by Francis X. Hezel, S.J.
July 2007 (MC #68) Health
We can't say we haven't been warned. For several years now posters have been screaming at people in the islands to beware of HIV/AIDS. Drawings of open graves and death skulls that paper the walls of our hospitals and health centers provide a chilling warning of the human toll that this epidemic will exact once it strikes the islands. Conferences on the dangers of HIV/AIDS have multiplied, local health teams have been formed to combat the danger, and health officials here and abroad have issued a red alert to the public.
The public seems to have regarded HIV/AIDS as a distant threat, something along the lines of global warming and sea level rise, which will trouble us someday if we're not careful. People have been slow to grasp the fact that HIV is already with us. The issue is no longer keeping the disease from gaining a foothold in the islands; in point of fact, the virus has been present for some 15 years already.
Now that islanders, belatedly, are beginning to accept the fact that the virus they once regarded as remote a life threat as a poison snake bite has come to roost in the islands, reaction in some quarters has become shrill and insistent demand that every measure be taken to protect others from contracting the virus, even if this means exposing those who currently are HIV-positive.
At a workshop on HIV/AIDS that I attended not long ago, some of the participants called for health authorities to release the names of HIV victims to the public. Their argument was that people have a right to protection, no matter what burden this places on the sufferers. The hidden assumption here, it seems, is that those with HIV have only themselves to blame for the virus since they brought it on themselves by irresponsible behavior. Health officials, on the other hand, do not share this assumption, for they know that HIV strikes the virtuous as well as the promiscuous, faithful wives as well as faithless husbands. Moreover, they are adamant in their insistence that the confidentiality of the patients be respected, even when their standards of privacy seem a trifle unrealistic in a tight island society. Health officials may also fear reprisals, such as those visited upon some of the first HIV victims in the islands years ago.
But the most compelling case health officials make is that outing the known cases won't help very much, if what epidemiologists say is true when they state that for every reported case of HIV, there are an estimated ten unreported cases. If this is the case, announcing a register of HIV patients will leave the waters nearly as dangerous as they were before. In a presentation on HIV in the Pacific, this was represented by a slide showing a crocodile gliding through murky waters with only the eyes and a bit of the snout exposed. The real danger lurks beneath the surface-the vast majority of HIV victims who don't even know they have the illness. If they themselves don't know-and perhaps don't want to know-how can we hope to protect their sexual partners?
The danger of HIV/AIDS went unrecognized for a long while. Now that the virus is known to be with us, the public appears to want some assurance that they can be protected. The method that some islanders strongly espouse-publicizing those known to be infected-is regarded by health officials as unacceptable. Meanwhile, the type of protection the latter have advocated up to now-widespread distribution and use of condoms in all segments of the population-is just as repugnant to many island communities. When one foreign medical consultant visited one island in FSM to urge stronger attempts to get condoms out to the youth, she met with a hostile reaction from community leaders who believed that this would only condone sexual promiscuity among the young.
It's high time that we developed a sensible strategy for dealing with HIV/AIDS in the islands, one that is factually informed and embraced by all major parties. But to do this, we will have to review what we know about the HIV/AIDS epidemic and the medical advances that have been made in halting its spread and offering relief to those who have contracted the virus. And that is the purpose of this article.
No one knows for sure just how AIDS was introduced into humans. One theory is that the virus came from Africa, where it was passed from monkeys or chimpanzees to humans. In any case, the first manifestation of AIDS occurred in the US in 1981, when gay men in New York started turning up with a disease known as Kaposi's Sarcoma and others in Atlanta began exhibiting a rare form of pneumonia. This set of symptoms was not the disease itself, we would discover, but simply a result of the weakening of the human immune system. Once the immune system was weakened sufficiently, the patient was vulnerable to what were otherwise rare diseases. A healthy immune system, of course, would have easily protected victims from such diseases.
At first, AIDS was associated with homosexuality and called the "gay cancer." Before long, however, medical researchers began to associate the disease with other small groups: hemophiliacs, or people who were "bleeders" and required blood transfusions, as well as heroin addicts who injected the drug with a needle. Haitians immigrants to the US were also believed to be at high risk. Hence, AIDS was associated for a time with the four H's: homosexuals, hemophiliacs, heroin users and Haitians.
