AIDS: 25 Years Later
Monday, June 5, 2006; 1:00 PM
Since the first five cases of AIDS were reported on June 5, 1981, the disease has claimed more than 22 million lives worldwide, including more than 500,000 people in the United States. Last year there were 4.1 million new infections worldwide.
Despite increasing awareness about HIV/AIDS in recent years, the epidemic continues to expand. What fuels the spread of the virus and what role does stigma play? What were some of the most salient issues discussed last week at the United Nations conference on AIDS? What are the implications for the United States coming out of the conference, and where do we go from here?
Frank Beadle de Palomo, senior vice president and director of the AED Center on AIDS and Community Health, was online Monday, June 5, at 1 p.m. ET, to discuss last week's United Nations conference and programs that work to solve critical social problems in the United States and developing countries around the world.
The transcript follows.
Frank Beadle de Palomo: Hello, my name is Frank Beadle de Palomo, I am a Senior Vice President and Director of Global HIV/AIDS Programs for the Academy for Educational Development. I have been involved in HIV/AIDS programs (prevention, care, and research advocacy) in the United States and globally for over 20 years. I appreciate those of you who have joined the chat for asking questions and/or reviewing the discussion I must say, as a preface, I never thought 20 years ago that I would still be involved in AIDS I had thought that it was an epidemic that we would fight, we would prevent, we would find a cure, and we would go on to other public health issues or passions 25 years is much too long of a time ... We have to all fight harder to end this pandemic!
Washington, D.C.: Did last weeks UN events in New York shine a light on the epidemic in the U.S. If yes, how? Miguel
Frank Beadle de Palomo: Yes, I did attend. The United Nations General Assembly Special Session (UNGASS)on HIV/AIDS was an important meeting, as the prior meeting set a framework for what needs to be implemented to battle the epidemic. This meeting, in addition to providing a chance to see how far or how little we have moved since the last UNGASS, providing a far richer discussion around treatment outcomes and financing (i.e., how we will pay for treatment, care, and prevention). In terms of the U.S., the meeting was a reminder that we have a far way to go in our won domestic epidemic. We do not have a unified AIDS agenda (prevention care and treatment), we do not have guaranteed access for HIV-positives (the Ryan White CARE Act re-authorization is currently being debated and is not in good shape), we are still debating over issues and restricting proven approaches such as condom access and sterile syringes.... It basically shed the light on the fact that we, in the United States, still have to focus on our domestic epidemic...it is not over, and we have a tremendous amount still left to accomplish.
Woodland, Calif.: Hello! To what extent are drug manufacturers involved in removing access barriers to more expensive drugs in Africa? Are you enjoying a fruitful cooperation? What would you wish for in this regard? Thank you!
Frank Beadle de Palomo: To a large extent, each of the major drug manufacturers (pharmaceutical companies) such as Bristol-Meyers Squibb, GlaxoSmithKline, Abbott Laoratories, etc., has established a lower-cost or donation program for global markets that either drastically cuts the price of their drugs or provides them at no cost. My experience has been, especially in the past two years, positive cooperation. In addition, several large group deals, for example, where they have worked with Clinton Foundation to reduce costs for several countries, have been very successful. That said, the biggest cost reduction continues to be via generics coming largely from India and Brazil. Groups are also beginning to look at production of generics in Africa. In fact, in Nigeria, the Government is planning to invest in building an ART manufacturing facility.
washingtonpost.com: Frank Beadle de Palomo adds more to his response later in the transcript. Click here to read his added response.
Cheverly, Md.: What is the projected rate of HIV infection in 5 and 10 years for the world? Where are the biggest projected problems and how does this compare to the infection rate of the Washington, D.C. area?
washingtonpost.com: Once at Front Line of AIDS War, District Is Now Fighting Blind (Post, March 26)
Frank Beadle de Palomo: Projections of HIV prevalence in five to ten years are difficult to estimate. There are some newer projections that perhaps global incidence (new infections) has peaked and we are looking at an epidemic where HIV prevalence will be determined as much by new infections as by the proportion of people living with HIV who have access to care, treatment and support services. (Shelton and Halperin; Lancet March 2006).
