in sub-Saharan Africa’ (report p 17). Currently, more than 4 million people in middle and low income countries receive antiretroviral treatment; this 10 fold increase has come between 2003 and 2008, but still leaves nearly millions of individuals without hope of any treatment intervention. Last year 2.7 million new HIV infections were acquired and 2 million AIDS-related deaths occurred.

The launch of the 2009 AIDS Epidemic Update was an opportunity for WHO to praise their Chinese hosts for progress made in stemming the spread of HIV/AIDS. China’s low HIV/AIDS prevalence rates were described by Hiroki Nakatani, Assistant Director General of WHO, as ‘another example that China has shown to the world’. There are now reportedly 319,000 people living with HIV/AIDS in China; an almost miniscule prevalence rate for a country of nearly 1.5 billion people. However, it is also important to be mindful that for every officially reported HIV positive individual in China, 2 more are officially estimated to remain undiagnosed. Chinese HIV/AIDS social worker and activist, Zhao Chunki, speaking at the launch, described her own personal and working experience. She described ‘AIDS (as) the disease of those who love their children’, as villagers became paid blood donors in order to feed their families, they also became infected with HIV and began dying from AIDS. They left devastated homes, HIV positive infants and orphans. This moving experience gives the easier to swallow side of the pandemic. Current data shows that over 70% of HIV transmission China occurred by sexual transmission, with 32% of new infections last year occurring between men who have sex with men (MSM).

There are preventative strategies, proven to work efficiently and effectively to reduce the spread of this pandemic. The ‘Zero grazing’ and other grassroots awareness raising campaigns, condom use and male circumcision are known and important intervention which have proven efficacy in preventing and reducing the spread of HIV/AIDS. Removal of stigma and criminalisation around HIV/AIDS is also an essential component of effective prevention and intervention strategies.

So, why are some strategies so easily overlooked? Why aren’t existing preventative interventions being used effectively? Will new treatment interventions present the same implementation challenges and the same ill-fitting solutions as existing treatment interventions? Will the result be a failure to reach those most in need? 

Although there is much promise in new antiretroviral drugs treatments, at best new drugs will not be available for several years to areas with highest HIV/AIDS prevalence. While a vaccine which results is 32% fewer HIV infections is indeed a significant result, a vaccine with high efficacy remains a distant dream. Building awareness of how the virus is transmitted and supporting grassroots community activism is an effective intervention for stopping the spread of this pandemic today.

HIV/AIDS is sexy disease. Research is essential and there is money to fund it. However, HIV scientific research has been shaped by quests for high impact publications and prizes, with such concentration on proprietory research that the scale, impact and challenge of the pandemic has often been obscured. While the large bounty may still seem within reach for those who might crack the code with which to break HIV/AIDS, the mood of compromise does seem to slowly be reaching HIV/AIDS researchers. Possibly previous vaccine trial failures, and inability to fully understand what constitutes an effective immune response to fight HIV, will deepen lessons about the necessity of collaboration. Complementary societal, scientific, artistic and cultural tools will be required to beat this pandemic… there is no magic bullet. In many ways, the challenge of the HIV/AIDS global pandemic begins today.

1^st December 2009 is World AIDS Day.

Two patients have been discharged from the hospital, three patients are still being treated at the unit, one remains in critical care. The sixth patient was reported today; there is currently no update on the patient’s condition. Household contacts for all infected patients are being followed up. Test results for one additional patient who was in contact with the now 6 infected cases are imminent. However, all other patients in the unit have tested negative for H1N1.

In the USA, 4 Tamiflu resistant H1N1 cases have been confirmed at Duke University Medical Hospital. The cases have occurred over the past 6 weeks, and were recently confirmed by the Centers for Disease Control & Prevention (CDC). Like the UK cases, all Tamiflu resistant viruses came from an isolated ward of the hospital, and all patients had underlying chronic conditions. ‘Experts from CDC, State of North Carolina Public Health Department, Durham County Health Department, and the Duke Division of Infectious Diseases are now working to better understand the nature of these cases’.

These UK and US cases have all been treated with alternative antivirals, and it appears the spread of the particular drug resistant H1N1 viruses is contained. These cases emphasize that medical advice should be followed in using H1N1 antiviral medication. Drug resistant organisms can develop and spread rapidly.

H1N1 Vaccine Update:

The global rise of H1N1 continues. Currently over 526,000 infections and around 6700 deaths have been confirmed. The Americas account for 72% of all deaths with around 4800 reported deaths. In contrast, while 166,750 cases are confirmed in the Western Pacific region, there are lower mortality rates here than in the Americas; 613 deaths are confirmed in this region ¹.