Within a year or two, medical researchers began to notice that the disease could be transmitted through heterosexuals as well. AIDS was no longer simply a gay disease. It could be passed on in other ways as well-through normal male-female sexual relationships, and even from mother to child. It was clear that the virus somehow got into the bodily system through transmission of bodily fluids from one person to another, sometimes through blood transfusions or the use of an infected needle, but most often through sexual intercourse.
Just two years after the initial outbreak of AIDS, French doctors were able to isolate the virus that causes AIDS. This virus was labeled the Human Immunodeficiency Virus, or HIV. It is transmitted through direct contact with the bodily fluids of someone who is already infected with HIV. Given enough time, HIV will weaken the immune system of the human body-the protective system in the white bloodcells that guards the person against disease and infections. When the system is sufficiently weakened, AIDS (Acquired Immune Deficiency Syndrome) will result. At this point, the protective system in the body is weakened to the point that it can provide almost no resistance to infections. With the protective system of the body disabled, the person is vulnerable to any opportunistic infection, whether pneumonia, a rare disease or some ordinary infection. In a person without the normal resistance, such infections often cause death. AIDS victims, then, normally die of infections they have picked up when HIV has weakened their system to the point that it is no longer able to protect them.
During the early years of the AIDS outbreak, there was little that doctors could do to help those who developed the disease. There was no immunization available to protect against the virus and no medicine that could lead to the recovery of those afflicted with AIDS. Meanwhile, the world watched in helpless horror as the number of AIDS cases multiplied each year. In 1986, according to figures provided by WHO, there were 44,000 cases worldwide. A year later, the number of reported cases had almost doubled. By 1989 there were 142,000 cases, and in 1991 the number of cases stood at 450,000. By 1994, there were a reported 985,000 cases. The following year the number jumped to 1.3 million AIDS cases.
But these were just the reported cases-the tip of the iceberg, according to WHO estimates. For every reported case, there were many others who had contracted the disease but had not been diagnosed with it. The rule of thumb used by medical researchers was that for every person who had been discovered to have the disease, there were ten others who were still undetected.
The number of persons infected by HIV was growing exponentially. By the end of 1993 there were an estimated 2.5 million cases around the world. By 1994, the estimated number was 4 million. In 1995, the estimate was put at 6 million. By the end of 1997, according to the UN AIDS Program, the number of people infected by HIV throughout the world was even higher than was previously thought; accordingly, the figure for HIV-infected persons was revised upward to 30 million. By 2000, the number was put at 40 million, which is where the figure still stands today.
The effects were horrifying. By the late 1990s, an estimated 2 or 3 million people were dying each year of AIDS. During that decade alone, some 13 million children had been orphaned by the disease, many of them in Africa.
Since 2000, the advance of HIV has slowed in most highly developed countries, thanks to the general awareness of the danger of infection. Even so, the UN AIDS program reports that there are 14,000 new HIV infections each day, most of them occurring in low and middle income countries. Nearly half of those infected are women, it should be noted.
Just a few years after its first outbreak in the US, HIV/AIDS had become a Pacific problem as well. There were just a handful of HIV cases in the Pacific in 1985, but five years later, 250 cases had been reported. The number has skyrocketed since then. In 2000, there were more than 4,000 identified cases in the area; and by 2005 there were over 11,000 people with the virus. The vast majority of the HIV infections-over 10,000 people-are found in Papua New Guinea, where an estimated 2 percent of the population is now HIV-positive. The other hotspots in the region are New Caledonia with 272 reported cases, French Polynesia with 243, and Fiji with 182.
The Micronesian region has seen a similar sharp increase of HIV infections in the past ten or fifteen years. In 1990 there were a total of about 40 reported cases. By 2000, the number jumped to 200 reported cases in the region, a large number of them on Guam and in Kiribati. Today there are about 170 known cases in Guam itself, with close to 50 in Kiribati and 25 in the Northern Marianas. There are 36 people in FSM known to be infected with HIV, 8 in Palau and about 10 in the Marshalls. Yet, these relatively small numbers belie what seems to be a growing epidemic in these island groups.
