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El sida, 30 años después
Por Fred Tasker, Charlotte Observer
28 de mayo de 2011
Estados Unidos
Treinta años después que Estados Unidos comenzó a
batallar contra el VHI y el sida, las muertes vinculadas al virus se
han reducido significtivamente. Los casos nuevos de sida han bajado en
75 por ciento y la esperanza de vida se ha triplicado. Muchos
seropositivos viven activamente, en muchos casos con sólo una
píldora al día.
Pero la situación tiene un lado más oscuro: más de
1.2 millones de personas viven en Estados Unidos con el VIH y el sida,
y este año se esperan 40,000 nuevas infecciones y 16,000
muertes. Los medicamentos para combatir el virus cuestan $20,000 o
más al año por paciente. Los efectos secundarios incluyen
lesiones hepáticas y halucinaciones, y la esperanza de vida es
siete años menor que para el resto de la población.
Lo que es peor, algunos investigadores afirman que han identificado una
nueva amenaza, llamada immunosenilidad, el envejecimiento del sistema
inmunológico causado por restos del virus incluso en pacientes
controlados con medicamentos. Aunque no todos los expertos coinciden,
algunos temen que esté causando cáncer, infartos
cardíacos, pérdida de lucidez mental y otros males
vinculados con el envejecimiento.
Así las cosas, cuando se acerca el 3 aniversario de la
enfermedad, hay tanto esperanza como preocupación.
“Los medicamentos antiretrovirales avanzados han sido un éxito
tremendo en los últimos 20 anos”, dice el Dr. Mario Stevenson,
jefe de enfermedades infecciosas en la Facultad Miller de Medicina de
la Universidad de Miami.
Ron Cox, de 44 años y de Wilton Manors, quien a los 28
años vio a su pareja morir de sida, ha batallado por vivir una
vida relativamente normal desde que lo declararon seropositivo, de 40
píldoras diarias a sólo siete.
“No me dejo vencer. Soy un fisioculturista”, dice. Cox hace ejercicios
regulamente y puede hacer cuclillas con 250 libras de peso en los
hombros.
Pero para Dale Penn, de 54 años y de Miami Beach, seropositivo
desde hace 20 años, el concepto del envejecimiento prematuro es
una especie de reconocimiento. En su momento fue un banquero destacado
en Nueva York, pero ahora dice que “no se puede levantar todos los
días con la certeza de que tiene la energía mental para
resolver problemas complejos”.
Mientras las investigaciones avanza, los médicos dicen que la
cura absoluta no es segura.
“No está claro si conseguiremos una cura real pronto”, dijo el
Dr. Tae-Wook Chun, investigador del Instituto Nacional de Salud, en un
simposio celebrado en Miami en abril.
Las nuevas investigaciones ocurren en momentos en que los pacientes de
HIV están tan bien controlados que muchos creen que la crisis ya
pasó. Una encuesta de la Kaiser Family Foundation
concluyó que aunque 44 por ciento de los estadounidenses
consideraban en 1995 la crisis de VIH y sida como el problema de salud
más grave de la nación, para el 2006 esa
percepción había bajado al 6 por ciento.
Eso molesta a Charles Martin, director ejecutivo del South Beach AIDS
Project, que ofrece terapia a pacientes.
“Hemos avanzado mucho, pero la gente sigue muriendo. El otro día
se murió un amigo”, dijo.
A pesar del éxito en controlar el VIH, es un enemigo adaptable.
Los casos nuevos en Estados Unidos tocaron el máximo de 160,000
en 1985 y bajaron a 40,000 para 1991, cuando las víctimas
potenciales aprendieron a protegerse. Pero desde entonces no ha bajado
más, según el Centro de Prevención y Control de
Enfermedades.
Y como todos los años hay casos nuevos y los ya identificados
viven más tiempo, aumenta el número de pacientes. A nivel
nacional, la cifra aumentó de unos 950,000 en 1995 a más
de 1.2 millones en el 2009. En la Florida hay 98,000 personas con HIV y
sida.
___________________________________________________________
In South Florida as across the nation, heroic efforts are going on to
fight HIV/AIDS. Deaths peaked in the mid 1990s and dropped by
two-thirds by 2009. Tom Liberti, chief of the Florida Department of
Health AIDS Bureau, credits new drugs but also aggressive testing.
