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 | Science in the Cinema 2008 Transcript: LifeSupport |
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National Institutes of Health
Science in the Cinema — "Life Support"
Post-Film Discussion — Dr. Lauren Wood
Dr. Fuchs: Our speaker this evening is Lauren Wood, M.D. Dr. Wood received her medical degree from Duke University School of Medicine and completed her clinical training in internal medicine and pediatrics at Baylor College of Medicine.
She received further subspecialty training in allergy and immunology at the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), and subsequently became board certified in allergy and immunology, in addition to certification in pediatrics and internal medicine.
While working in the laboratory of Dr. Anthony Fauci, her research focused on investigating cellular and humeral immune responses to HIV infections.
Dr. Wood joined the Pediatric HIV Working Group and the National Cancer Institute in 1992. As a senior clinical investigator within the HIV and AIDS Malignancy Branch, Dr. Wood’s research focused on clinical investigation of antiretroviral and immune-based therapies in children and adolescents with HIV infection.
Since April 2005, Dr. Wood has been with the National Cancer Institute's Vaccine Branch, implementing clinical research studies investigating vaccines and immune-based therapies for both cancer and HIV infection.
Please help me welcome tonight's speaker, Dr. Lauren Wood.
Dr. Wood: I want to thank Dr. Fuchs and the entire staff of the Office of Science Education at NIH for the opportunity to speak with you. You all are truly privileged in that you have just seen a film that is very, very true to the reality of living with HIV infection, particularly in the black community.
It is contemporary. It is relevant. I was not aware of the film until it was brought to my attention by the Office of Science Education at NIH because I don't have HBO or Cinemax.
But this is the first effort for Nelson George. And for those of you who may not be aware, it's based on the story of his sister, Andrea Williams. Unfortunately, we weren't able to show a clip that's in the bonus feature on the DVD. For those of you who rent the DVD or have the opportunity to look at those bonus features, item number 4 is actually an interview with Andrea Williams. She was the fair-skinned woman with freckles; kind of had her hair pulled back in a pony tail that was wearing a light blue shirt and let the balloon go and said the name Colleen. This is actually her story.
She has a very powerful interview at the end of the DVD where she discusses very frankly — and her brother talks as well — about how her drug abuse and her acquisition of HIV caused such a fracture in their family relationships.
I think that one of the strengths of this particular movie is that it's not only high on the accuracy of details — and I'll highlight for you the few inaccuracies that were there — because there were a few. But it's not only accurate about the clinical and the scientific aspects of the virus. It's very, very accurate about the psychosocial and the emotional impact of this disease.
In the United States of America, the initial HIV epidemic disproportionately affected homosexual men. Consequently, people in the United States have always thought of HIV and AIDS as a gay disease. I'm here to tell you that HIV and AIDS is overwhelmingly a heterosexual disease. Ninety percent of people on the planet who have HIV or who have died from HIV and AIDS got it through heterosexual sex.
It's not clear whether or not Ana and Slick got it from heterosexual sex or from abusing drugs because they were doing both — both of which are risk factors. When you use drugs, you tend to have sex with a lot of people; you then have sex so that you can get money for your drugs, and so forth. So it's not clear whether or not they got HIV from heterosexual transmission or from using drugs or from, possibly, a combination of both.
One of the things that are highlighted in this movie is the impact of relationships. And I think you saw a little bit of the blame game going on. Slick blames Ana. Ana blames Slick. Kelly has a lot of resentment because she wasn’t around for her mother; her mother was abusing drugs, she had to live with her grandmother.
Her grandmother was at least very honest about the fact that she is still very, very hurt by the kind of behaviors ands the impact that her daughter's drug abuse had on her life.
The young man, Amare, it's not clear. You might think initially from the beginning of the movie that maybe he has HIV that is sexually acquired because he clearly has a boyfriend. In the beginning of the movie, he tells Kelly to get with it, that he's now with Michael. Louis was past history — that was last month.
Often young individuals with HIV or just teenagers have multiple sexual partners. You know, you're in love and you're going to be in love forever and that lasts for about six weeks and then it's on to somebody else. It turns out that Amare actually had vertically acquired HIV infection. His parents were both drug users, like Slick, and Ana, and both of them acquired AIDS and died. He was born with the virus.