Severe symptoms of pandemic H1N1 2009 can result in hospitalisation and death. Virulence factors could associate pandemic H1N1 infections with more severe disease; H1N1 virulence factors have not been reported. Epidemiological data continues to indicate that pregnant women, young children under 5 years of age and individuals with chronic underlying conditions, (including respiratory problems, obesity and diabetes) are at significantly greater risk of severe disease symptoms than the wider population.

Specific H1N1 (swine flu) vaccines are being administered, but apprehensions about pandemic H1N1 disease severity and vaccination are re-iterated around the world. Concerns abound regarding whether pandemic H1N1 disease risk is great enough to warrant vaccination. Unease about vaccine safety and effectiveness is also frequently expressed.

The World Health Organisation (WHO) estimates that 80 million doses of H1N1 vaccine have been distributed, and an estimated 65 million cumulative doses administered. H1N1 immunization campaigns are in progress in 40 countries and regions. Dr Marie-Paule Kieny, Director for the Initiative for Vaccine Research at WHO commented that H1N1 vaccines ‘include different products, inactivated (virus) with or without adjuvant as well as live attenuated vaccines.’ To date there has been ‘no significant difference in the safety profile between different types of vaccines‘.

One adverse event is reported for every 10,000 H1N1 vaccine doses administered. From these adverse event reports, 5 out of 100 are considered serious. Less than a dozen cases of Guillain-Barre syndrome, (which was associated with H1N1 vaccinations in 1976) have occurred in association with 2009 H1N1 vaccines. Guillain-Barre syndrome disease was transient and all patients recovered. No deaths have been associated with H1N1 vaccines. While there have been around 30 reports of death after H1N1 vaccine delivery, none have been directly associated with these vaccines. 

The goal of vaccination is to increase individual and population-level specific disease immunity, reduce illness and mortality rates, and slow the spread of specific disease. Timing of vaccination is crucial in determining vaccine effectiveness. Studies have shown that H1N1 vaccines can generate specific immunity and indicate that responses will be effective against H1N1 ^{2 3}.

With the scale of infection, it remains important that all antiviral treatment follow medical advice in order to reduce the development and spread of H1N1 anti-viral drug resistance. Dr Nikko Shindo, a Medical Officer in WHO’s Global Influential Programme recommends prompt antiviral treatment when flu symptoms occur, particularly for individuals in at-risk groups. Medical practitioners are also encouraged to prescribe anti-viral medication to individuals not among at-risk groups when persistent or rapidly worsening symptoms occur. Such symptoms include vomiting, diarrhoea, difficult breathing and high fever lasting more than 3 days.

Whether or not you choose to get vaccinated, you can implement other H1N1 disease reduction measures. Those predicted to be at greater risk of severe disease are encouraged to be immunized, but if all at-risk individuals rushed out to get the vaccine in the coming days and weeks, most would have a very long wait. 

1. WHO. Pandemic (H1N1) 2009 - update 75. 2009;

http://www.who.int/csr/don/2009_11_20a/en/index.html

2. Greenberg ME, Lai MH, Hartel GF, Wichems CH, Gittleson C, Bennet J, Dawson G, Hu W, Leggio C, Washington D, Basser RL. Response after One Dose of a Monovalent Influenza A (H1N1) 2009 Vaccine — Preliminary Report. N Engl J Med 2009;

http://content.nejm.org/cgi/reprint/NEJMoa0907413.pdf?resourcetype=HWCIT

3. Clark TW, Pareek M, Hoschler K, Dillon H, Nicholson KG, Groth N, Stephenson I. Trial of Influenza A (H1N1) 2009 Monovalent MF59-Adjuvanted Vaccine — Preliminary Report. N Engl J Med 2009;

http://nejm.highwire.org/cgi/reprint/NEJMoa0907650.pdf

Red blood cells, S Kaulitzki

Halloween is just as good a time as any, if not better, to consider sharing our essential fluids. Not only could vampires, zombies and perhaps other un-dead beings profit, but living beings could also benefit from a fresh batch of blood every now and then. Blood donations are essential for life saving blood transfusions, but with shortages in many countries, frequent blood drives are needed to encourage donations. Screening already suspect blood from donors may not only be detrimental to the donor, but also cost ineffective for the blood drive. However, blanket exclusions of large groups, including all men who have sex with men and individuals who have lived in certain countries, severely limits possible blood donors.

