Professor Peter J Mc Donald
Microbiologist and Infectious Diseases Physician
Conference Paper: AIDS – Have we got it Right?
A conference organised by The Australian Doctors Fund Ltd.
Hosted by Professor Fred Hollows & ADF Chairman Dr. Bruce Shepherd
Sheraton Sydney Airport Hilton
May 14th and 15th, 1992
Mr Chairman, this presentation reflects my personal views and not necessarily those of the CARG which I chair nor of ANCA with whom I have been privileged to work for the last 3 years.
The first point I wish to make is that AIDS is the end-stage of infection caused by HIV and that we must follow the principles of I.D. control in containing this pandemic.
There is currently misleading intellectual joust that HIV unrelated to AIDS and that AIDS is a consequence of lifestyle factors that are confined to gay men, drug users and persons from the third world. This contention ignores the clear evidence that HIV in blood products has infected thousands world-wide, that progression of disease with HIV is directly related to virus-induced changes in the immune system, and that anti-retroviral (HIV) treatments have, slowed the progression of disease and prevented death for many years.
The key factor about HIV is that it is a virus that is transmitted by private behaviours and that the traditional approaches of Infectious Disease control aimed at the prevention of transmission by aerosol (as with T.B.) or by fecal-oral spread (as with typhoid) are wt directly applicable to HIV.
HIV is related to AIDS in the same way that mycobacterium T.B. is related to tuberculosis. Tuberculosis is a disease carried by the body’s reaction to the mycobacterium and only a small percentage of people infected with mycobacterium T.B. actually develop tuberculosis. The control of Tuberculosis requires control of the mycobacterium. AIDS is a disease caused by the body’s reaction to HIV and there have been fluctuating views as to the lethality of HIV. In 1986 (slide) there was a perception, based on reasonable scientific grounds at the time that HIV was a retro-virus that had moved into the human race as a single mutation from primates and that HIV would behave like most viruses. Most viruses and bacteria do not kill the host they infect: this is not in the long term interests of survival of the virus or bacterium. T.B. is a good example of a bacterium that infects many people but causes serious illness and death in only a minority of the people who are actually infected – as demonstrated by scars on chest x-rays or a positive skin/mantoux test.
It was therefore not unreasonable to say in 1986 that HIV infection would not always progress to AIDS. Many in this audience will recall predictions that only 5 – 10% of HIV infections would progress to AIDS and great emphasis was placed on identifying those lifestyle, nutrition and therapeutic strategies that would boost the immune system to resist the virus progressing to AIDS.
In the event it became clear that HIV progressed to AIDS in a large proportion of infected persons. This conclusion was based on the type of analyses shown in this next slide where the only longitudinal studies of various cohorts of infected people that have been conducted would not have been analysed to show that after 8 years from infection, between 20% and 50% of infected people will have progressed on to AIDS. (Now) Once AIDS is established I think there is general agreement that death from HIV will ensue although newer treatments are retarding death.
The important factor I wish to convey from this slide is that the predictions from these studies have been translated into a perception that all people infected with HIV will die prematurely with AIDS in contrast to the 1986 prediction, that projected that only a small proportion of HIV infected people would die of AIDS.
The truth undoubtedly lies somewhere in between: my own bias is that some people infected with HIV over 10 years ago are remaining well and that there may be some survivors – of the order of 10% – 20%.
I present these facts to underscore a major difficulty in the AIDS debate – namely a propensity to jump to conclusions in the absence of sound information. I think there is a public and oven professional propensity to seize upon those scientific and pseudo-scientific interpretations that support particular views, fashions or attitudes that are not justified on the basis of the, actual data.
We should acknowledge that there are several unresolved issues in relation to HIV/AIDS. It is crucial to take these into account when devising policies to manage the epidemic. These unresolved issues are depicted on the slide viz:
- mechanism of lymphocyte depletion
- strain variation
- infectivity
- proportion of survivors
- impact of treatment on, infectivity
Given the imperative of stopping transmission of a lethal infectious agent that is spread by private behaviours that are not able to be constrained by the traditional/conservative approaches to I.D. control of aerosol and fecal/oral transmissions and given the uncertainties referred to in the slide it becomes easy to understand how particular groups may seek to hijack the policy agenda.