It is estimated that 1 in 50 people in Washington DC are living with AIDS and that as many as 1 in 20 (5%) are infected with HIV, the virus that causes AIDS. According to UNAIDS, the estimates are that 1% of adults globally are living with HIV; in Sub-Saharan Africa, the numbers are higher, with a little over 6% of adults living with HIV.
Within the District, like in much of the world, most at risk groups or vulnerable populations are at the heart of the epidemic. As we move forward with developing prevention, care and treatment and support programs we need to ensure that resources and efforts are targeted where there can be the most impact, working with vulnerable groups where new infections are taking place as well as implementing proven strategies to engage people living with HIV in care, treatment and support services.
Also, we need to focus on the African American community (heterosexual and gay), an make sure that we are supporting community leadership, capacity, and innovation.
Check out these links:
Link to DC Appleseed Report (pdf)
Lancet Article: Shelton and Halperin; March, 2006 (Reprint not authorized for placement on Webcast) thelancet.com
Washington, D.C.: Why is so little attention paid to the U.S. AIDS sufferers, especially those with very resistant forms of the virus? I am sure their numbers have been slowly rising. None of the current approved drugs work for me and yet with the VIOXX scare etc, most drug companies are not risking new drug tests.
Frank Beadle de Palomo: It is difficult to say sufficient resources and attention is being paid to individuals living with HIV in the U.S., however, realistically, we must recognize unparalleled access to care and support in the U.S. as opposed to most developing countries. As for new drugs - there is the challenge of drug company perspectives on potential profitability. On the one hand, we argue rightfully for universal access to drugs, and the need for generics, however, on the other hand, such arguments will scare companies from investing substantial funds into R&D for new drugs if their patent may be over-ridden. There seem to be some new drugs in current company pipelines, but none are guaranteed successes.
Washington, D.C.: I appreciate you being here to chat. I really want to do something to contribute to this "fight". As a non-HIV-positive, non-medical professional, non-psych or sociology student, what can I do to contribute (other than just my money)?
Frank Beadle de Palomo: Your desire to contribute is invaluable, so what we need you to do now is to act!
One of the greatest things all of us can do as individuals is to talk openly about HIV and ensure that our partners, friends, and family members understand the global impact of HIV and what they can do about it in their personal lives. So, first of all, continue to educate yourself about the global pandemic and the epidemic in the U.S. (you might look at unaids.org, healthstrategies.org; aed.org; hivaidsta.org; effectiveinterventions.org; smartwork.org for more information about the epidemic and effective strategies). Secondly, get tested and encourage others to seek testing as well, knowing our status is the first step we can all take to protecting ourselves and our communities. Support your friends, family members, and loved ones to get tested, too. Thirdly, practice safer behaviors.
Lastly, there are a multitude of organizations in the U.S. that provide care and support services for people living with HIV and are often looking for volunteer assistance. In Washington DC, Food and Friends and Whitman Walker Clinic are great places to start. If you live in other areas, you can look at ANSA's Web site aidsnutrition.org and find a food program near you that delivers food to people living with HIV.
Alexandria, Va.: So Magic Johnson has been HIV positive for how many years now? Hardly a fatal disease.
Frank Beadle de Palomo: I believe Magic tested in 1991...so 15 years ago.... Clearly, the perspective on HIV has changed, and just as recently as this week, Dr. Anthony Fauci (NIH) was sharing his own perspective that this is not a fatal disease, but chronic, if treatment is available. However, the availability of treatment is key, and globally we are very far from achieving universal access, as we continue to experience wait lists (and people dying while on those wait lists) for the AIDS Drug Assistance Program in the U.S. Lastly, while 25 years is a long time, and 15 years is a long time for some like Magic Johnson, we do not know the longer term impact of these drugs, continued resistance, and possible drug failure over time. I think we should think of HIV as a critical and deadly virus, that prevention efforts can stop 100%; and think of AIDS as a more treatable condition, especially with highly active anti-retroviral therapy.
Bakersfield, Calif.: Hi Frank, this is your sister and I was wondering how do rural communities have access to information that large populations/media centers have for an educated (AIDS) population? I believe we need more people in the trenches. Congratulations.