Many children who are born with the virus are actually able to live for long periods of time now, on into adolescence and even young adulthood because of very, very dramatic advances that we’ve made as a consequence of research, i.e., understanding the virus, the life cycle of the virus, identifying medications that actually are able to stop the virus from making copies of itself, and understanding how to give combinations of medicines.
But as highlighted in the movie, if you don't take your medicines, they're not going to work for you. Amare died of pneumonia, presumably an infection that we see when individuals are very severely immunosuppressed. It's a very common finding.
What were the inaccuracies in the movie? Well, there were really only a few. One thing I want to highlight to you is that most people who take antiretroviral medications have to be very careful about taking them. You saw Queen Latifah line up her pills, put them in four little sections and then line them up. She talked about having to take twelve pills a day. That's true for a lot of people with HIV, particularly those who have had HIV for long periods of time because the likelihood is that they've got multi-drug-resistant virus. We have great drugs, but they don't work for everyone and they don't work forever. If you can get a treatment regimen to work for you for about five, six, even seven years, you're getting incredible mileage. But there’s one thing about this virus that makes it such a formidable enemy, and that is, it’s able to mutate. It’s constantly able to mutate, mutate, mutate, mutate, mutate within an individual, among individuals, in a population of people. And so it makes it a very formidable foe.
Currently, we've got better drugs than we've ever had before. There's actually a combination pill that came out two and a half years ago that contains three drugs in one, and it’s one pill, once a day. It is a very potent cocktail regimen, which is wonderful.
But for a lot of people who have HIV for prolonged period of time, that's really not an option because they need much more potent medicines that are more advanced and usually require them to be taken twice a day.
Well, what are some of the inaccuracies? Well, you saw Ana walking with a cane. The reason she was walking with a cane was she had a very painful condition called neuropathy. That's a fancy medical way of saying you've got inflammation and irritation of your nerves. And neuropathy particularly affects the fingers and the feet. It's the extremities. And it's just caused by an abnormal sensation. It's tingling. She said it felt like frostbite.
Some people feel a burning sensation. Some people feel a pins-and-needles sensation. The closest thing I can liken it to is if you were to bang your elbow and you hit your funny bone and you know how you get that kind of zappy sensation? Well, it's zappy all the time. It makes it very hard for people to walk, to get a sense of position and balance and so forth. And the neuropathy that she has can be caused by the virus itself, but we also know that some of the drugs that we give to treat the virus can cause neuropathy.
She had stopped taking a medication called Neurontin. This is actually an antiseizure medicine. You might go gosh, what is she doing taking a seizure medicine for numbness and tingling in her feet? Well, many times in clinical medicine and in research, we find out things fortuitously. We find out answers to problems when we weren’t even looking for those answers. And basically, many individuals can have neuropathy, not only due to HIV, but it's a common condition for people who have diabetes that is longstanding, they can have diabetic neuropathy, and individuals notice that people who were taking antiseizure medicines who had neuropathy, their neuropathy got better. And actually, Neurontin and other anti-seizure medicines are actually approved therapies for neuropathy.
She was using a cane. Her doctor said if she didn't take care of herself, she would lose the use of her feet, and I think that was a bit of a stretch and a little bit of Hollywood license because even while neuropathy can be very painful usually, it does not cause people to lose functional use of their legs or their feet. It's just very painful and it makes it difficult for them to ambulate and to walk, which is why she was walking with a cane.
And, actually, in an interview after the end of the DVD, Andrea Williams talked about the fact that she had neuropathy. It was very challenging. We treat it with Neurontin. We try and change the drugs. Sometimes it gets better just by stopping the drugs, but other times the neuropathy just sticks around for a very long period of time. She was at one time using a walker and a cane. But she continued to go to physical therapy and take treatments. She's now no longer walking with a cane.
One of the drugs that the physicians were going to suggest as a replacement for Neurontin was Vicodin. Vicodin is a narcotic. That is a very bad choice in an ex drug abuser. Nobody would ever do that. We’d go to acupuncture or other things. That's another error that I thought was kind of a Hollywood license.
Another error is Amare selling his meds. There are actually people who sell their prescription antiretroviral drugs — the drugs that are used to treat HIV. What they were implying is that Amare was selling drugs that had been prescribed for him to help with wasting.
