25 Years and Counting

This column was written in May, the month of this year that marks 25 years since the identification of the virus we now know as HIV, the human immunodeficiency virus. Surprisingly to some who may recall the rather bitter rivalry between the two, Robert Gallo and Luc Montagnier appeared together in Paris to mark the anniversary date by raising many scientific questions that remain unanswered.¹ While the discovery of the virus was hailed on front pages around the world, both observed that the continuing toll of the infection often goes unmarked. Dr Gallo was quoted as saying, "The [2004 Indian Ocean] tsunami made great headlines, as it should have––200,000 people died in one month, but every month, there's an AIDS tsunami––200,000 people die of AIDS. Do you think it gets the attention it deserves?" For some this may recall the slogans of the anti-tobacco campaigners who identified the tobacco-related deaths as equaling several airplane crashes every day, but without the parallel attention.

Policy columns written for daily publication (to say nothing of Internet blogs) have an immediacy that is not possible in a scientific journal such as The AIDS Reader. When picking up a morning paper, it is possible to see a pundit remarking (whether cogently or not) on political and public events less than 24 hours old. In today's world, immediacy has become the expectation: Like you, I want to know what is happening, everywhere on the planet, right now! Yet knowing about (or at least reading about) events going on thousands of miles away may or may not make me more likely do the right thing in my own world today, this week, this month, this lifetime.

Knowing that tens of thousands have just lost their lives in Myanmar may not prevent US homeowners from building in river flood plains or coastal dunes––disasters happen to other people, in countries without our resources, where the illusion of controlling nature is not so strong. Reading about the futility of walls built in China (centuries ago), Berlin (decades ago), or Israel (today) does not stop us from attempting to build a wall along our nation's southern border (by a government agency authorized by Congress to ignore any other laws that get in the way of wall building). Similarly, reading about how HIV infection continues to spread because economic limitations keep women in powerless sexual relationships or because the lack of adequate prenatal care ensures neonatal exposure has not forced policy makers to enact comprehensive prevention programs in the United States.

The scientific progress in understanding and controlling HIV has been nothing short of phenomenal, despite our impatience. But the current stagnation in vaccine development illustrates that progress in science does not happen at a uniform rate; that great successes are often followed by disappointments; and that, so far, human knowledge is never what we imagine it could be. Policy progress is yet more uneven. Periods of openness and commitment to education, inclusivity, and support are followed by periods of rigidity, limitations, and avoidance of unpleasant information. In the current political climate, no matter what the policy desires will be of the new administration in January, the economic reality of indebtedness acquired in recent years severely restricts any opportunity for new investment or even the potential for maintaining all HIV-related programs at their current funding levels. Yet in the face of budget shortfalls, Congress, in its wisdom, has decided to maintain support for our strategic mohair wool supply in the face of cuts in Medicare, Medicaid, and other health programs.

What will we be reading at the 50-year anniversary of the identification of HIV? Given our current level of "success" with other vaccine-preventable diseases; blood-borne, sexually transmissible infections; and other chronic conditions, we are still not where we should be. While we can point to the eradication of smallpox as a global triumph, the resurgences of polio and measles remind us just how difficult it is to achieve universal vaccination. The continued presence of syphilis, gonorrhea, and Chlamydia infection should be a sobering warning that human sexual activity is often based in drives and motives not accessible to a simple recitation of risks. And the continuing amputations and blindness secondary to diabetes, coupled with the rise of type 2 diabetes mellitus influenced by weight gain and lack of exercise, should drive us to completely reassess the way we approach the support of wise health choices in adults as well as in children.

The balance of political and policy choices over the next quarter century will be driven primarily by the general distribution of social preferences and economic engagement in our society. This includes decisions about HIV and AIDS, no matter how much we want them driven by science alone. The indications on the economic front are far from encouraging: the richest 10% of society have gotten increasingly richer, and the rest have barely held their own or grown poorer. Absent a vigorous middle class in America, our society is beginning to resemble a feudal society in which most are left with few choices, continued indebtedness, and a sense of futility, while those at the pinnacle of power enjoy unmeasured luxury. And if those who have power can buy whatever support they require or want, their sense of shared destiny with the wider society is severely limited.

Social engagement is an even more difficult process to understand. Polling data suggest that, overall, our society is beginning to understand the range of human gender experience and to realize that our sexuality cannot be neatly categorized into traditional roles. There is evidence that some courts are coming to the conclusion that setting up a 2-tiered system that recognizes legally bound couples is not acceptable. The most recent example is the California Supreme Court ruling that "domestic partnerships" are a form of discrimination, making marriage the rightful label for couples whether of different or same sexes. However, the emergence of "purity balls" during which fathers read a solemn vow to protect their teenaged daughters" chastity until marriage sounds rather medieval in tone and would appear to disparage the ability of daughters (disregarding sons) to make their own decisions even at 17 or 18.

Now is the time to loudly and clearly affirm that HIV policy is a long-term investment, not amenable to any quick fix or one-time investment. The scholars and scientists who work on the basic building blocks of HIV prevention and treatment need to know that money will be sustained, whether or not the movement toward a solution is immediately evident. The persons and families struggling to live with the disease need to know that doctors, nurses, pharmacists, and other health care workers will have the appropriate salaries, space, medication, and equipment day after day, year after year. And every child born anywhere on the planet each day for the next 25 years and beyond should be enveloped with care, support, and the message that he or she is a valued part of our human family, receiving all of the education, nurturing, and encouragement necessary to arrive at a healthy adulthood. These commitments would be a policy statement worthy of full political support from every spectrum of our shared lives.

References:

Reference1. HIV/AIDS experts call for new ideas, increased funding on 25th anniversary of paper identifying virus. Kaiser Daily HIV/AIDS Report. May 20, 2008. http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=52236 Accessed June 11, 2008.