The position I would like to develop is that there are enough facts about HIV to develop firm policies for control of spread that recognise – the principles of I.D. control whilst taking account of the variable/unknown factors, and the social context within which infection is spread in Australia. An additional point is that the Australian clinical, social and epidemiological networks are well placed to answer some of these questions and to continue to provide international leadership.
The principles of I.D. control are illustrated on this next slide and I would like to comment on each
- Identify infectious
- Prevent transmission
- Change circumstances that foster spread
How do these translate into HIV in Australia – and have we got it right?
In terms of identifying infected and infectious you have heard about the epidemiology strategy and how we are in a position to concentrate on those who are infected and their direct contacts.
A key factor in the epidemiological network is the testing programme which has been criticised because of the lack of compulsion. In fact 3.5 million tests have been done per year in the last 2 years and this has lead to the present state of knowledge about where infection is in Australia. The key factor which is being pursued by EAC is to ensure that sentinel testing of key risk-groups is sufficiently comprehensive. This I can assure you is receiving priority attention and the emphasis is on achieving comprehensive testing in the most appropriate way. The fact that this is being achieved in a climate of respect for individual rights and insistence upon consent is a tribute to those involved and an indication that community involvement in programmes may actually achieve greater penetration than compulsory programmes.
A note of caution should be raised about individual doctor-driven testing. At Flinders Medical Centre I was surprised to note that 36% of all HIV antibody tests were for ante-natal patients and more such patients were tested for HIV than for Rubella. This is because of a policy that does not repeat Rubella tests in those with a previous high titre.
This sort of information begs the question – Are we testing the right people? I cannot fully answer this question but I suspect that we are doing too many tests on the wrong people(like elderly ladies having hip replacements) but I am comfortable with the efforts of the Epidemiology Advisory Committee that is responsible for ensuring that adequate surveillance systems are in place, and there is a strategy paper available to members of this audience who wish to be provided with details.
The second principle – namely preventing transmission from those who are infected is the area where most success has been achieved. This has been largely dealt with by other speakers and I only wish to underline the importance of having easily accessible treatments so that those at risk can be exhorted to seek testing and are in treatment programs they can participate in specific education programmes that contain spread from such people.
The third principle – and the arms where we must now place emphasis whilst maintaining the initiatives previously outlined, are listed on this slide. There are the difficult ones that require major professional and community change if we are going to the early success of the HIV/AIDS strategy.
Since others are addressing these issues I will concentrate on the major barriers that I believe need to be addressed.
Firstly the infrastructures for I.D. had been largely dismantled by 1980 and we have had to set up entirely new I.D. structures for HIV – a good example is epidemiology. This next slide compares the physicians in I.D. with other speciality disciplines. Why have we failed to train sufficient numbers of I.D. physicians? Perhaps more importantly, why have we accorded second class status to venereology in terms of training, practice and professions recognition? To the best of my ability I am only able to identify 45 practising venereologists in the country. It is no good complaining about difficulties in treating HIV/AIDS as an infectious disease without providing staff and training to support programmes. I.D. and venereology must receive a high priority.
Further barriers in HIV are the poor level of HCW education and practice of I.D. This is related to the small numbers of staff and the paucity of education in the area. Perhaps this explains the substantial difficulties in applying universal precautions.
Sex and discrimination are being addressed by other speakers but I would like to highlight a major barrier that I perceive, and that is the difficulty of planning and implementing strategy in a rapidly changing environment. The only solution is to promote good communication and consultation and to be prepared to adapt to the new circumstances. This is difficult to achieve, in a rigid health system and amongst an essentially conservative medical profession.
How can we move forward?
I believe that research is a key and I will briefly outline the situation with Commonwealth AIDS Research.
