Conant Foundation

Reprinted from UN Chronicle Online, Vol XLVIII, Number 1, 2011

“In the beginning, the AIDS epidemic struck like a thief in the night—suddenly, terrifyingly, and deadly. At first, there were a few cases of a rare malignancy, Kaposi’s sarcoma; then came the appearance of Pneumocystis pneumonia; and finally a plethora of opportunistic infections including systemic candidiasis, cryptococcal meningitis, and Mycobacterium avium–intracellulare—all rare diseases associated with this new mysterious, unknown, and unnamed spectre.

Infectious disease doctors had been predicting that mankind would completely conquer all infectious diseases, and that these ancient plagues would be eliminated at the end of the twentieth century. In just one generation from Alexander Fleming’s discovery of penicillin, the scientific community was able to develop antibiotics and antiviral medication to treat most of the world’s known infectious agents. Suddenly, out of Africa came a new infectious disease heretofore unknown and deadly. Society had just experienced and conquered Legionnaire’s disease and toxic shock syndrome, and most of us felt that the identification and elimination of this new scourge would occur quickly and decisively. None of us anticipated that 30 years later we would still be battling one of the most lethal infectious agents known to man.
As with every epidemic, this one went through the four seminal stages of societal response:

First, as always, was denial. Some countries, such as South Africa, denied that AIDS was even happening. Most countries, such as Saudi Arabia and Japan, felt it was something only happening to other people, and would not happen to them. But, of course, with every epidemic, it did happen to them.
Then came blame: it was the fault of gay men; it was the fault of promiscuity; it was God’s punishment for immoral behaviour. Some people thought that it would never happen to them because they did not have “those kinds of people” in their society. To their surprise, they did have those kinds of people, and it did happen to them.
Inappropriate legislation always follows a new epidemic. As one of the countries first and hardest hit by the epidemic, the United States passed laws to exclude HIV-positive individuals from entering the country—a classic case of closing the barn door after the horse has bolted. United States Senator Jesse Helms championed legislation which prohibited American scientists, paid for by the United States Government, from attending international meetings dedicated to understanding and treating the disease.
And finally, as in all epidemics, society lost faith in its institutions. Suddenly the American people found that the Food and Drug Administration was not doing its job to bring life-saving drugs to those in critical need of these treatments.

Institutions that had been established to address this very type of catastrophe were thwarted by bureaucracy, ignorance and fear. The Centers for Disease Control and Prevention were supposed to identify new diseases and take immediate action to ameliorate the spread of a new risk to society. These efforts were totally crippled by the Reagan Administration, which treated this disease as a criminal problem, rather than a medical one. The National Institutes of Health were supposed to devote funds to seek new treatments for emerging diseases: it took congressional investigations years of advocacy to remind them of their mandate. Blood banks in America were staffed by physicians who were hired extensively to protect the nation’s blood supply. Instead, these blood bank physicians joined hands and for four years denied that “those kinds of people” would even come to blood banks to donate blood. As a consequence, 28,000 Americans were infected with HIV through transfusion, and untold numbers of foreign haemophiliacs were killed by the export of American blood products.

Thirty years later, we have treatments for HIV, but the United States still has 56,000 new infections every year. Education and prevention programmes remain unchanged since the early 1980s, and are woefully inadequate. The United States Congress has vowed to cut funding even for the meagre education programmes that exist. Annually, 27 per cent of all new cases of HIV infection occur in women—a harbinger of a heterosexual epidemic still in its infancy.

To stop the AIDS epidemic in the United States, we need to acknowledge that the entire society is at risk and take the appropriate steps to stop the spread of this fatal disease. Everyone who comes into contact with the health care delivery system should be tested for HIV and other sexually transmitted, and potentially fatal, diseases. When an individual tests positive, he or she should be educated and offered life-saving medications, which have the additional societal benefit of reducing the transmission of the disease and, eventually eliminating infections from society. Finally, public health authorities should follow up with those individuals who are known to be positive and who are not taking antiretroviral medications, to educate and persuade them of the need to protect themselves and their intimate contacts.

