_AIDS: THE MILLENIAL BUG _
By: Elizabeth Kelly
AIDS: THE MILLENIAL BUG By: Elizabeth Kelly, SPN January 1, 2000 INTRODUCTION
At the beginning of the 20th Century it was believed by many, including the
United States Patent Office, that there was nothing else to invent. Now, 100
years later at the beginning of the new millenium the ancient Egyptian
philosopher is more relevant, "there is nothing new under the Sun". While
HIV/AIDS may be a new disease, there is nothing new about a novel epidemic,
which can potentially or actually decimate a population. In the late middle
ages, the Black, now known as the Bubonic Plague, swept through Europe killing
virtually half the population. It was introduced by a single or small group of
rats that came to Italy abroad a trading ship from what is now Turkey. Small
Pox transmitted by trade goods from the Hudson Bay Company wiped out entire
Native American tribes. There are other examples of diseases accidentally
introduced to a population that had no genetic immunity to them. Not to
mention NASA's fear of an unbeatable super virus from outer space. Now as in
previous diseases, one of the dangers of HIV/AIDS is not only in its plague
proportions but also in the almost superstitious misunderstanding of the virus
itselfIn the treatment of all illness, it is necessary to understand the
emotional, economic, psychological and sometimes even political impact that is
brought about by the disease. This is particularly true with a disease that is
as devastating and heretofore misunderstood as HIV/AIDS AIDS is the
punishment of God on sinners. AIDS is a plot by the CIA and the South African
Government to wipe out the population of black Africa. AIDS is the result of
medical experimentation during the development of the polio vaccine employing
the use of rieces monkeys as guinea pigs. AIDS is this, AIDS is that; AIDS is
the end of the world. There is nothing new under the Sun. As we enter a new
millenium, we are still controlled by prejudice, fear and superstition. AIDS
is not the end of the world, it is simply the latest challenge the medical
community needs to meet. There are new things to invent including an
immunization and cure for HIV/AIDS. But before that we must overcome the
age-old superstitious fears of the unknown and rise above the prejudices that
we harbor of, "those people". Let us understand HIV/AIDS AIDS, the acronym
for acquired immunodeficiency syndrome, is the end stage disease of the human
immunodeficiency virus (HIV). The result of this disease is the destruction of
the patient's immune system. Since the infected person has no ability to fight
off any infection because the virus is replicating in and destroying the cells
that normally fight infection, he/she then becomes susceptible to all
opportunistic disease. Ultimately death occurs as a result of the body's
inability to fight infection In the early 1980"sThe Center for Disease
Control and Prevention became aware that a new "virus" was effecting certain
segments of society. In 1985 researchers isolated a virus believe to be
responsible for AIDS. Since that time the definition of this disease has
changed many time. In 1993 the definition was expanded to include conditions
more applicable to women and injecting illegal drug users. The new definition
includes all HIV infected persons who have a CD4 cell count of 200 cells per
microleter of blood. Also added were three clinical conditions. The current
definition states that AIDS is an illness characterized by laboratory evidence
of HIV infection coexisting with one or more indicator diseases. Most patients
are diagnosed by these criteria HIV, as its name indicates is a virus and is
therefore and obligate parasite. Such parasites can only replicate while
inside another living cell, or host. Parenthetically, HIV carries its genetic
material in RNA rather than DNA, and while in the host the virus converts RNA
to DNA in order to replicate. In seeking hosts, HIV is typically attracted to
cells with CD4 + molecules on their surface such as T-helper lymphocytes and
similar cells. HIV reproduces at a phenomenal rate, which causes massive
destruction to the host cells. Cell destruction grows geometrically as the
virus replicates and seeks new host cells. Immune system breakdown primarily
results from the dysregulation and destruction of T-helper cells or
CD4+lymphocytes HIV is particularly sinister in its attack on T-helper cells
since one of the functions of those cells is to recognize and alert the immune
system to alien infections Initially the body's immune system, to a certain
degree combats the virus. However, since the virus virtually targets
CD4+lymphatics or T-helper cells, the immune system begins to loose its
ability to even recognize let alone defend the invading virus. The immune
system remains relatively healthy as long as its count of CD4 cells is greater
than 500 per microliter of blood. Since CD4 + cells are designed to attack
infection, they are ironically drawn to the virus where they are subsequently
infected. Ultimately the infection spreads through the lymph system and
lymphoid tissue becomes a reservoir for HIV replication. As the disease
progresses viral particles begin to enter the blood, this results in the
infection of body tissues where the virus begins to replicate in infected
macrophages. Massive reproduction of HIV in these cells causes the macrophage
to burst allowing HIV to infect surrounding tissues. The skin, lymph nodes,
CNS, lungs and possibly even bone marrow are infected in this manner. The
virus at this point is well on its way to infecting every organ and tissue in
the body The symptoms of HIV, while highly identifiable to the patient, are
general in nature and are attributable to any number of causes. Early signs
are consistent with flu like viruses. They include abdominal pain, chills and
fever, coughing, diarrhea, dyspnea, fatigue and headache. Later symptoms are
more severe and could be consistent with other diagnosis including cancer.