Frank Beadle de Palomo: Hello (and thank you for your support...it always means the world to me)...rural communities, like Bakersfield, CA, are important places for this epidemic, too, as the epidemic has matured, it has moved from urban to mid-urban and rural settings. Having people in the trenches is key! However, having educated and trained in the trenches is even better. The local health department should be playing a key role in providing information and a place for folks to get together, and local community-based organizations can and should take up the fight to train and educate people. From our international experience, we know that rural communities can access information through outreach sponsored by state and local agencies and non-governmental organizations (NGOs). For example, small grants can be given to local organizations, health centers, and schools to provide information, education, and communications (IEC) programs. In rural communities of western Kenya, a common activity of youth groups in primary and secondary schools is to perform drama skits in order to convey HIV risks and prevention measures. These kinds of activities should be taking place in schools, in churches, and in community centers in places like Bakersfield.
Keep up the activism (you trained me well)!
Washington, D.C.: Thanks for sharing your knowledge and experience with us.
Do you think that HIV/AIDS patients are better off today than they were 10 years ago?
Jean M. Lohier
Frank Beadle de Palomo: On the whole, absolutely: we have better treatments, better access, and more legal protections. However, we must remember that life experiences will be different for everyone, and while on the whole, things may be improving, it certainly is not where it needs to be and some individuals may be experiencing worse outcomes today.
Furthermore, the number of years that folks are now living with the virus may have its own implications, as folks need to re-adjust their life perspectives and outlooks. Stigma and discrimination are still quite real in the U.S., and abroad, and the levels of access continue to vary by geography, class, and can be linked with a whole host of other factors.
Washington, D.C.: I liked the video about AED's Speak for the Child program. Can you tell us what kind of impact the program is having and what else is being done for children orphaned by AIDS?
washingtonpost.com: VIDEO: Caring for AIDS Orphans
Frank Beadle de Palomo: Key program impacts include:
1) Immunization: completion rates for children under age 2 increased from 0% to 94%
2) Preschool enrollment and Grade 1 eligibility: increased from 42% to 90%
3) Severe malnutrition rates: nearly halved, from 39% to 21%
4) Vitamin A supplementation: nearly doubled, from 20% to 39%
Unfortunately, it is clear that not enough is being done to support children orphaned and made vulnerable by AIDS; only 10% of orphans receive any type of support/services. Many programs provide one-time material donations of clothing, food, and/or school fees or one-time trainings for caregivers of orphans. However our experience in Kenya has shown that comprehensive support packages are required to meet the numerous care and development needs of children. Supports in the areas of nutrition, health, education, protection, psychosocial care, and economic/livelihood activities are critical to providing effective and meaningful improvements in care for OVC.
Alabama: You mentioned being amazed at still talking about this disease after 20 years. Without a cure for AIDS on the horizon, is containment the best strategy for fighting the pandemic? And how would you evaluate the efforts of Russia, China and India (where AIDS cases are starting to expand) in trying to avoid the catastrophe Africa has experienced?
Frank Beadle de Palomo: Russia, China, and India's epidemics are still being driven by most-at-risk groups (e.g., injection drug users, sex workers, men who have sex with men and some other higher risk groups such as long distance drivers). Harm reduction strategies have been used in these countries to work with injection drug users and mitigate their risk for acquiring infection. Even though incidence is growing in Russia, India and China, it is believed that the epidemic will not reach the same levels as in Southern and Eastern Africa where the epidemic is more generalized, but rather will continue to be a lower prevalence targeted epidemic like in West Africa and some other parts of Asia. That said, it is important to acknowledge that more efforts are needed to target both groups of people at risk (e.g., IDUs, MSM, sex workers, etc.) as well as efforts that are targeted at where infections are taking place e.g. working in brothels, bars, needle sharing points, etc. Thailand has become a leader for condom use and integration of programming in high risk/red light districts and more work is needed to scale up these efforts.
Woodbridge, Va.: I am a program specialist working with youth prevention programs. The censorship I deal with while trying to promote the prevention and protection from this disease is stifling. If you could suggest one social justice aspect of the HIV/AIDS epidemic, we as social workers should focus on, what would that be? Thank you.
Frank Beadle de Palomo: First of all, I would say that all of us as HIV practitioners have a responsibility to educate our clients as well as those that support our efforts. More public officials need to be made aware of the benefits of effective HIV prevention programs and what constitutes behavior change. So, vote, contact your state and local representatives, and advocate your position.