“Because of our testing, as many as 86 percent of HIV-positive people
are aware of their status so they can get treatment and protect their
sexual partners,’’ he says. “When I started here 30 years ago, it was
only 10 percent.”
Liberti also credits statewide anti-HIV programs such as “Man Up,” a
campaign urging men to take responsibility for their actions by
promising to be faithful, use condoms and take other measures.
Over the past decade, the face of HIV/AIDS in South Florida has
changed. The state health department says that in Miami-Dade and
Broward, new HIV cases have plummeted among “injection drug users,”
declined slightly among African-Americans and shifted toward “men who
have sex with men.”
• Injection drug users: In the early days of AIDS, up to 25
percent of new HIV infections came from addicts sharing dirty needles.
That declined with education about risks and as states instituted
needle exchange programs or allowed needle sales without prescriptions.
In 2010, only 3 percent of new HIV cases in Miami-Dade and 2 percent in
Broward were injection drug users.
• Men who have sex with men: Reducing HIV in this group has been
more difficult, Liberti said. Across the country, 53 percent of new HIV
cases in 2010 were in men who have sex with men. In Miami-Dade it was
72 percent. In Broward it was 80 percent.
“If we could reduce that, we could cut back the whole epidemic,”
Liberti said. “But younger men haven’t seen the devastation. They
haven’t seen their friends go through the cancers and the wasting. They
haven’t sat down with a doctor who told them they had six months to
live.”
• African-Americans: In both Miami-Dade and Broward, HIV rates
have fallen slightly among African-American males in the past decade,
and more sharply among African-American women — although both remain
higher than other racial and ethnic groups.
“We’ve put more focus on the African-American community,” says Terry
DeCarlo, spokesman for Broward House, an HIV/AIDS service agency in
Fort Lauderdale.
HIV/AIDS first was recognized in the United States on June 5, 1981,
when the CDC reported five cases of a rare pneumonia among previously
healthy young men in Los Angeles. Within a year, the root cause would
have a name: AIDS, for Acquired Immune Deficiency Syndrome.
In the early years, death often came in months. The psychological toll
was devastating. Penn, the former New York banker, was diagnosed in
1991 when his doctor, crying, told him he had six weeks to live. Two
weeks later, he recalls, a nurse called to say the doctor had read the
wrong chart: “She said I actually had two years to live.”
Over the years, researchers developed powerful drugs that to some
extent have tamed HIV/AIDS. In 1987, the federal government approved
AZT, the first effective HIV treatment, developed in major part by UM
medical school researcher Margaret Fischl. In 1995 came the first of
the complex, multi-antiretroviral-drug cocktails. That ushered in the
era of HAART, or “highly active antiretroviral therapy.” AIDS deaths
dropped.
HIV patients had to take pills in handfuls, 20 or more a day. In 2006,
the FDA approved Atripla, by Gilead Sciences and Bristol-Myers Squibb,
the first triple-drug treatment in a single daily tablet. Now,
pharmaceutical firms make about 30 HIV medicines in five drug classes,
each targeting HIV in a different way.
Today, a new HIV patient might live 25 to 30 more years — or longer,
doctors say.
“With drugs and proper care and diet, people can live long, long
lives,” DeCarlo said.
An example is basketball great Earvin “Magic” Johnson, who in 1991
retired from the Los Angeles Lakers, announcing he was HIV positive.
Fans feared it was a death sentence. But with AZT, then multi-drug
cocktails, he has maintained his health and become a high-profile
crusader for HIV awareness.
Still, patients who can get by on a single pill a day are the newly
diagnosed and those whose status is caught early. Penn has been on
antiretroviral multi-drug cocktails since they were developed in the
mid-1990s, and has had to change his regimen five times to stay ahead
of HIV’s chronic mutations.
“Medication management is a huge issue,” he said. “You can’t run out.
Miss a dose and the virus mutates.”
New treatments are in the works. Fischl, at the UM medical school, is
working on a therapeutic vaccine to treat patients who are already
HIV-positive.