Some symptoms include disorders of the lymphatic system, malaise, muscle and
joint pain, night sweats, oral lesions, shortness of breath, skin rash, sore
throat, weight loss and disorientation. Additionally in the majority of HIV
cases there are neurological manifestations as well In addition to symptoms
preliminary diagnosis can be made by deduction in ascertaining whether or not
the patient engages in high-risk behaviors. If combinations of symptoms are
present and are accompanied by high-risk behaviors, then immediate clinical
testing is advised The individual's blood is tested with ELISA or enzyme
immunoassay (EIA), antibody tests that detect the presence of HIV antibodies.
If this test is positive than the same blood is tested a second time. If a
second EIA test is positive a Western blot is performed. This is a more
specific confirming test. Blood that tests positive to all three screenings is
reported to be positive for HIV. IF the results are inconclusive or
indeterminate, the tests are repeated in 4 to 6 weeks. Again, if repeated and
the results remain indeterminate a culture is done to determine the viral
load, this is done through testing the DNA of the individual. These tests,
whether positive or negative does not confirm nor dismiss the diagnosis of
AIDS. That is done according to the 1993 CDC definition of HIV. A negative
test is not an assurance that the individual is free of HIV since
seroconversion takes up to three months after initial infection. And if the
individual continues to engage in risky behaviors, transmission of the disease
is likely to occur At the present time it is believed that the modes of
transmission of the HIV virus are clearly identified and understood. Although
generally perceived by the public as a sexually transmitted disease, the
method of HIV transmission is far broader than simple sexual contact. As
previously stated an obligate virus HIV requires a host organism to survive.
Once leaving the human body the virus is extremely fragile and cannot survive
outside of a host. Thus, HIV is transferred from person to person through
infected body fluids including blood, semen, cervicovaginal secretions, breast
milk, pericardial, synovial, cerebrospinal, peritoneal and amniotic fluids.
It has been discovered that not all body fluids, which contain HIV, transmit
the virus. These fluids include saliva, urine, tears and feces. Further, the
ability for HIV to be transmitted via an infected fluid from one human to
another is mitigated by a variety of variables such as duration and frequency
of exposure, the amount of the virus inoculated and the virulence of the
organism. The efficiency of the immune system is also a factor. Once the virus
has been passed to another individual, the newly infected individual then is
immediately capable of passing the virus to yet another individual. However,
there are apparently cycles when the probability of transmission is greater
than others. The greatest potential for transmission occurs immediately after
infected and during their end stages of the disease. Nonetheless, it must be
stressed that it is possible for HIV to be transmitted at anytime during the
entire disease spectrum As a practical matter, the most common method of
transmission of HIV is through sexual contact. Vaginal and anal intercourse
are two of the three most common modes of HIV transmission. Throughout the
world it is believed that 75% of the total AIDS cases were the result of
sexual contact. Anal intercourse is the most frequent method of HIV
transmission. This being the result of the frequent tearing of the rectal
mucosa which allows for direct infusion of the infected semen into the blood
stream In all cases of intercourse the receptive partner is far more
susceptible than the insertive partner. This is not only true of anal and
vaginal intercourse, but also for oral intercourse as well. HIV can also be
transmitted through oral genital sexual contact but such cases are considered
rare. The homosexual community was seriously impacted by HIV in the early days
of the epidemic. This was the result of the tendency for unprotected and
casual sexual encounters as well as a higher tendency for anal intercourse.
The prostitution subculture was and still is seriously impacted by the HIV
virus. Causes of this include their numerous and varied sexual encounters,
pre-existing sexually transmitted diseases in addition to life style issues
such as alcohol, smoking and illegal drug use which weakens the immune system.