When you do communicate with your representative or public leaders, use the facts: ABC (Abstinence, Being Faithful, and Condoms) is an effective comprehensive strategy, but it needs to be tailored and targeted to the behavior needs of the population being addressed. Behaviors don't occur in a vacuum and behavior change programs that are addressing the needs of vulnerable groups such as youth need to be tailored to meet their needs.
Has AIDS stigma eased enough to allow change in strict rules on HIV testing? (By Associated Press - Bostonherald.com)
Sunday, June 4, 2006 - Updated: 12:10 PM EST:
HIV is a human behavior based disease. Until human behavior is changed, the prospects will not change. If 20 percent of the carriers are unaware that they are infected, testing and informing them might help.
Frank Beadle de Palomo: You are very right...HIV/AIDS is a human behavior-lead disease. That said, HIV/AIDS-related stigma and discrimination creates major barriers that dissuade individuals from accessing prevention programs, being tested (knowing their serostatus), from accessing treatment, and from staying on their regimens. HIV testing is a critical tool, and getting folks who are infected and do not know their status to get tested would really help (as the literature tells us that when an individual knows their positive serostatus, they are less likely to transmit). However, HIV testing is not a behavior change approach and will not work alone. We need also to prioritize reaching folks before they are infected, and work on changing their risky behaviors.
Washington, D.C.: Are there any further technological breakthroughs on the horizon in prevention or treatment? Something that can really change the equation for those in developing countries?
Frank Beadle de Palomo: There are several areas where we are seeing promising work being done in the development of technologies to help prevent and treat HIV/AIDS. Perhaps one of the biggest on the horizon for prevention is the work being done with microbicides as a means for women to have more control in sexual relations. Unlike the female condom, which never really has taken off, microbicides allow women to protect themselves in a more discreet fashion so that the man may not object. In situations where women find condom negotiation difficult or even impossible, this development will empower them to protect themselves.
Also, while not technology, new findings on the effectiveness of male circumcision to reduce risk of infections (a protective factor found of 65% in the Orange Farm South Africa Study) may have huge implications for approaches to prevention.
San Francisco, Calif.: Thank you for chatting today. I was very disturbed to read that new Ugandan AIDS cases went from 60,000 in 2002 to 130,000 last year, primarily due to the Bush Administration's insistence that US money be spent on abstinence. Now that the C (condoms) has been taken out of the Ugandan ABC success story, AIDS is winning there. Any comments?
Frank Beadle de Palomo: Without knowing the most up-to-date statistics on HIV incidence in Uganda, it is important to note that it is too soon to attribute changes in national numbers to the ABC policy in Uganda. Changes in prevalence take a number of years to register and to be validated. Comprehensive strategies that include abstinence, being faithful and condom use are needed to successfully address the epidemic. That said, I think what we are seeing in the U.S. and in other countries is that the more comprehensive approach to prevention, the better. Thus, if we reduce or minimize access or use of a proven technology/intervention of condoms, then the prevention programs are going to be weaker. AIDS is a complex disease that requires comprehensive approaches to effectively combat it.
It is also worth noting that with statistics on individuals living with HIV, an increase in number may actually reflect success as less people may be dying as a result of infection. The numbers we want to go down are not prevalence, but incidence.
Anonymous: In your opinion, is the United States government doing enough on the worldwide AIDS efforts? If not, what more should our government be doing?
Frank Beadle de Palomo: In terms of funding and providing fiscal leadership, I think we are doing a tremendous amount (more would help, too). However, where I think we need to more is in providing leadership on supporting SCIENCE...proven, evidence-based strategies! Supporting and implementing them here, and then holding the countries that we provide funds to accountable for implementing them, too. That kind of leadership from the top would make a huge difference.
Washington, D.C.: Could you explain a little bit about the AED Center on AIDS and Community Health and what you are doing to increase awareness and prevent the spread of HIV?
Frank Beadle de Palomo: The Center on AIDS and Community Health is part of the Academy for Educational Development (www.aed.org). Founded in 1961, the Academy for Educational Development is an independent, nonprofit organization committed to solving critical social problems and building the capacity of individuals, communities, and institutions to become more self-sufficient.
AED works in all the major areas of human development, with a focus on improving education, health, and economic opportunities for the least advantaged in the United States and developing countries throughout the world.