Wasting is basically when people with HIV or cancer — you see it with people who have cancer as well — get very, very thin. They get gaunt in the face. They lose a lot of fat in their cheeks and they just don't look healthy. There are medications we can give that help build up the body. But we really don't give steroids that bodybuilders would want. There's an oral steroid called Megace which we used for a little while in the early portion of the epidemic because it made people gain weight, but it didn’t make them gain the right kind of weight. It’s related to the testosterone family, but it just made people really fat and it didn’t give them lean muscle mass. And lean muscle mass is really what makes your body stay healthy. So, him selling steroids on the street — he really wouldn't have been prescribed steroids by his physician.
There is a drug that has been approved for wasting and it’s called growth hormone. It's a recombinant protein that naturally occurs in your body. It occurs in young children, and it's what makes them grow up fast, tall — it peaks in adolescence, makes you buff, and makes your muscles grow. It's approved for use in HIV-associated wasting. I think those were just the minor things that I could mention.
The young woman who was killed by her husband, the movie didn't come out and state it outright, but the implication was there that she might have been killed because she was HIV positive and maybe she revealed this to her husband.
You saw the scene earlier in the movie when the young Jamaican woman just wasn’t able to tell her husband, had not been able to tell her husband. And the concerns and the threats of personal violence and domestic violence are very real, even to this day in 2008.
In the early days of the epidemic, clearly, there were people who were totally shunned by their family. They were kicked out on the street. They were homeless. That's the situation with Amare. And unfortunately, still to this day, 25 years into the epidemic, there's still a phenomenal amount of stigma associated with HIV infection.
I thought Ness's comment in the church support group was very reflective of what people still encounter. The pharmacist didn't want to touch him. He just threw the meds on the counter. And this is a healthcare professional. And there are individuals who still encounter that kind of stigma, even with healthcare professionals. So there are tremendous issues dealing with this disease.
I think one of the things that I like most about the movie is that it ends on a positive note of hope and celebration. It also reflects the fact that there's been some reconciliation and some healing. Kelly doesn't have her braids in anymore. She has her hair out like her mom wanted. Both her mother and grandmother come to the rooftop celebration. You don't know that they've never come before, but they're there participating and there to support Amare as well as Slick and Ana.
And one of the things that people who have HIV infection will tell you is, they're not different from anybody else. They have hopes, dreams, you know, they made bad choices. Who hasn't made bad choices? Fortunately for most of us, our bad choices have not gotten us a life-threatening disease that we could pass on to other individuals.
It is a challenge to remain hopeful, to continue to want to be healthy, even though those who are close around you keep dying. That's a major issue for individuals who have HIV infection. They have constant grief. Some people have said, you know, they were like, “I just stopped going to funerals, I can't take two funerals a month. I can’t take three funerals in six months.” Things are dramatically better as a consequence of research.
And I'm pleased to tell you that as a consequence of research in 2008, HIV is a chronic disease. It is no longer a death sentence. It is like asthma, diabetes, high blood pressure — conditions that require chronic medications.
Life expectancy for those people that are taking antiretroviral drugs is as if they didn't have HIV, which is really a phenomenal advance. I think the consequence of that — that's the negative backlash — is that people have become very complacent, particularly young people. They don't think it's a big deal. If they get HIV, they think they'll just take the cocktail or they’ll just take some meds, and no problem. They think, “Look, everybody's living with it.” But the bottom line is that despite all of the advances that we've had, in terms of treatment advances and research advances and what we understand about the virus, no one would ever want to have this infection.
We don't have a vaccine. Things have been very disappointing in the vaccine field as it relates to HIV, particularly in the last year.
We don't have a microbicide. Yet this is an acquired infection. And we couldn't show the interview with Andrea Williams because we didn't have closed-captioning, but she actually makes a statement that I’m going to read to you. It's not as powerful because I'm saying it and you all think I'm the doctor and the scientist from NIH but she’s on the front lines. And she states "You don't have to have HIV. With all the education and things that are out there, there's no reason why anybody ever should become infected." The other thing that she says is “if you do have HIV, you can live with it. You can live a normal, healthy life, but you don't have to get HIV. It's not something that you have to get.”
So I'll kind of leave with that message, and we'll open up the floor to questions. There's no such thing as a dumb question. I'm happy to answer those that you have.
Question: Regarding these very valuable medicines, how expensive are they? Are they covered by any government subsidy?