Although there is no way of knowing the number of full-blown AIDS cases in the area, we do have reliable data on the deaths resulting from AIDS in FSM. As of October 2004, 18 Chuukese had died of AIDS-related illness; eight of them were living abroad, either on Guam or Hawaii, when they passed away. These Chuukese deaths include four infants, who contracted the virus perinatally, and four adult females. Three Kosraeans, including one of the first persons in FSM to be identified with the disease, have also died of AIDS. Pohnpei lost one person to AIDS prior to this time, but three others, all from the same family, died just last year. Yap has just one recorded fatality due to AIDS.
When we add to these 26 fatalities the 3 who have died in Palau and the 2 in the Marshalls, we can appreciate what it means when health educators warn us that it is futile to try to keep HIV/AIDS out. It is not an impending danger; it is a disease that has struck the islands and puts everyone here at risk.
Since there is relatively little danger of contracting HIV through infected needles, since intravenous drug use is a negligible problem in this part of the Pacific, and since blood used in transfusions is carefully screened, the assumption is that the HIV virus will generally be passed on by sexual intercourse. Aside from the relatively cases in which the virus is transmitted from mother to child, this assumption is no doubt correct. Accordingly, sexual transmission was to be the battleground for the war against HIV/AIDS.
The standard prevention strategy throughout the Pacific has been what is called the "A-B-C Approach": Abstinence, Be faithful to your partner, Condoms. Who can argue with the first line of defense or with the second? Abstinent individuals are at almost zero risk of getting HIV. Likewise, persons who confine their sexual activity to a single partner (assuming, of course, that the partner is equally faithful) have very little chance of contracting the disease. The problem, of course, is that a large proportion of the population-perhaps much larger than many of us are willing to admit-fall outside the A and B categories.
Youth, for instance. According to a sample survey done in FSM three years ago, nearly half of all high school students had already engaged in sexual activity, and 20 percent of the total sample had a total of four or more partners. I think it's safe to say that adults, too, at times stray from the path of virtue. As in any community, there are a few who make a name for themselves by their sexual adventures, but even persons who could not really be called promiscuous can easily slip into extramarital activities now and then. It's not just sex workers-the women who slink down to the port when the fishing boats are at anchor or the bar girls with a reputation for offering customers a good time when work is done-who are at risk for HIV. It's a very large portion of the population.
Condoms, then, were seen as the last and most critical line of defense against the spread of HIV in the islands. If the appeals to abstinence and fidelity to a single partner went unheeded, then people had to be provided with what was needed to ensure "safe sex." Thus began the campaign to promote condoms-the CondoMan figure on billboards everywhere, the distribution of condoms to dispensaries, schools and public centers, and the public education program to urge safe sex.
But not every island community was enthusiastic about this approach. People in some places regarded the widespread distribution of condoms among the young as little more than an invitation to promiscuity. Youth, with their raging hormones, were all too ready for sexual adventure anyway, but equipping them with condoms was seen as a green light to engage in sexual conduct that the community frowned upon. A young health consultant, who had traveled to one island to enlist the support of people for a safe sex campaign, was dismayed to find that she was soon at odds with the local church and community leaders over her program. Far from uniting the community behind the "safe sex" banner, she ended up engaging the community in battle.
An even greater problem, though, lies in persuading people to use the condoms. Notwithstanding the crusade to promote safe sex, it appears that the use rate for condoms is discouragingly low. A behavioral survey conducted by CDC in 2001 in one state of FSM revealed that only 13 percent of those persons with multiple sexual partners used condoms all or most of the time. Young men on the prowl for a female companion at night might bring a flashlight and plans for an escape route if discovered with their companion, but it's doubtful they will bring along a pack of condoms. Unplanned sexual encounters, which seem to be common enough everywhere, offer an even greater challenge to safe sex. If the use of condoms is to be the last line of defense in the battle against the spread of HIV, the forecast for the outcome of the battle doesn't look particularly bright.
