Newsday - August 16, 2001
Laurie Garrett, Staff Correspondent

"We are at a transition point in HIV prevention in so many ways," Dr. Helene Gayle said in her closing remarks to the 3,000 health workers attending the Second National HIV Prevention Conference here yesterday. "We don't have to go far to see the impact HIV is having on our lives. It's all around us."

Gayle is soon to retire as chief of all AIDS-related programs at the Centers for Disease Control and Prevention.

She and dozens of other speakers described a classic public health paradox: What is good for the individual is not always what's best for the society as a whole.

Because of combination drug cocktails used for treating HIV since 1996 in America, the number of Americans staying alive, and potentially infectious to their sexual partners, has increased steadily. But because of a host of nasty side effects and cumbersome drug adherence problems, with time it gets harder for individuals under treatment to maintain their safe sexual practices. And evidence regarding just how infectious a person on HIV treatment may be is highly contradictory.

Dr. Tom Quinn, of the Johns Hopkins Medical School in Baltimore, sparked hope in HIV prevention circles that anti-viral treatments for individuals could stem the spread of the disease. His work in Uganda with African scientists found a correlation between viral loads and the risk of transmitting HIV sexually. Quinn and his colleagues followed a large number of Ugandan couples in which one partner was HIV-positive, the other uninfected. Over time, they found, partners whose viral loads exceeded 50,000 HIVs per milliliter of blood were 12 times more likely to infect their spouses than were those whose viral loads were less than 1,500 viruses per milliliter of blood.

Based on Quinn's findings, published last year, a team of 138 Harvard faculty called for widespread treatment of HIV-infected Africans, arguing in part that that would help slow the continent's epidemic.

Yesterday, however, Dr. Kenneth Mayer of Brown University warned at the conference that Quinn's findings might not be relevant to treatment because the Ugandans were not receiving treatment. Their viral loads were low because the individuals' own immune systems were somehow managing to control the virus, and that might have relevance to how infectious they were.

Nevertheless, this week Quinn suggested that widespread use of anti-HIV drugs might slow the U.S. epidemic if every single American whose HIV viral load exceeds 10,000 viruses per milliliter of blood were on effective drug treatment.

That will be a tall order, as studies presented at the conference show that about 30 percent of infected Americans are unaware they carry the virus.

This week the CDC's Dr. Michael Campsmith reported the results of surveys of 18,150 HIV patients from 12 regions, including New York City. "Forty percent were diagnosed with HIV within a year of going into frank AIDS," Campsmith said in a news conference. "Which means they went a decade without treatment." The finding indicates that these people first learned they carried HIV about a decade after they became infected. The virus develops into AIDS about 10 to 11 years after first infection, if the individual is not treated.

And that's a decade during which their viral loads probably often exceeded 10,000 HIVs per milliliter. Any hope of using treatment to prevent HIV's spread rests with figuring out how to get that 40 percent diagnosed and treated far earlier.

There, too, findings are disturbing, according to Leo Hurley of Kaiser Permanente, the nation's largest HMO. A review of the charts of 434 of the 12,000 HIV-positive individuals enrolled in the Kaiser system found that 44 percent weren't diagnosed until they had actual AIDS. Examination of old charts revealed that many of the patients had signs of early illness that were missed by their doctors. And in some cases the physician recommended an HIV test years earlier, but the patients refused.

The importance of the Kaiser findings, Hurley said, is that, "even with access to quality health care, HIV may go undetected for years."

This flies in the face of long-held assumptions in the AIDS community that late diagnosis and treatment were because of poverty and lack of access to health care. Dr. Carol Ciesielski of the Chicago Department of Public Health surveyed 1,024 men who were treated for syphilis in the city's clinics between January 1998 and December 2000, 83 percent of whom were heterosexual. Despite the fact that sexual behavior can make one vulnerable to syphilis and HIV, a third of the heterosexual men and a fourth of the gay men with syphilis had never had HIV tests.

Cornelius Baker, who runs the the Whitman-Walker Clinic, the largest HIV services organization in Washington, D.C., spoke of his "mixed emotions, conflicting data about where we are ... ."

Baker concluded, "I'm not quite clear what we're saying and what the overall impact is going to be with time. As we pursue this discussion of prevention, we have to think about the impact it will have on people's lives. ... We are at a crossroads."

Baker, along with representatives from the National Association of People With AIDS and four other national AIDS treatment groups, endorsed the CDC's plan to slow the American epidemic to 20,000 new infections per year by 2005, at an estimated cost of $300 million per year.

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