COACH, or the Center on AIDS and Community Health (coach.aed.org) (formerly the Center for Community-Based Health Strategies) was established in 1997 by the Academy for Educational Development to help communities create innovative programs and policies to improve public health. We are committed to helping communities develop methodologies and programs to enable them to address the health problems they face, particularly in the prevention of HIV/AIDS and sexually transmitted diseases. COACH works in the United States and internationally to implement HIV/AIDS programs and provide technical assistance in HIV prevention, Organizational Capacity for NGOs working on HIV issues domestically and internationally, Workplace Programming to involve the Government, the private sector and labor unions in the fight against HIV www.SMARTWORK.org, programs for orphans and vulnerable children, voluntary counseling and testing activities, anti-stigma and comprehensive behavior change programs.
For more information, please visit:
Los Angeles, Calif.: What's the latest word on the integrase inhibitors coming from Merck and Gilead?
Frank Beadle de Palomo: For several years, work has been done with integrase inhibition but the first compound did not make it very far. Recently, work with integrase inhibitors, drugs that target the integrase enzyme in virus replication, has been more successful. Today there are two integrase inhibitors that have made it to clinical trials. They are S-1360 (from GlaxoSmithKline/Shinogi) which is in Phase I/II and L-870 (from Merck) L-870, 810.
The pharmaceuticals makers have run tests of their integrase inhibitors in trials involving patients and are currently focusing on large-scale studies that, if successful, would mean that the companies could apply for FDA approval in 2007.
Washington, D.C.: Do you think it will be possible to control the epidemic within the next 10 years? If so, how?
Jean M. Lohier
Frank Beadle de Palomo: Twenty years ago I thought it would be accomplished, now, I am not so hopeful. We have the tools and the ability to slow transmission, to prevent new cases, and to treat those who are infected. However, I think what we lack is individual, community, and national leadership. I fear that all of our progress will backslide once current funding priorities end, when the deficit devours more discretionary funding, and when politicos get tired of talking about AIDS.
Arlington, Va.: How do those working to stem the spread of AIDS deal with those supporting abstinence only? What kind of tension has this created in recent years?
Frank Beadle de Palomo: Lots of tension. I am often called a "pro-sex" sexual health advocate. And I guess I could be called worse things...in reality, I am very much an advocate for sexual health education, and for teaching individuals (youth, adolescents, and adults) age-appropriate skills and information about their bodies. I am the father of two little girls (5 and 2), and the last thing I want is for them to become sexually active before they are mature and ready. That said, I hope that we can develop science-based abstinence approaches that work. Also, I hope that we can find and support science-based approaches that delay sexual debut for young people. Given the scant evidence-base, my wife and I will make sure that we educate our daughters and prepare them to live: I would rather have a healthy, HIV-free child, than one who did not know, and acquires HIV due to my negligence.
Washington, D.C.: Over 20 million deaths since 1981. That is a large number. A few years ago I was working on a congressionally mandated study of NIH and spoke with the head of the institute that deals with AIDS. He said that there always was sufficient money and awareness for AIDS, and then proceeded to tell my of a far greater killer, that receives no funding at all. What do you think is the number of people that have died from Malaria since 1981?
Frank Beadle de Palomo: Over a million people die annually each year from malaria, and it remains one of the greatest killers globally. The cumulative numbers are hard to estimate. For more information on malaria, please see the Roll Back Malaria Web site www.rbm.who.int with the World Health Organization, and AED's NetMark project (link below). AIDS, TB and Malaria are the three leading causes of death globally. There have never been sufficient resources applied strategically and effectively to address any or all of these diseases. It is important that we remember that this is not AIDS versus Malaria, but rather a fight for global health and protecting lives.
Lessons learned and progress in addressing HIV, Malaria, and TB can be shared across disciplines and together we can work collaboratively to address these pandemics. For more information, please visit:
Washington D.C.: Why don't we have a cure? Is is the science? It's really just that hard to find a cure? Is it the funding? I'm only four years older than the epidemic and I'm starting to think that there never will be a cure.
Frank Beadle de Palomo: The HIV virus is a very complex. I do think that we will have a vaccine, one day. However, the efficacy (how well will it work) will be a big question mark, and so will timing. Now, prevention is really the best thing we have: HIV infection is 100% preventable...don't lose hope....