Dr. Wood: That's an excellent question. The medicines are very, very expensive. The average treatment regimen for what is called a highly active antiretroviral regimen, which usually consists of three antiretroviral drugs to help control the virus, a potent cocktail regimen that's really been out since about 1996 and has resulted in the dramatic decreases in deaths from HIV and AIDS, averages about $15,000 to $17,000 a year, wholesale.
That's not including trips to the physician's office, that’s not including monitoring for CD4 T cell counts, which is the main cell of the immune system that the virus affects that we like to keep up. That's not including viral loads, which is what we do. We measure the amount of virus in the blood directly. So it's very, very expensive.
There are government programs that are administered through Ryan White, Title IV, and they’re called ADAP programs, which stand for AIDS Drugs Assistance Programs. While part of this is federally funded, how much money actually goes to the ADAP program is determined by the states. There's an incredible amount of variability state to state in terms of the number and types of medications, whether or not there's a waiting list, and how much is covered.
Question: Thank you, Dr. Wood, for your insightful comments after the movie. Would you be willing to comment on some of the interventions, policies, legislation, and research studies that need to be designed? I am also interested in knowing more about familial intervention, even community interventions, that could be used to help stem the tide of this epidemic among young black women. Recent data indicate that we need to address this issue.
The question comes to mind when I think about the scene we saw with grandma and Kelly when she came in late and grandma was, as my colleague says, old school in her way of dealing with young Kelly. We see that Kelly is, at least for the purposes of this film, not living with the virus, although everyone around her is. From your experience, I’m wondering what sorts of interventions you might be able to suggest at any level.
Dr. Wood: One of the things I'll preface this by is that outside of one circumstance — and that is mother-to-child transmission — HIV infection and AIDS is spread by behavior. Unfortunately, we are very, very good at molecular virology studies, identifying the genes, identifying the cells of the immune system, etc. But when it comes to behavioral research, it's a very, very complex area because people don't even understand why they engage in the behaviors that they've engaged in. In one of the support groups, there's a woman who said, "I'm like, what was I thinking, I'm so dumb. I wake up in the middle of the night. Why didn't I do that?"
It is very challenging to come up with behavioral interventions and do behavioral research, because we know that behaviors really need to be sustained in order to truly affect change. Think about how difficult it is to sustain behaviors which would keep people from being obese, from smoking cigarettes, and starting to exercise. About half the people here in this audience probably have gym equipment in their basement, their closet, somewhere. So changing behavior itself is very, very hard to do.
One of the things that has come out from behavioral research is this: one size does not fit all. A behavioral prevention intervention is not going to work the same for young men who have sex with men who live in San Francisco who are in their teens versus middle-aged men who have sex with men who may be very affluent living in New York or California. It will be very different from heterosexual African American women who are in rural South Carolina and North Carolina and just having sex with people on Saturday night because there's just nothing else to do. The things that we do understand about behavioral interventions are that they need to be population specific and they need to be sustained. A flash-in-the pan approach isn't going to get it. A six-week intervention doesn’t work, i.e., six weeks of handing out condoms, six weeks of having a survey group, and doing it for a couple months.
It also appears that comprehensive approaches to life skills work better than just trying to focus on HIV alone. You need to learn how to communicate. How are you going to use a condom if you can't talk to somebody about using a condom? Many people can't communicate about that simple issue, even as it relates to a sexual encounter that they're going to have with somebody that they're regularly involved with.
There are women who are married who know that their spouse is involved and engaged in sexual relationships with other women, but they are not able to suggest that their husband where a condom because they might be the victim of domestic violence. They can't even suggest that maybe he might get an HIV test.
There are a whole host of issues that have to be addressed. The preventions and interventions are complex. The one thing I can say, in terms of policy, is that we do need to spend more money on prevention research because HIV is preventable.
Question: You answered a lot of what I was thinking. As a science educator, being in the classroom trying to educate young youth in Washington, D.C., where it's currently the highest rate of HIV/AIDS in young people, it was kind of annoying and irritating at times because it was hard to educate these youth. They felt like they already knew it. And the things that were incorporated in the classroom as a science educator, I don't think they could really relate to or maybe I couldn't speak to them on their level because of their backgrounds and where they were coming from.
So I guess my question is, I'm excited about this film because, first of all, the people — the actors that you have in it. I think that it would grab the attention of youth. How would you inform schools and educators so that this film can be promoted?