It may be time to change our strategy in the battle against HIV/AIDS. Rather than rely entirely on promoting the use of protected sex, we might want to take the measure of that crocodile lurking somewhere beneath the surface of those murky waters. If we can successfully promote testing for cervical cancer and sexually transmitted infections, other sensitive diseases, why not do the same for HIV? To mount a successful testing program in the islands, however, we will have to undo much of the wrong-headed public education on HIV that has relied on naked fear tactics and has had the unintentional result of stigmatizing the disease and those who bear it. It's time to tear down those posters of open graves and death skulls and begin to take a more realistic and hopeful approach to combating the disease.
While HIV remains a fearsome threat, it is no longer the death sentence that it was twenty years ago. When the early AIDS epidemic first struck the US in the early 1980s, there was no cure at the time, no medication that was effective in treating the disease. AIDS was incurable and those who suffered from it were outcastes, seen as a danger to the all others in the community. In one well-publicized case, a 13-year-old American child who had contracted AIDS through a blood transfusion was banned by school officials from attending class for fear that he would somehow transmit the disease to other students.
By the late 1980s, however, medical research produced its first results. In 1986 the first blood test for the virus was licensed in the US, and a year later an early drug (AZT) was proven to slow down the progress of HIV in a patient and improve the patient's chances of survival. By late 1989 the cost of AZT was reduced substantially and a new drug (DDL) became available. Just a few years later, in 1992, the first combination therapy was used in treating AIDS when AZT and DDC were taken together to provide greater effect against the virus. This is the treatment that was prescribed for Magic Johnson, the Los Angeles Lakers basketball star who was diagnosed with AIDS in 1991.
As more medical advances were made during the early 1990s, there were encouraging signs that the damage done by the virus might be eventually checked. By 1997 New York City saw significant declines in rates of infection and death due to the efficacy of combined therapy for HIV. AIDS deaths were halved from the previous year and rates of mother to child transmission were dramatically reduced.
With the development of the new generation of antiretroviral drugs during the past ten years, even greater steps have been taken to reduce the threat of HIV/AIDS. In 2003 the new drug Fuzeon, when injected into a patient, could prevent entry of the virus into the cells. It was also used as part of a combination therapy. Two years later a new drug (Nevirapine) was discovered that could prevent transmission of HIV from an infected mother to a child. Just last year, Atripla, a single pill combining three different drugs in a single daily dosage, was marketed. Not only did it make it easier for patients to follow their daily drug regimens, but it reduced some of the nasty side-effects of the earlier generation of drugs.
Medical science has come a long way in the prevention and treatment of HIV/AIDS. Although there is still no effective immunization against the virus, the new generation of antiretrovirals has proven more effective in checking the effects of the HIV virus so that it does not develop into full-blown AIDS. Moreover, the drugs can be purchased more cheaply and taken far more easily. In the early 1990s, the drug cocktails that were prescribed for AIDS victims were so large they would have filled a lunch pail and each pill had to be taken in exact order every day. In 2006, the drugs had been improved so much that the patient only had to take one or two pills once each day, while most of the unpleasant side-effects had been eliminated.
Life expectancy for those who contracted HIV has steadily increased due to medical advances. According to one medical report, HIV-positive individuals who could expect to survive for seven years back in 1994 could look forward to about 22 years of life by 2000. Even those whose HIV has developed into AIDS need no longer despair. A medical journal article reported that the lifespan from the time of AIDS to death was increased eightfold between 1998 and 2001, and by another factor of eleven between 2001 and 2003. Not only are those with HIV living longer and more productive lives, but even those who have developed full-blown AIDS.
A few months ago I attended a presentation on HIV/AIDS in the Pacific offered on Pohnpei by a regional team of experts that opened my eyes to how far medical research had advanced in the past ten or fifteen years. I like to think of myself as reasonably well informed about such matters. Yet, if I was taken by surprise at what I heard, I wondered how many others, like me, may continue to view this health problem through the lens of the past. Many of us are aware that normal heterosexual relations accounts for most of the HIV infections today in the Pacific, but we may be ignorant of what can be done to treat the infection.