Undoubtedly, the most powerful form of transmission from one human to another
of the HIV virus is through direct blood transfusions employing infected
blood. However, this has resulted in a miniscule number of cases. But the
accidental or intentional use of contaminated injecting equipment is the third
most common method of HIV transmission. The frequency of transmission being in
the deliberate and repeated use of contaminated syringes by infected persons
generally occurs in users of illegal drugs. These users typically share
syringes and or other improvised injecting paraphernalia. While any illegal
drug can be injected, heroine and cocaine are the most widely used injectable
illegal drug Less frequent forms of HIV transmission are vertical
transmission and occupational exposure. Vertical transmission occurs when a
mother, either during pregnancy, at time of delivery, or after birth (through
breast-feeding) infects an infant. Occupational exposure is considered to be
rare but does occur. Studies ending in 1996 found 52 documented cases and
another 111 cases of possible occupational transmission. These cases, by
enlarge, involved health care workers who acquired the disease after
percutaneous injury, mucocutaneous exposure and exposure through open wounds.
Most of these cases involve puncture wounds from needle stick type injuries.
In addition to health care workers, at risk personal include police officers,
fire fighters, military personal and prison employees. Since often the
infectious contact is the result of elective human behavior, there are
strategies for preventing the continued spread of HIV virus. At the center of
these strategies is education which must be world wide, multileveled,
intercultural and, of course, non-judgmental. Modifying behavior through
education would include teaching safe sex practices, including stressing the
proper and consistent use of effective condoms. Similarly for the person who
continues to use injected drugs, the use sterile needles must be taught.
Deactivation of HIV requires only a 30-second exposure to 100% bleach.
Instruction in the cleaning methods used to deactivate HIV should be done.
Education without resources can only achieve marginal results. Therefor,
although problematic and controversial it is necessary after education to
provide easy and in most cases free access to condoms, sterile needles, early
HIV testing and follow up medical treatment As discussed, while most but not
all HIV transmission is the result of risky behavior, there are other causes
of transmission as well. Prevention then must entail education, discipline and
procedures to minimize infection through transfusion and safety procedures to
prevent accidental transmission to people engaged in certain occupations such
as health care workers. On this last point herein lies another controversy
which is beyond the scope of this paper. That subject deals with what level
should a person who is living with the HIV infection have his/her medical and
or other records reflect that fact. At what point is the individual's right to
privacy negated, if ever, in regards to the individuals who are charged with
caring for the infected person The public at large uses interchangeably the
terms HIV and AIDS. This sloppy inaccuracy is one of the basis for the gross
misunderstanding of the disease. HIV is divided into two categories; type I,
which is found throughout the world and has resulted in most of the reported
cases of infection, and type 2, which is localized to Western African coastal
nations and areas outside of Africa which have commercial and cultural
relations with that region. HIV infection ultimately leads to the disease of
AIDS. But it is not AIDS in and of itself Within one to three weeks of
initial exposure seroconversion occurs. This is the detectable development of
HIV antibodies. While the virus is usually detectable, acutely veril and can
be passed along, the infected person shows few or no symptoms. From the
initial exposure period or roughly from two to six months flu like symptoms
will appear in the infected person. The individual will begin to develop
antibodies to fight the infection. The individual will frequently appear to be
acutely ill. Well before the end of the first year the HIV infection will
become asymptomatic. (It should be noted that during this period of time the
disease is not dorment but is systematically destroying t-helper cells).
During this phase, which will last perhaps into the eighth year of infection,
the infected individual will manifest no symptoms of disease. But,
nonetheless, will be infectious. Between the eighth and tenth year of
infection symptoms of HIV disease will manifest After ten to fourteen years
HIV disease advances into its terminal stage which is known as AIDS. This
stage is epitomized by the body's inability to fight any infection. Thus any
infection is potentially fatal to the AIDS patient. In no way to make light of
the subject, it is reminiscent of the turn of the century novel by HG Wells,
"War of the Worlds". In this first science fiction story that deals with an
alien invasion of earth by undefeatable machines, human bacteria proves lethal
to these unstoppable forces. Similarly, the most mundane infection is a
potential lethal agent to the AIDS patient. However, some opportunistic
infections are more frequently associated with AIDS patients than others. Of
these opportunistic infections the most frequently encountered are those that
are respiratory in nature, particularly pneumoncystic carinii pneumonia and
Kaposi's sarcoma. Interestingly, prior to the discovery of HIV/AIDS these two
diseases were extremely rare and the dramatic increased occurrence of chronic
ailments lead to the discovery of HIV/AIDS. While respiratory system diseases
or organisms are most typical other OI can, with fatal consequences strike
AIDS patients. The OI can attach any of the body's systems including the
integumentary, gastrointestinal and neurologic systems. For any of these
diseases a variety of diagnostic tests are appropriate and similarly with each
disease a variety of treatment regimes have been established. However, there
is no cure for AIDS. This is not to say that in the early stage of the disease
the OI may be successfully resolved. But in the final analysis the OI that
strikes the late stage AIDS patient will at some point become fatal There
are several drugs that are available for the treatment and management of
opportunistic disease associated with AIDS. Prophylactically used these
medications have contributed to the decrease morbidity associated with HIV
infection. The individual must take these medications throughout their lives
to attempt to control the opportunistic disease as the body's immune system
degenerates. These drugs are more effective if used in combination with each
other, combination therapy has become the standard of care. These "cocktails"
are more effective than single drug therapy. Since patients have become
resistant to many drugs over the long periods of time they must take them,
studies have shown that combinations of antiviral drugs may reverse the
resistance that has taken place. However, the side effects of these
medications are severe, at best Nucleoside Analogues: zidovudine is the drug
of choice to be used initially in combination therapy. Side effects of
headache and nausea usually resolve within one month. Other side effects can
be more serious such as granulocytopenia, thrombocytopenia, seizures, bone
marrow suppression and anemia. Some of these side effects only occur after
long term use. This class of drugs inhibits replication of HIV virus by
incorporating into cellular DNA thereby terminating the cellular DNA chain.