Dr. Wood: As a science educator, maybe you'll be inspired. I think that one of the things that does need to be done is that educational tools — movies that truly are informative — need to be used as part of the educational process. School systems have their own sets of politics, their own issues to vet.
There's actually a CDC study of school educators who provide HIV and STD [sexually transmitted disease] counseling. It's kind of shocking the number of high school teachers and middle school teachers who are really not getting any kind of informed curriculum at all. It's about half that do, half that don't. It's higher in some jurisdictions, it's lower in others.
I think one place that we could start is at least at that level in terms of making sure that the individuals who are responsible for science education in their particular school districts — and talk about HIV and AIDS education and so forth — have really good tools that are relevant.
There are three things that your point raises. In the movie of the discussion group that Ana was leading — remember there was a woman with her young daughter there who got up during this discussion? It's very important that parents be involved because parents are — no matter what they say. Your adolescent children think they know everything, I'm sure. Even though they know think they know everything, they do want to hear it from you.
The preference is, they want to hear it from people in their lives. Research has shown this. They are able to better judge the importance of what you're saying. How relevant it is to them. You are a trusted resource. The other science education issue is HIV and AIDS awareness. I told you that it's important to address a broad spectrum of issues. I've conducted groups for adolescent young women in D.C., and we were talking about HIV/AIDS awareness and issues with transmission. But we were talking about a whole list of things that can happen with sexual behaviors. So it wasn't only about HIV and AIDS. It was about you can get genital warts associated with human papillomavirus, which is sexually transmitted, and alcohol use. Do you know what impressed them the most? They saw those genital wart slides. They were like uh, uh. They said you know what, I don't care about HIV and pregnancy, but I am not getting that! You never know what particular piece of information that you present in the broad context of trying to promote safer, healthier behaviors is going to be the hook that somebody can latch on to. I think that's part of the reason why broader-spectrum approaches tend to work better than narrow, focused approaches.
Question: Can I ask one more? The problem is that in education, your hands are bound to a certain extent. As a science educator, I did that; I went on the Web and got pictures, I brought in the school nurse, and I went to Whitman-Walker and got a video that was appropriate. To some extent, it was like my hands were tied. My question is, what role can NIH play in educating science educators? Not just teachers, but the administration as well, that this is an important issue that needs to be addressed to impact our youth and our future?
Dr. Wood: The hands-tied issue is a very real issue, and it varies according to school districts. I think one of the things that is necessary to do is to mobilize the community.
It's very challenging because it's almost like the communities that are most burdened with HIV and AIDS also have the most drug abuse and the most incarceration. There are just multiple challenges to the community. You basically want to say to folks, “Even though you're worried about paying your light bill, getting evicted, worried about whether or not somebody is going to be able to take care of your children, or you can keep your job, you also need to come to the school district and advocate before the school board and the school council about what kind of education can be done.
There was a reference to that, too, in the movie in the sense that Ana is passing out the condoms kind of under the table at the church support group. When you look at the kind of interventions that have been most successful in terms of impacting HIV transmission on a global scale, the shining star is actually Uganda. They had an approach where there were multiple venues. It was not just about condoms, it was not just about abstinence. It was about if you are not sexually active, remain abstinent. Remain abstinent until marriage. If you have five sexual partners, go to one. If you are sexually active and don’t use condoms, start using condoms. Every individual, wherever they were on the spectrum, had an opportunity to continue or advance to another level of a positive, health-promoting behavior.
In terms of the role of NIH, I do think that NIH could do a better job in terms of educating school professionals and health professionals. How exactly we would do that, I don’t know off the top of my head. But one of the things that help is if one government agency could talk to another government agency, like the Department of Education. That might be a start.
The other thing that I tell families and I tell communities is, if you just watch network television, the many kinds and the large numbers of sexual behaviors that your children are being exposed to are staggering — and we're not talking cable or PG-13 movies — this is just network television. There's a lot of reticence on the part of many individuals. They're like, “We don't want to talk about it,” but the issue is that your children are being exposed to it incessantly through the web, text messaging, movies, television, etc. When was the last time in the last thirty days that you can think of any reference to a condom in any movie, sitcom, cable, or direct TV episode that you watched? At the same time, I'm sure there were hundreds of implied references to sexual encounters.