- About 9 million or 10% of the NH&MRC research allocation is spent on AIDS research. Very little other money goes to AIDS research unlike the situation with cancer, heart disease, paediatrics and the like where there are major foundations supporting research.
- All grants are subjected to external review using experts from the NH&MRC assessors lists and no grants have been funded where the scientific rating was less than NH&MRC equivalent rating.
- There are 3 national research centres that are independently evaluated by assessors experts.
- CARG members are excluded from receiving grants.
- Especially in the last year, many projects have been curtailed after evaluation and this has lead to some public protestation of foul play, cronyism and biased assessment by those who have been disenfranchised. I would welcome any scrutiny of the CARG granting process in terms of fairness, scientific merit and relevance to the goals of the overall strategy.
- One particular difficulty I would share with you is the problem of commissioning research in priority areas by allocating funds without ensuring that feasible research protocols have been developed. In the early years of AIDS research, some groups and individuals were provided with funds to develop research programs. When we came to evaluate the success of commissioned research it became clear that some programs were not achieving aims and that predicted events which did not come about such as the probable movement of HIV into IDU meant that some projects could not proceed. It has therefore been necessary to revise directions, and this process of redirecting research on the basis of changing knowledge has created angst amongst those people who have not been able to adapt to the change.
The actual allocation of funds is outlined on the next 2 slides.
- The three national research centres each received in excess of 1 million each in calendar 1991. About 10% of the research budget is allocated to fellowships or training and 3.5 million to projects.
- The number of applications and financial allocations in project grants are indicated on this next slide. I would like to draw your attention to the small proportion of grants funded in relation to the actual number of applications shown in brackets.
Is there enough money for research? and how should It be managed? Yes and No.
I have been disappointed that some major research groups have not focuses on AIDS research for example mucosal immunologists, health economists and social historians. I do not believe this is entirely due to a lack of funds but more a lack of resolve or commitment. In the long term I believe AIDS research should be mainstreamed into standard research system – but not until programs have been consolidated and the credibility of AIDS research firmly established.
Have we got value for the research dollar? The answer must be yes because AIDS research has set up essential epidemiological clinical and social programmes that have underpinned the success of AIDS control to date in Australia – if I had more time I could go into specifics.
I would like to conclude by indicating those areas where we need to focus to go into the stage of HIV control beyond condoms and needles. These are listed on the slide and they are self evident.
The key issues we need to emphasise and these are already underway are
- To identify and study those who are being newly infected. Hence the M.S.M. campaigns and research emphasis which opens up possibilities of assessing treatments and preventive strategies that are directed to the important groups responsible for transmitting HIV.
- Contact tracing that is sensitive to civil rights is now becoming possible as the infrastructure in venereology and S.T.D. is being reinforced. This area requires more attention.
- We need to work out which education actually works and this process is now just becoming possible.
- Finally many important reforms in the health system are occurring around HIV/AIDS. I can point to the major changes in drug approvals and TGA that have been achieved by AIDS initiatives, there is now a new recognition of patients rights within the health system, the involvement of the community in health policy and implementation, defining the balance between individual and public welfare and developing optimal structures to provide compassionate and cost-effective care for chronic conditions. These have all emerged around HIV. Most important of all is the insight that HIV control is providing for prevention of illl-health that arises from private behaviour and amongst marginated and discriminated groups in our community.
My concluding plea is that the lessons learned from HIV/AIDS should he extended to the health care system as a whole. Otherwise our effort will be wasted and we will lay ourselves open to explosion of diseases like T.B. and Syphilis in New York which are both eminently treatable conditions in the traditional medical model but they only spread because the disenfranchised communities rebel with anti-social and unhealthy behaviours.
Locking people up in prison for drug offences has not reduced the drug problem – and prison is quarantine. We need to recognise that the solution to social problems that produce disease is to work with those who are disenfranchised to improve their lot. Maybe love thy neighbour is a reasonable strategy!