The UK recently began to re-assess the policy of excluding blood donations from men who have sex with men. Globally sex between men is estimated to account for up to 10% of Human Immunodeficiency Virus 1 (HIV) transmission, but in developed countries such as the UK and the US this proportion is thought to be much higher. 77,400 people are estimated to be living with HIV/Acquired Immune Deficiency Syndrome (AIDS) in the UK; 20,700 are thought not to know their status. 45,947 men who have sex with men have been diagnosed with HIV in the UK ¹. Men who have sex with men are the highest risk group for acquisition of HIV; particularly when sex is unprotected. In the UK, 63% of HIV infected men are thought to have acquired the virus through sexual contact with other men ²; this estimate is similar for the US. However, the numbers of men living with HIV/AIDS, particularly in developed countries such as UK and USA, are relatively few. The American Red Cross states also that you should not give blood “if are a male who has had sexual contact with another male, even once, since 1977“. A complete ban on blood donation from men who have sex with men may be unwarranted; as such the current UK policy review is welcome. Blood donation restrictions should reflect the risk of HIV transmission via blood transfusion, rather than historical fear and stigma associated with HIV. Policies need a basis in current evidence regarding the costs and benefits of excluding large proportions of the population from giving blood.

HIV is thought to have first infected humans during the end of the 19^th or beginning of the 20^th century. The HIV/AIDS pandemic is thought to have begun in the 1970s, before being identified in 1982 among gay men in the USA. During the 1980s and 1990s, HIV infections as a result of infected blood were identified in 32% of haemophiliac and blood transfusion recipients in the UK and 50% in the USA. There have also been a number of high profile individuals criminally indicted for blood supply safety concerns ³. Today, blood donations are routinely screened and tested specifically for HIV, and for other infectious organisms including hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and human T-lymphotropic virus (HTLV) ².

Blood bag, K Brofsky

I too have been among the bad blood ranks. My blood has been refused - twice! The first time was in the UK; I was anaemic - so it was for my own benefit. The second time, I was healthy and tried to make a donation in the USA. I was to learn that my blood was unacceptable to the New York blood drive, not because I had spent an extended period of time in a developing country, but because I had lived in the UK!

It’s suspected that thousands of people in the UK may be infected with a Prion protein which causes a rare transmissible spongiform encephalopathy, referred to as variant Creutzfeldt-Jakob Disease (vCJD). There is no reliable means to routinely test for the protein, and incubation periods could be up to 50 years. Mis-folding of the Prion protein is hypothesised to result in the characteristic neurodegenerative, fatal disease, vCJD. Consumption of beef and beef products from cows suffering from Bovine Spongiform Encephalopathy (BSE) is the proposed route of Prion disease transmission. There is evidence to suggest blood-borne transmission of vCJD, but I learned that the UK, followed by much of Western and Eastern Europe, is on the NY Blood Centre’s list of countries at risk of vCJD ⁴. 

In fact, because 129 cases or this rare and fatal disease were identified between 1996 and 2002 in the UK, it ranks top of the list of excluded countries. Six cases have been identified in France, and one each in Canada, Italy, Ireland and USA. Apparently I could be one of thousands harbouring the responsible mis-folding Prion protein ⁵. In which case, I have already incubated the protein for over 20 years. No matter that I haven’t eaten meat since around the time that the BSE was declared a notifiable disease in 1988.

I had expected to depart the blood donation clinic at least a little light-headed, having had a light sweet snack, and with the knowledge my blood would be shared with someone in need. I didn’t leave empty handed, but did leave a little shocked, having been turned away with a consolation prize mug. Still, I can take comfort that my blood is still good in other parts of the world and may not go to waste this Halloween night.

1. Noble R. United Kingdom Statistics Summary. AVERT 2009   http://www.avert.org/uk-statistics.htm

2. NHS. Exclusion of men who have sex with men from blood donation. Blood & Transplant Mar 2009   http://www.blood.co.uk/pdfdocs/position_statement_exclusion.pdf

3. Weinberg PD, Hounshell J, Sherman LA, Godwin J, Ali S, Tomori C, Bennett CL. Legal, financial, and public health consequences of HIV contamination of blood and blood products in the 1980s and 1990s. Ann Intern Med 2002; 136 (4) 312-9 http://www.annals.org/content/136/4/312.full.pdf+html

4. Countries at risk for vCJD. NY Blood Center 2009 http://live.nybloodcenter.org/files/Media/85/mediumFilename/vCJD.pdf

5. WHO. vCJD Factsheet. 2002    http://www.who.int/mediacentre/factsheets/fs180/en/