Dr. Fuchs: My office actually creates free curricular materials for science teachers, so I can add to that just a bit. We are actually allowed to do things at the NIH that the Department of Education is forbidden from doing by law. One thing they can't do is create curriculum materials, by law. So I've actually had people at the Department of Ed sort of kick me under the table and say, “Well, we can't do this good thing, but you can. We have a lot of free materials on our Web site for teachers. You can find them at http://science.education.nih.gov. They touch on a number of sensitive topics, e.g., HIV infection, drug addiction, and alcohol abuse for middle school students. We know for a fact that these materials get used in some communities by teachers but can't be used in others because the community simply won’t allow it. That's about as far as we can go officially. We can make the information available. NIH will put it out there for teachers to use.
One of the things we're thinking about for this Science in the Cinema series is making the transcripts of each post-film discussion available online so that teachers around the country could rent the DVD, show the DVD in their classroom, and have the benefit of Dr. Wood's discussion. If you think that would be useful, we would love to hear from you, either myself or one of the people who work in the office.
Question: I was curious. What is known scientifically about men with wives or female lovers who are sexually involved with men or boys — as there was an implication in this film? I didn't notice anything in the literature as far as bisexuality and where that fits in with the incidence of HIV/AIDS. I was also curious if there is any research being conducted on bisexuality. I know there's been research and theories about genetic links to homosexuality, but I haven't heard claims or anything put forth about bisexuality.
Dr. Wood: Well, there certainly is behavior research. Let me address your question from several standpoints. What you're referring to is the fact that clearly, Amare's boyfriend is older. It is implied that they have a homosexual relationship. Michael has a wife and two children with a white picket fence on Long Island and is engaging in sexual behaviors with both men and women.
When the Centers for Disease Control and Prevention (CDC) monitors HIV transmission and transmission categories, it does not make a distinction between bisexual men or men who are exclusively homosexual. It just has the category MSM — men who have sex with men. It's very important to understand that there are a lot of men who have sex with men as well as women, but they would never self-classify as being bisexual. As health professionals, one of things that we do is we just talk about people's behaviors. And you specifically ask them about their behaviors rather than saying, “Are you gay? Are you bisexual?” Are you homosexual”? There are many people who do not self-identify.
In the black community, the phenomenon where a married man is having extramarital sex with another male is called the "down-low." That's the community term: being "down-low undercover.” And in recent years, there have been several studies that have tried to look and get at how common this particular behavior is in African American communities, Caucasian communities, and Hispanic communities. It is highly variable, depending upon where the research is performed and which cohorts are looked at. It can be as low as one in ten individuals (10%) or a response as high as one in five individuals (20%), depending upon the reported study.
Dean Hamer was actually the scientist at NIH who published in Science about the possible association of a genetic association with homosexual behaviors. But that really hasn't panned out. And I'm not aware of any research that specifically looks at genetics related to bisexual behaviors.
Question: First, we need to thank you for a very lively and interesting discussion. My question is related to the timing. In 1980, we recognized the epidemic of HIV. How did it happen prior to 1980? Human behavior has not really changed so much that we did not have this epidemic. Can you comment on that?
Dr. Wood: HIV has actually been around much longer than the 1980s. One of the earliest specimens that were positive for the virus is traced back to a case in England that occurred around the 1940s. The issue is that there have been dramatic changes in sexual norms and sexual behaviors. It started in the 1960s. It's important to know that sexually transmitted diseases are as old as time.
We all think of the classical composers — Mozart and Beethoven. We think that is kind of stodgy music. But back in their day, they were the rockers. At that time, many people died of syphilis because there was no treatment for it.
We saw an evolution of sexually transmitted diseases emerge with each subsequent decade. It was syphilis during the 1940s. So all of the older grandparents and everything say, “Well, we didn't do that thing even though we were under the boardwalk." Syphilis was epidemic until penicillin came along in the 1940s. Then we had gonorrhea that came in the 1960s. The epidemic really exploded after Vietnam. At that time, no one could think of anything worse than resistant gonorrhea. Then we had herpes. It was the virus that people couldn’t get rid of. There was herpes angst in the 1970s and into the 1980s. Then HIV came along.
And I think there were several factors that have contributed to it — not only due to changes in sexual mores, but people are delaying marriage now and people are living together. We are also a much more global community. People can be in the Caribbean, Europe, Africa, and Asia — all in one week — as a consequence of travel. Even though HIV has been around for a long period of time, it really didn't take hold until the 1980s.