Frank Beadle de Palomo: This refers to the question about the drug manufacturers:
The Pharmaceutical manufacturing industries are doing a lot to combat HIV globally. For example, Pfizer has launched the Diflucan donation program where Pfizer donates fluconazole (an important drug in addressing OI care needs); Pfizer has also launched a program where they support their employees to volunteer with global outreach programs. Merck has supported ACHAP, a Botswana initiative which is working to get folks on to care and treatment initiatives. Also within the pharmaceutical sector many companies have reduced the cost or donated supplies for test kits, reagents, etc. for the global markets. Internationally, pharmaceutical companies in India have begun to produce generic drugs for greater access and WHO has launched a licensing initiative to certify quality. Many of the major drug companies internationally are working with National AIDS Control Programs to work with governments to supply the drugs, tests, etc that are needed. That said, there is still a long way to go in the resources available for purchasing of commodities, as well as the production and distribution efforts to ensure drugs are being distributed properly. There is also potentially a greater role for other members of the private sector to support the fight against HIV. (Back to first back Q & A on drug manufacturers)
Washington, D.C.: Is there a geographic breakdown of people with AIDS in the U.S.?
Frank Beadle de Palomo: In general terms, urban areas (New York, Los Angeles, San Francisco, Houston, Dallas, Miami, Washington, D.C.) have been and continue to be most affected. The epidemic has transformed from an initial bi-coastal epidemic to a national epidemic. Now, the coast continue to have higher prevalence, but the South is also now one of the most impacted and affected areas.
There are regions in the United States where HIV/AIDS prevalence rates are higher than in other areas. To get a state-by-state breakdown of the HIV/AIDS prevalence rates in specific states and parts of the country, please visit:
You will find specific information at this site.
Washington, D.C.: Congress is in the process of reauthorizing the Ryan White CARE Act to provide hundreds of millions of dollars in support to community-based agencies across the country. The Act is reauthorized every 5 years, but this time around, they are considering removing funding for nutrition services, including food. Without these funds, agencies that currently serve the needs of people living with HIV/AIDS across the country will be forced to close their doors, thus removing the only secure access to food these folks have. These are overwhelmingly despondently poor people who will have nowhere to turn for their nutrition needs. It is important to note that while HIV meds are fantastic and help keep folks alive, the drugs are useless without access to proper nutrition.
Can you please speak to the value of nutrition in treating people living with HIV/AIDS?
Frank Beadle de Palomo: The reauthorization process for the Ryan White CARE Act has been especially painful this time. The CARE Act has been a phenomenal program, and access to medications and medical care is an important part of why it has been so effective, and why AIDS-related mortality has dropped in the U.S. However, you are very right: nutrition is an important component of a comprehensive HIV care program. Proper nutrition can help support an HIV-positive individuals' immune system, improve treatment outcomes, and can delay the need to begin treatments. It is very short-sighted to cut out nutrition-related support for persons living with HIV/AIDS. Drugs and medical care are important, but so is nutrition, mental health services, and ancilliary services such as transportation, child care, translation services, etc. Let's hope that they do not make the mistake of cutting such a vital component.
On the international side, it should be interesting to note that nutrition is getting more and more visibility and importance as its role in helping HIV-positive individuals either delay treatment or improve treatment and overall health outcomes is better understood.
The following links (largely internationally focused) may be helpful reference and information tools for you and others:
WHO Fact Sheet AIDS Treatment, Nutrition & Food Supplements, March 2005
Counseling Materials for Nutritional Care and Support of People Living with HIV/AIDS
Nutrition and HIV/AIDS: Evidence, Gaps, and Priority Actions
Frank Beadle de Palomo: Thank you to everyone who asked questions and to those who read the transcript from this chat (and to my colleagues). Twenty-five years is much too long...let's hope that we can find the energy, creativity, and will to stop the spread of the epidemic in the U.S. and globally so that we don't have to suffer through another 25 years. Please do your best to reach out and educate and support your family and friends to be aware, to get tested if they are or have been at risk or if they think they might be positive, support individuals living with HIV/AIDS, and do everything possible to combat stigma. People, sadly, contract HIV/AIDS. As humans, we can do better...we need to deal with this epidemic with all of our combined humanity.
Editor's Note: washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.