Tuesday, June 5, 2001


Epidemic has only begun spreading its global devastation

Sabin Russell, Chronicle Medical Writer,  from the SAN FRANCISCO CHRONICLE


Twenty years after doctors in Los Angeles reported the first cases of AIDS, the devastating epidemic that followed in the United States is becoming a footnote to a larger story of global catastrophe.

Since June 5, 1981, when University of California at Los Angeles immunologist Dr. Michael Gottlieb and colleagues described five cases of rare pneumonia among gay men, AIDS has killed nearly 450,000 Americans -- including 18,600 in San Francisco alone.

Yet two decades into the epidemic, the outbreak of AIDS in America turned out to be just a foreshock, an early warning of a worldwide pandemic the likes of which have not been seen since the Black Death of the Middle Ages.

HIV, a tiny virus that destroys key blood cells of the human immune system, is only beginning its worldwide rampage.

"Relatively speaking, this is still a new disease," said Dr. Helene Gayle, director of HIV prevention for the federal Centers for Disease Control and Prevention in Atlanta. "And it's going to get worse before it gets better. . . . Clearly, the global dimensions of this disease are staggering."

The epidemic is relentlessly expanding. Twenty-two million already are dead.

Thirty-six million are believed to be infected. In sub-Saharan Africa alone, 25 million are living with HIV. Six million are infected in India and Southeast Asia. AIDS rates in the Caribbean are the highest outside Africa, and the disease is making inroads in Latin America, China and the nations of the former Soviet Union.

AIDS is leaving a legacy of orphans. According to the United Nations, there are 13 million AIDS orphans in the world today, 95 percent of them in Africa.

One year ago, President Bill Clinton declared HIV to be a threat to national security. On June 25, the United Nations will convene an unprecedented special session of the General Assembly on AIDS.


Public health experts have been documenting the global spread of HIV since the early 1980s, but for years the world paid scant attention. That changed last July, when the 13th International AIDS Conference took place in Durban, South Africa, where more people are living with HIV than any other nation on earth.

"Durban was instrumental in bringing this issue into the open and showing the inequity of the situation," said Dr. Anne-Valerie Kaninda, medical adviser for Doctors Without Borders. "Ninety-five percent of the people with HIV live in the developing world and do not have access to treatments."

Doctors Without Borders was among a handful of activist organizations that began a campaign to slash the price of AIDS drugs for impoverished nations hard-hit by the epidemic. A year's supply of AIDS drugs in the United States costs $12,000 to $15,000, impossibly out of reach for people in nations where annual health spending is only a few dollars per person.

But in two remarkable years, political pressure on the U.S. government and a competitive threat from producers of low-cost knock-off versions of AIDS drugs have dramatically improved the odds that AIDS treatments will reach millions who previously had no hope.

A core of American legislators, some of them tested in the early years of AIDS, are also turning their attention to the global threat.

"We could see a total wipeout of generations in sub-Saharan Africa," said Sen. Dianne Feinstein, who was mayor of San Francisco when the epidemic began. "The global AIDS problem is a crisis. We have to meet it with education and drugs at the cheapest possible prices."

Feinstein has repeatedly introduced legislation that would allow poor nations to sidestep patents on AIDS drugs to ensure a supply of low-cost generic medications.

Yet even at the $350-a-year price quoted by Indian drug maker Cipla, treatments will remain out of reach for millions, and drug expenses are only part of the cost of treating AIDS. Medications are all but useless where there is no clean water and no money to pay for the simplest blood tests. Without a vaccine, prevention efforts remain the best hope of curtailing the epidemic.


In April, U.N. Secretary General Kofi Annan put a price tag on the problem - - $7 billion to $10 billion a year -- and called on wealthy nations to contribute to a global fund to fight the epidemic.

When President Bush responded with a pledge of $200 million, U.N. AIDS officials were publicly grateful, but the amount seemed shockingly low to AIDS activists.

"It's beyond being insufficient. It's an insult. It's immoral," said Eric Sawyer, a New York activist who has worked closely with the international effort to lower the costs of AIDS drugs.

Sawyer said that 20 years of AIDS has been a tragedy of missed opportunity. "We were sending out a call to arms in the gay community 20 years ago," he said. "At that time, the number of cases was in the hundreds." But it took a ballooning death count, and the passing of celebrities such as Rock Hudson, to stir America out of its indifference.

Now, the world is paying attention to the implications of a global pandemic,

but it may already be too late, Sawyer said: "In India, there are three to four people sharing beds in hospitals, and two or three more on the floor, waiting for their shift. . . . This is not an old epidemic. It is just starting. In 20 years, we could be talking about a billion cases of AIDS."

Current efforts to bring cheap AIDS drugs to Africa are highlighting how medical technology has become a new measure of the great gap between rich and poor.

"HIV continues to point its finger at everything that is wrong with our society," said Tom Coates, director of the University of California at San Francisco AIDS Research Institute.

In the developing world, AIDS is thriving in an environment where health services are minimal, and the plague is accompanied by other diseases such as malaria and tuberculosis, as well as famine and warfare.

AIDS in the United States began among gay white men and remains largely confined to homosexuals, drug users and their sexual partners. In Africa and the rest of the developing world, AIDS is a heterosexual epidemic, and young African women bear the brunt of new infections.


Still, the epidemic in Africa at its core shares a fundamental trait with those that are occurring in Western nations: AIDS is a slow killer that works its way through populations long before the first signs of illness.

Gottlieb sensed this 20 years ago, when he identified the first cases of a previously unknown disease. Two decades later, he is still chilled by its stealthy efficiency.

"This is a deadly and tricky virus that takes advantage of our blind spots, " he said. "It works the blind spots in the human immune system and the blind spots in human consciousness. It plays on denial."