Why wasn't it until the 1980s? Why is Sub-Saharan Africa so severely affected? What are the exact origins of the HIV virus? That's the sixty-million-dollar scientific question. It's an important question to answer. But the challenge is that if you come home and your house is burning down, you don't really care. You're not really asking yourself, “Did I leave the toaster plugged or the teapot?” You really want to know whether or not the fire department is on the way. I think the same thing applies to the global HIV epidemic. It's very important that we pursue scientifically where the origin of the virus was and what caused the epidemiologic explosion. But the important thing is that the virus is burning down the planet's house and we need to address that first.
Question: I have a question. Amare was dying. He had pneumonia. I think you used a term, immunity-resistant. The end of HIV shares that characteristic with other medical conditions, right?
Dr. Wood: I will clarify that for you. Amare was dying of pneumonia. The pneumonia that he was dying of was probably a pneumonia that we call PCP, which stands for Pneumocystis carinnii pneumonia or, as it is now called, Pneumocystis jiroveci. It is the most common opportunistic infection. Most people who become infected with HIV through a sexual encounter have no idea they've been infected with the virus because it usually doesn't cause any symptoms. If it does cause symptoms, e.g., a little sore throat, fever, swollen lymph glands, a minor rash, it eventually goes away.
We used to think that because individuals take eight to ten years before they get sick with these kinds of unusual infections, that the virus was quiet in the body — that somehow individuals got infected and the virus just kind of laid there dormant and didn't do anything.
As a consequence of science and advances in research and mathematicians as well as physicists and molecular virologists getting involved, we have an understanding that the virus makes billions and billions and billions of copies of itself everyday. In essence, a war goes on in an infected individual. While the virus is making billions of copies of itself, the immune system is cranking out billions of immune cells. The virus actually infects the cells of the immune system and eventually destroys those cells, making them weaker.
This war goes on day in, day out, week in, week out, month in, month out, year in, year out. Eventually, there are no replacements for the immune system. The immune system gets worn down. The CD4 cell of the immune system is a critical cell of the immune system called the helper cell. They act as the “master quarterback” of the immune system. CD4 cells tell all the other cells what to do — and that is what HIV infects.
So you can imagine, if you want to take the team down, what do you do? Sack the quarterback. And that's exactly what happens with HIV. Then when those immune cells get so low, then other invading armies can come in and take over and destroy the body. And that's what opportunistic infections are. These are infections that are normally in the environment, and if you have a healthy immune system, they don't cause you any kind of problem.
You and I get exposed to them, and if we have healthy immune systems, they're not going to cause us to have any problems. But if our immune systems are suppressed — either from HIV or even from cancer chemotherapy because we are intentionally suppressing the immune system because we are trying to kill those cancer cells — those individuals are at risk for those kinds of opportunistic infections.
And that's what happened to Amare.
Question: I have a two-part question. The film seemed to touch on the issue of women who have been exposed to the HIV virus and are also recovering from addiction. Have there been studies on how well hormonal contraceptives work with women who are in those situations?
My second question is about the morning-after pill. There are so many women engaging in risky sexual behavior and are not using contraception. Is the morning-after pill available in the USA for such people??
Dr. Wood: In terms of the role of hormonal contraceptives, it's actually an emerging area of research in terms of the actual effect and the impact of a woman's normal hormonal variation in her menstrual cycle and how it might affect the immune system, response to infections, and so forth.
That has come rather late in the game as the epidemic has emerged to be a real issue among women. We do know that hormonal contraceptives can interact with some of the antiretroviral drugs. All of the antiretroviral drugs that are currently licensed have been studied alone and in combination with hormonal contraceptives both in infected and noninfected women to determine their interaction. Sometimes the antiretroviral drugs reduce hormone levels. Consequently, some women must use different hormonal contraceptives or use additional barrier methods of protection. Other times, hormonal contraceptives can actually lower the level of the HIV medication within the body. In such cases, it is important to make sure that the appropriate interventions are undertaken. For example, in some cases you may need to stop using certain medications, or you may have to increase their dose.
In terms of the morning-after pill being used as a method of contraception, that is not a huge issue. We find that most HIV-infected women are not irresponsible about pregnancy or getting pregnant.
