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As Epidemic Matures, the Battle Shifts

By David Brown
Washington Post Staff Writer
Sunday, August 31, 1997

For most of the 15 years since AIDS entered our vocabulary, this odd acronym built around a word for help has been the quintessential symbol for helplessness.

Now, things are changing. They're changing because -- in the most literal sense -- the global epidemic is becoming mature.

The days when the death count from AIDS rose every year everywhere are gone. So are the days when the disease's inner workings seemed to defy understanding or scientific decoding. Gone also, in some places at least, is the sense of impotence many AIDS sufferers, and the doctors who cared for them, felt as they faced the disease.

Today, in many parts of the world, the AIDS epidemic burns less fiercely than in the past. A decade and a half of research has brought insight, and finally treatment of unexpected potency, to bear against the disease. The monotonous pessimism AIDS called forth in the early years of the epidemic has been replaced by a diverse mix of hope, accommodation and resignation.

A series of articles in The Washington Post over the next five days will sketch a picture of this new world of AIDS.

Last year, approximately 22.6 million people around the world were living with human immunodeficiency virus (HIV) infection, or its late stage, AIDS. There were 3 million new infections, the vast majority in people younger than 25, and almost half of them in women.

Despite those huge numbers, however, the epidemic has actually leveled off in many places.

The incidence of new infection peaked in the United States in the 1980s. Last year for the first time, deaths from AIDS fell in this country, and experts believe that event marks the start of a trend.

The rate of new infection has also peaked in Europe, Australia and Latin America. Even in Africa, where the disease emerged and has caused the greatest devastation, the rate of new HIV incidence has reached a plateau, or is about to. In each of those regions, however, there continue to be places or populations where the disease is still spreading rapidly.

Today, the greatest growth of HIV infection is in Asia. In India in particular, incidence is climbing steeply. It is also rising in China, the great wild card of the epidemic that has avoided the onslaught so far but may not forever. Even in Asia, however, there are places (such as Thailand) where HIV's explosive growth has stopped.

The slowing of HIV's spread is a product of both the natural course of epidemics and the hard-won efforts of people to stanch the spread of this particular one. But change is occurring in more than populations. It is also changing in individuals.

After a long period of frustration, medicine in the last few years has finally started to catch up to the disease and can now offer, for the first time, treatments that may substantially lengthen life and in some cases even restore health. In the United States, and other affluent societies with a tradition of aggressive medical care, the trajectory of HIV illness is substantially different from what it used to be.

Unquestionably, the most important development in AIDS in the United States in the last two years has been the arrival of protease inhibitors, a new class of drugs that are used, in most cases, in three-drug combinations with other antiviral medicines.

Scientists now know that, despite the seeming quiescence of HIV in the early stages of a person's infection, the virus and the immune system are actually locked in all-out combat from the start. Every day, up to 10 billion individual viruses are made and killed off, with the immune system losing only after years of furious struggle.

"Triple therapy" can stop, or nearly stop, that cycle of virus replication. It is a treatment that, while probably unable to eradicate infection, nevertheless strikes at the source of HIV's pathological effects.

The Centers for Disease Control and Prevention estimates that between 650,000 and 900,000 Americans are infected with HIV. In only about two-thirds has the infection actually been diagnosed. Of the people who know they are infected, perhaps 200,000 are on triple therapy.

Like most new treatment strategies, this one was was first tried on the sickest patients. However, it may turn out that triple therapy's real promise lies elsewhere.

Almost certainly, the most famous American undergoing chronic treatment for this disease is Earvin "Magic" Johnson. The former star of the Los Angeles Lakers announced in 1991 that he was infected with the AIDS virus. A combination of antiviral drugs, Johnson and his doctors have said, suppressed the virus to levels below the ability to detect them in his blood. It appears the basketball star has been healthy throughout the course of his infection.

It is that state -- early, symptom-free infection -- that triple therapy may be able to maintain for long periods of time. Most AIDS specialists now believe that if an infected person comes to treatment early enough, he or she may never experience the ruinous assault of AIDS. The truly dramatic stories in the new world of AIDS may turn out to be those of people who led altogether ordinary lives after they became infected.

For the moment, the new treatment's obvious effects are in sick people suddenly made well. Its dramatic benefits are not always lasting, nor are they easy to achieve. (Triple therapy costs up to $ 12,000 a year, and its psychic demands on patients are equally large and unforgiving.) Nevertheless, there is a growing urgency to put as many people on triple therapy as possible, because its benefits appear to be so great.

AIDS was first described in 1981 among gay men. (It wasn't named acquired immunodeficiency syndrome until the next year.) Most of the victims were white and middle-class. That didn't change -- either in fact or in public perception -- for much of the first decade of the epidemic.

Now, HIV infection in America is rapidly becoming a disease of the poor and the nonwhite, of the socially unstable and the economically disadvantaged.

People of color, who were 39 percent of AIDS patients in the years 1981 to 1987, accounted for 57 percent of cases last year. Infections attributed to sexual contact between men have fallen from 64 percent to 44 percent. At the same time, infections attributed to injection drug use or heterosexual contact have risen from 20 percent to 38 percent. Women -- most of them drug users, or the sexual partners of drug users -- now account for one-fifth of AIDS patients.

Bringing good medical care to poor people, or people with unstable lives, has never been easy. Bringing them triple therapy is turning out to be similarly difficult. The new HIV treatments are now testing the limits of the nation's patchwork, and often charity-dependent, medical system. In that effort lies one of the biggest social and clinical challenges of the epidemic.

Some things, however, have not changed in the new world of AIDS.

Prevention is always the most important victory in the battle against an incurable disease. That remains as true in the battle against HIV disease as it has always been. Preventing infection is no less urgent in the current era of therapeutic optimism than it was in the long period of pessimism it replaced.

In recent years, the task of preventing the spread of HIV in this country has become less national and centrally conceived, and more local and home-grown, than in the past. Today, more than ever, the nation's prevention efforts reflect the needs -- and the prejudices -- of the myriad communities and cultures AIDS touches.

In just the most high-profile example, needle-exchange programs designed to slow the spread of infection among IV drug users are in place in several cities, but have never been widely implemented or endorsed by the federal government.

Also unchanged is the search for the ultimate tool of prevention -- a safe and effective vaccine. Many scientists believe only a vaccine has the power to stop, and ultimately reverse, the HIV epidemic worldwide. Current research, however, suggests a good AIDS vaccine is still years away. Even when promising "candidates" emerge from the laboratory, testing them in human populations will be an enormously tricky and expensive undertaking.

Finally, this series of articles will look briefly at a place more representative of the AIDS epidemic than the United States.

In the West African country of Ivory Coast, HIV infection continues to rise, and people with it continue to suffer severe ostracism. The new treatments so rapidly being adopted in affluent countries are out of reach of all but a handful of people.

There, the new world of AIDS looks painfully like the old.

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