GLOBAL AIDS EPIDEMIC DRAMATICALLY OUTPACES U.S., ACCORDING TO EMORY AIDS EXPERT

Thousand of AIDS patients in the United States and Europe have escaped death and debilitating illness over the past few years due to the advent of HAART (highly active anti-retroviral therapy). The new drugs were responsible for a 47% reduction in mortality due to HIV in this country from 1995 to 1997, according to the Centers for Disease Control and Prevention. These optimistic statistics are in shocking contrast, however, to the devastation resulting from the worldwide AIDS epidemic.

As of the end of 1998, 34 million people around the world were estimated by the United Nations to be living with HIV. In reality, points out international AIDS expert Carlos del Rio, Emory associate professor of medicine, HIV worldwide is not just one, but a whole group of individual epidemics, each with its own characteristics. And despite the tremendous success of protease inhibitor drug therapy in the United States and Europe, HAART is almost completely irrelevant to HIV anywhere else in the world, he says. Even reduced-price drugs are unlikely to make a significant dent in the AIDS epidemic worldwide, 95% of which is concentrated in developing countries. Dr. Del Rio recently outlined the global AIDS problem to a group of Emory physicians.

The heaviest burden of HIV disease is in sub-Saharan Africa, Asia and the Indian subcontinent. Of the 2.5 million people who died of AIDS in 1998, 2 million of them lived in sub-Saharan Africa. "In many countries in Africa, the adult population has been almost totally wiped out," said Dr. del Rio. "The epidemic in South Africa did not exist until shortly after Apartheid, when the country opened and migration began to occur. Now between 8 and 16% of South African adults ages 15-49 are infected with HIV and about 50% of pregnant women are infected."

India is currently the country with the highest number of HIV-infected people, with an epidemic fueled mainly by injection drug use, prostitution and trucking. Almost 40% of the prostitutes in India are HIV infected. In China the epidemic is just beginning, but the prevalence of HIV has grown more than 100% in the past few years.

"With the number of people living in China, the epidemic there could quickly reach dramatic proportions compared to Africa, where the population density is much lower," Dr. del Rio pointed out. And preventive measures like condom use would be impractical in China because the world supply of condoms would simply not be adequate for widespread use.

The consequences of HIV in developing countries extend far beyond health concerns, Dr. del Rio said. A country's economy, productivity, national security and education all are severely affected by HIV. Many countries must make hard economic decisions about whether to devote money to AIDS care or to education. The cost of treating one patient with HIV is generally about the same as the cost of educating 10 children. The widespread death of young adults to AIDS creates a shortage of workers and soldiers, leaving countries poor and defenseless.

Life expectancy has been seriously affected by HIV throughout the world. In Cote d'Ivoire, for example, the life expectancy of an adult has dropped approximately 11 years due to the impact of AIDS. In Brazil it has dropped 3.5 years and in Botswana and Zimbabwe it has dropped 10 years ­ from 60 to 50. The rise of adult mortality in Africa has affected the health of non-HIV infected children also, many of whom have lost their parents and must live either alone or with very elderly grandparents. These children often do not receive adequate health care and they die from vaccine-preventable diseases. Many of the health gains in children from vaccination over the past 10 years have now been lost to AIDS.

In Mexico, where Dr. del Rio was director of the national AIDS program before coming to Emory two years ago, AIDS played only a minor role in mortality among young people in 1988. By 1992, however, it was the third most common cause of mortality among men ages 25-44.

One major step in stopping the global spread of AIDS is halting mother to child transmission through the use of antiretrovirals administered in the last weeks before birth.

At the current rate of infection, said Dr. del Rio, it would take eight years for the number of children born with HIV in the U.S. to equal the same number of HIV-infected children born in one day in other countries around the world.

Targeted prevention programs such as increased condom use among soldiers and commercial sex workers and strict monitoring of the blood supply have had dramatic effects on halting the spread of AIDS in countries such as Thailand.

Emory's commitment to preventing the spread of AIDS internationally is growing dramatically along with its increased programs and funding for AIDS research. Dr. del Rio and his colleagues have joined Emory's multi-faceted Tbilisi Exchange Program, in which Emory physicians led by Kenneth Walker, M.D., professor of medicine, have for many years worked with Tbilisi physicians on health exchange efforts. Dr. del Rio has conducted two studies recently in Tbilisi on adolescent knowledge of HIV and on concentrations of infectious diseases within different populations. Even though the Republic of Georgia currently has only 61 HIV cases, since the fall of Communism the number of cases of syphilis and the use of injectable drugs has exploded, leaving Georgia vulnerable to a major HIV epidemic, Dr. del Rio said.

Under Dr. del Rio's leadership, Emory received funding last year as an AITRP center (AIDS International Research Program) with three international collaborators: the National Institute of Public Health in Mexico, the Georgian AIDS Clinical and Immunology Research Center in Tbilisi and the National AIDS Program in Vietnam. Over the next five years Emory will train two postdoctoral fellows and eight masters fellows and provide training in the U.S. and in the collaborating countries.

"Emory is set to play a major role not only nationally but internationally in stemming the AIDS epidemic," said Dr. del Rio. He recalled the words of Jonathan Mann, the international AIDS leader killed in the recent Swissair Crash: "When the history of AIDS and the global response is written, our most precious contribution may well be that at the plague, we did not flee, we did not hide, we did not separate ourselves."

GLOBAL AIDS

• Approximately 34 million people worldwide are living with HIV
• 90% of AIDS cases are in developing countries
• More than 2.5 million people died of AIDS in 1998
• 5.8 million new AIDS infections occurred in 1998
• Almost 14 million people have died of AIDS