As a matter of fact, because HIV is a chronic disease, Ana's child was born HIV-negative. In this country, the major, major, major, major success has been the prevention of mother-to-child transmission. In this country, in 2008, pediatric HIV infection from mother to child is a rare disease. In 2006, there were 456 children born in the entire United States who were HIV infected. That is phenomenal.
I think the morning-after pill is available by prescription through your provider. I'm not sure that there's any data out there in terms of how frequently it's used by HIV-infected versus HIV-negative women — either way. But there are many women who have HIV infection who are in monogamous, stable relationships who choose to have children because they can have healthy children who are not infected with the virus. It is something that they desire to do as a consequence of, basically, returning to a life where they feel like they can live. They have hope. They have a future. They want to have a family and contribute to society.
Dr. Fuchs: I’m an immunologist by training. In 1980, I was a second-year graduate student. So this disease has been a major facet of my working life. One of the professors in my department received a call from the gay student union that year, actually 1981, and he was asked to come address the student union about what was, at that time, known as the gay cancer.
He asked if I would go give that talk. It wasn't an unusual request because I like going out to talk to the public, still do, but he came to me later with a guilty confession saying he didn't want to go talk to that group because who knows what people might think if he was talking to the gay student union? This was an academic professional.
So we have moved from that level of stigma to thirty years later, what you addressed in your opening remarks, to an almost cavalier attitude on the part of some young people. “Yeah, maybe I can get this, but I would just have to take pills, then.”
What are your thoughts on talking to young people? What is the proper level of respect for this disease? We don't want to go back to the early 1980s, but I worry today that young people don't give this disease the respect that it's due.
Dr. Wood: Well, I'm so glad that you still enjoy speaking to the public. We thank you for that. I want to make a distinction between complacency and stigma. They are two very different issues. Stigma still remains. We are not burning down people's houses, but there may even be some of you here in this audience who have co-workers, friends, or relatives that have HIV, but they have not disclosed. And there's a reason for that.
We have whole families where only a sister knows, only an auntie, or one grandmother, because those were the only individuals within a person's environment or support group who they felt safe sharing the diagnosis with. There's still a huge amount of stigma that remains. People don't go around broadcasting the fact that they're HIV positive. Nobody does that.
Regarding the issue of complacency, I do think that there is a lack of respect for this virus. But you know, there's a lack of respect for anything that doesn't give an immediate consequence. The same is true for smoking. Why do people smoke? We all know that it causes lung cancer, but it doesn't happen right away. If you picked up a cigarette and two weeks later you couldn't breathe, like Amare, and you were walking around choking like crazy, nobody would smoke cigarettes.
I think that's part of the greatest challenge of this virus, is to keep it at the forefront because nobody could think of anything worse than syphilis or gonorrhea at one time. Then we got herpes. Nobody could think of anything worse than herpes. Then along came HIV. Nobody can think of anything worse than HIV. It’s already here — multi-drug-resistant HIV. HIV is now being transmitted from person to person and from individuals who have had the virus for many years. The virus has been exposed to many, if not all of the drugs that are currently available. Today, the first virus that a person becomes infected with may be a virus that is already resistant to many of the drugs that we have available to treat HIV infection.
I think the way we do it is we are honest, we are transparent, and we tell people that it's not an easy thing. I personally feel that unless we change our behavior significantly, HIV has got us in checkmate because it's a little virus. It's got nine genes. There are 40 million people who are infected, and it's defeating the planet. One virus! It is able to recombine, change, change up, and switch up. No matter what drugs we throw at it, it mutates. No matter what the immune system does to it, it mutates. It’s able to recombine — it is a very, very formidable foe. And actually, if you were going to invent the ultimate weapon to undermine a population, it would be HIV.
It’s designed to guarantee its perpetuation — continually — because it doesn't cause people to get sick for eight to ten years and they look like everybody else. They look healthy. Twenty-five percent of the people walking around the country with HIV today right now don't know that they have it. They're not willingly spreading it to someone else. They are just not aware that they have it. It is a very formidable virus. We’ve been dealing with this virus for 25 years.
I do tell people that there already is a cure for HIV. It’s called prevention. And that's your responsibility.
Thank you!
Dr. Fuchs: I'm going to invite you to come back next week to see the 2007 film "Reign Over Me." We're going to be discussing post-traumatic stress disorder. Please help me thank Dr. Wood for her presentation. |
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