Is there a lesson in this sordid history? Yes. The lesson is that social and political activism by individuals who clearly see a threat is essential in mobilizing local and regional governments to respond. Governments are necessary, indeed essential, and yet they are always mired in tradition. They suffer from the notion that the way we have always done it is the way it should always be done in the future. History has shown us, over and over again, that this approach will lead to disaster, and will change only if clear thinking, progressive individuals stand up and speak out. How many men died in World War I because the generals were unwilling to acknowledge that warfare had changed? How many civilians have died in Iraq and Afghanistan because the military failed to acknowledge that carpet bombing and killing women and children cannot win a guerrilla war? Why did people die from HIV-tainted blood? Because the blood banks were certain that their procedures were fail-safe and immutable. We will never win the war against HIV/AIDS by employing the same tired tools that have failed us in the past. We must stand up, speak out, and demand meaningful and compassionate government action.”

Dr Conant recently delivered a lecture, “How to Stop AIDS in America”, at the World Congress of Dermatology in Seoul, South Korea.

“What was true 30 years ago is no longer true today, and yet we’re caught in this time warp where we’re not changing how we approach the disease. My message really is what we were doing 30 years ago was applicable then, but it’s not applicable today.” – MAC

Original article from Internal Medicine News – 6/15/11

“SEOUL, SOUTH KOREA – It is time for a new strategy aimed at preventing HIV infection in the United States, an AIDS expert said at the World Congress of Dermatology.

This strategy ought to be built around universal testing, treatment starting at the moment of diagnosis, and public health monitoring of compliance, said Dr. Marcus Conant, a dermatologist at the University of California, San Francisco, who in 1981 was among the first physicians to identify AIDS and was a cofounder of the San Francisco AIDS Foundation.

The current prevention strategy has been in place since the 1980s. It is based on education about the use of condoms and other safe sex practices, along with voluntary testing for HIV – and it is simply not working.

Roughly 58,000 new cases of HIV have occurred annually in the United States over the past 15 years, with no drop-off trend. It is a prevention strategy that was developed when the epidemic was centered in the gay community. Now the epidemic is moving toward black and Hispanic individuals, who are poorly educated about HIV risk and don’t ask to be tested for HIV because they do not realize they are at risk.

“What was true 30 years ago is no longer true today, and yet we’re caught in this time warp where we’re not changing how we approach the disease. My message really is what we were doing 30 years ago was applicable then, but it’s not applicable today,” Dr. Conant said.

Today, one-third of HIV-positive individuals do not know they are infected. Another one-third are aware they are HIV positive but are not on highly active antiretroviral therapy (HAART), most often because they lack health insurance coverage. But it is the remaining third of HIV-infected individuals – those on drug therapy – who are of greatest concern, because only 19% of them have an undetectable viral load. The other 81% on drugs are potentially transmitting partially or totally resistant virus to their sex partners.

“It begs the question of how many years will it take until the virus in America is totally resistant to all of the drugs we currently have. We saw this happen with penicillin and Staphylococcus aureus. We’ve been there. We know this is going to happen. And yet we’re sitting here watching it happen and doing very little about it,” Dr. Conant said.

“With 58,000 newly infected individuals per year, and with only 19% of those being treated having undetectable viral loads, we are sitting on a prescription for disaster. Resistance is going to become a huge problem in the next decade,” he warned.

Recent studies have demonstrated that early initiation of HAART results in longer survival, fewer side effects, and better compliance. Plus, patients having an undetectable viral load are at lower risk of transmitting the disease to a sex partner. That is why Dr. Conant believes that stopping the HIV epidemic requires testing everyone, treating everyone who is infected, and monitoring all infected individuals in order to strongly encourage maintaining an undetectable viral load.

Everybody, regardless of age, who has blood drawn for any reason – a routine physical exam, pregnancy, induction into the military – should have that blood sample tested for HIV, he said. Pooled polymerase chain reaction testing of low-risk groups, such as women, could be done to make universal testing more economical. In any case, the pharmaceutical industry could easily foot the bill for universal testing. By identifying the one-third of HIV-positive individuals who do not know they’re infected, the drug companies stand to make a fortune in increased sales of HAART, according to Dr. Conant.

Current U.S. guidelines call for initiating HAART in HIV-positive patients with a CD4 count below 350 cells/mm³. But it makes more sense to begin treatment as soon as someone is found to be HIV positive, even though this practice isn’t supported by randomized controlled trial evidence. It’s better for the patient’s health, and it’s better for society because effective therapy stops transmission of the disease, he said.

All HIV-positive individuals could be logged into a computer-based tracking system so local public health departments could identify those who don’t have an undetectable viral load and visit them to find out why, Dr. Conant proposed.

He said he had no relevant financial disclosures.”