Didanosine, which is in the same classification and acts the same as
zidovudine but is used in patients who cannot tolerate zidovudine. Life
threatening side effects are pancreatitis, peripheral neuropathy, seizures,
CAN depression, leukopenia, granulocytopenia, thrombocytopenia and anemia.
Other treatable side effects are nausea and vomiting, diarrhea, abdominal
pain, constipation, stomatitis, liver abnormalities, oral thrush and many more
usually resolve in a month. These drugs must be taken around the clock to
maintain a therapeutic blood level Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTIS) a class of drugs which binds directly to reverse
transcriptase and blocks RNA, DNA conversion causing a disruption of the
enzyme site. Nevirapine is used in combination therapy along with other
antiviral drugs. Side effects include but are not limited to; rash,
thrombocytopenia, fever, headache, nausea, hepatitis, myalgia, etc. The
patient must be instructed to report any rash immediately since a rash may
progress to Stevens-Johnsons syndrome, which may result in death Delavirdine
is in the same class of drugs as nevirapine. This drug interferes with DNA
synthesis that is needed for viral replication. Some side effects of the drug
are; fatal metabolic encephalopathy, blood dyscrasias and acute renal failure.
Common side effects are nausea and vomiting, headache, vaginitis, rash and
elevated LFT's. Again, this drug is used in combination therapy Protease
Inhibitors, another class of drugs inhibits HIV protease, which prevents the
maturation of the infectious virus. Saquinavir is generally well tolerated
because of low absorption rate. This is used in combination with nucleoside
analogues, NNRTIS and other protease inhibitors. Side effects are; pain, rash,
diarrhea, buccal mucosa ulceration, abdominal pain, nausea, parathesia,
headache and hyperglycemia. This drug should not be used in children,
pregnancy, lactation and with caution in patients with liver disease The
patients must understand that adherence to the drug regimes is extremely
important since inadequate adherence can lead to drug resistance and
ultimately drug failure. There is little question that early detection is
essential to optimum therapeutic management. An obvious benefit of early
detection would be corrective treatment of other sexually transmitted
diseases, tuberculosis and immunization against the onset of OD and viruses.
Lastly, it must be recognized that often life style issues and high-risk
behaviors have seriously damaged and weakened the AIDS patient's immune system
and health prior to onset of AIDS. Therefore, along with medication life style
adjustment is an intricate part of AIDS treatment. Cessation of risky
behavior, abstinence from alcohol, tobacco and illegal drugs is essential
aspects of the treatment program. Additionally, it is believed that an
interdisciplinary approach incorporating acupuncture, massage therapy and
other non traditional remedies may be useful if only in raising the mental
attitude of the patient. Interestingly AIDS may be the vehicle for western
medicine to entertain more seriously the various treatments of non-traditional
therapies, if only to underscores the relationship between health and a
positive attitude. CONCLUSIONS In 1985 AIDS was viewed as an immediate
death sentence, and a horrific one at that, to the infected person. There was
apocalyptic terror that this epidemic could wipe out mankind. Now, although
there is still no cure for AIDS, education and other aggressive actions are
stemming the spread of the disease. On an individual basis, the length and
quality of life of people living with the AIDS virus is dramatically
increasing. Medicine will ultimately conquer AIDS and with the confidence of
having done so, medical practitioners will be better prepared and equipped to
meet the next plague when and if it comes.
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