“It will harness the immune system and control the virus so there is no
more need for antiretroviral therapy,” she said.
But some researchers now fear the virus is harder to suppress
completely than previously believed. Even when HIV patients seem
well-controlled on drugs, with blood viral counts near zero, a hidden
reservoir of virus might lurk in the lymphatic system, they say.
To explore the issue, UM’s Stevenson convened a symposium in April in
Miami with experts from the National Institutes of Health,
universities, the National Cancer Institute and the pharmaceutical firm
Merck & Co.
“Antiretroviral drugs can suppress the HIV virus in the blood, but the
virus can still replicate in the lymphatic system,” said Dr. Timothy
Schacker, director of the Infectious Disease Clinic at the University
of Minnesota, told those at the symposium.
Stevenson agreed: “Even when the patient goes on therapy early and
stays on it for years, and the virus is suppressed so it’s
undetectable, if you stop treatment the virus comes back in every
single person. It causes inflammation of the immune system, and that
causes health problems.”
Such health problems can be extensive, added Dr. Steven Deeks, AIDS
researcher at the University of California at San Francisco: “The
patients are at increased risk for heart disease, cancer, kidney and
liver problems.”
Penn says he recognizes signs of premature aging — heart attacks and
other problems — in acquaintances with HIV. He says he suffers from
kidney disease, chronic fatigue and other problems he attributes to his
well-controlled HIV. He blames it in part on the antiretroviral drugs
that are keeping him alive. Each time he changes his multi-drug
cocktail, he says, he worries the new combination hasn’t been
adequately tested in the haste to stay ahead of HIV mutations.
“Every one of us is a scientific experiment,” he says.
Deeks acknowledges that the idea of premature aging is controversial,
and not every researcher agrees with it. In a study published in the
Annals of Internal Medicine in October, Dr. Meredith Shiels of the
National Cancer Institute and others argue that the increase in cancers
is due to the growth and aging of the HIV population.
“People with HIV have not been shown to be at an elevated risk of…
breast, prostate and colon cancers,” Shiels said in an email. But even
her study agreed that lung and anal cancers were occurring earlier to
HIV-positive patients.
Despite doubts about quickly conquering HIV, Stevenson’s name for his
April symposium was “The Road to a Cure for HIV/AIDS.” And several
researchers took optimistic tones. They defined what a true cure for
HIV/AIDS might look like: when the HIV virus in the patient’s blood and
lymphatic system was so thoroughly suppressed that it did not return
even if the patient stopped all therapy.
And they cited the now-famous “Berlin Patient,” an HIV-positive patient
declared cured by doctors who treated him. In 2007, American Timothy
Ray Brown, then 44, was undergoing treatment for both leukemia and HIV.
Doctors in Berlin planned to fight his leukemia with chemotherapy and
radiation, then implant bone marrow stem cells from a healthy donor to
rebuild his immune system.
They decided to attack his HIV at the same time by harvesting stem
cells from an extremely rare donor born naturally immune to HIV. It
worked. Four years later neither Brown’s blood nor his lymphatic system
show signs of the virus.
It’s not a general cure for HIV/AIDS, Stevenson said. The patient had
both leukemia and HIV. HIV-immune donors are very rare. The treatment
had a 30 percent chance of mortality and cost hundreds of thousands of
dollars.
Still, HIV researchers say it may be a turning point, a demonstration
that the hidden reservoir of virus can be eliminated and HIV can be
cured.
At the symposium, researchers concluded it will take a multi-pronged
approach to move toward a cure. To start, that means new drugs to flush
the hidden reservoir of virus out of hiding so traditional
antiretroviral drugs can suppress it. Gilead Sciences, for one, is in
the early stages of research into that, said Dr. Andrew Cheng, the
California pharmaceutical company’s senior vice president of
development.
Researchers also will need new therapeutic vaccines to strengthen
patients’ immune systems and more radical genetic approaches to
engineer patients’ cells to become immune to HIV.
“This is the excitement, the biggest challenge in the field,” Stevenson
says. “It used to be heretical to consider the idea that we could
eradicate AIDS. Now even the NIH is embracing this… I’m optimistic.
Maybe a better word is stubborn — as stubborn as the virus.”
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