This information should offer us a new perspective on HIV. Those who have contracted the disease are no longer to be seen as walking corpses, persons for whom there is no reasonable hope of a normal life and who constitute a menace to the rest of society, as lepers were once regarded before the discovery of medical treatment for Hansen's disease. Lepers were once forcibly separated from their families and sent to isolated colonies-to Molokai in Hawaii, where Fr. Damien worked, and even more recently to Tinian during early post-war years-until medical advances and a clearer understanding of the disease made such treatment obsolete. In the same way, we can hope that better information on HIV will remove the stigma associated with this condition.
New research has produced drugs that are capable of allowing a person infected by HIV to live an active life, not just for months or a few years, but over a normal life span. Many of us who attended the recent Pacific-wide HIV/AIDS workshop on Pohnpei were surprised at the number of participants who declared that they were HIV-positive; some even admitted to having full-blown AIDS. Many had lived several years with their condition and were all looking forward to many more years of life. They were living testimony to the success of the treatments that medical science has uncovered, proof that individuals with the HIV virus can live long and productive lives-providing their condition is discovered early and treatment is provided.
But the key to successful treatment is early detection. If the HIV virus is detected early and suppressed by drugs before the virus does serious harm to the immune system, the patient can live for a very long time. This is the hope offered to patients today by the new generation of antiretroviral drugs.
Will an individual who might be at risk for HIV brave public opinion to be tested, knowing full well that confidentiality can not be guaranteed since there are no secrets on a small island? Yes, if the stakes are high enough. If the person believes that he can acquire medicine that will protect him from the worst effects of the virus and enable him to live many more years. The point of testing, after all, is not to identify HIV infected persons to keep them from contaminating others, but to diagnose an illness so that means can be taken to remedy it. If we want to persuade people to be tested, then, we will have to ease up on the fear campaign that has ruled in the past.
With the help of regional and global organizations, Micronesia is in the final stages of establishing the capacity for doing HIV testing. The laboratory equipment and supplies are in place and medical personnel have been trained to do the preliminary screening test. A second test, if required to confirm initial findings, would be sent out to Hawaii or the Philippines for analysis.
For those who are discovered to be HIV positive, antiretroviral drugs are now available for little or no cost, thanks to the support of the Global Fund. We were told at a presentation on HIV/AIDS in late 2006 that the generic drugs can be purchased for as little as $300 a year. This was surprising to many of us who still thought that a year's supply of drugs for the virus could run into the tens of thousands of dollars a year, as might have been the case when Magic Johnson was first being treated. Moreover, doctors are being trained to understand how the drugs interact with one another so that they can monitor the effects of the drugs on their patients and alter prescriptions as required.
The last steps are being taken to establish a testing program everywhere in Micronesia and to provide the drugs needed to treat those with the virus. All that is needed now is people to step up to be tested. Eventually, the HIV test will probably be added to the routine battery of blood tests that are done in the course of a medical examination. Until then, however, the success of HIV testing will depend on the willingness of people to submit to an examination for a disease that has been stigmatized and so makes them objects of suspicion in the eyes of the community. Given the stakes, however, health officials are betting that people will step forward to be tested. Most people who develop AIDS and do nothing to treat the condition die within a year. On the other hand, anyone infected with HIV who is treated quickly enough live indefinitely with the effects of the virus suppressed.
Who should be tested? Certainly those who have had sexual relations with several partners-sex workers, nightcrawlers, bar girls and those men who enjoy their company-but not just them. The man who got lonely for female companionship on a trip to Hawaii last year ought to check in. So should his wife, and perhaps any other wives who aren't entirely certain that their husbands have eyes only for them. Perhaps it's just safer to say that anyone who engages in sexual intercourse, with a single partner or many, should be tested.
After all, it's better to be safe than sorry. Only by testing can the virus be detected early and so permit treatment that will offer the person a long and normal life. Testing will also alert the person to the risk of communicating this virus to others. Testing will allow you to protect yourself as well as those you love.