HIV and the Double Burden of the Pandemic

Head of the Children\'s Infection and Tropics Division, Department of Pediatrics, Child HIV Coordinator at the Medical School of Unair/Dr Soetomo Hospital Surabaya

A milestone in medical science was reached on 5 June, 1981 when the United States Center for Disease Control and Prevention (CDC) announced in the journal Morbidity and Mortality Weekly Report the presence of pneumonia caused by the parasite Pneumocystis carinii in five young men.

Case detection had been carried out since October 1980 through biopsies at three hospitals in Los Angeles. The five active men also suffered from CMV virus and candida fungal infections. Two of the five men eventually died.

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This was the first report of the disease that later became known as HIV infection, and if it worsened it became Acquired Immune Deficiency Syndrome (AIDS). The disease then spread throughout the world, becoming a pandemic. However, unlike Covid-19, the speed of spread is slower and deaths occur more slowly.

The fear of an HIV pandemic strongly spread in the 1980s, mainly because there was no cure for this virus. It took two years to identify the HIV virus. In Covid-19, the speed with which doctors and experts in China found the SARS-CoV-2 virus was much better, in just a matter of weeks.

The identification of the HIV virus by Luc Montagnier and Francois Barre Sinoussi of the Pasteur Institute in Paris also caused controversy when another team in the US led by Robert Gallo published the same virus, a year after the publication of the French team. Later the 2008 Nobel Prize was awarded only to the Pasteur team and not Robert Gallo.

HIV case development

The HIV virus does not transmit through the respiratory tract, which greatly affects the speed of transmission and the methods of prevention. People do not need to keep their distance or wear a mask. Transmission that plays a major role is through sexual intercourse, sharing needles and transmission from mother to fetus. At that time many people were infected through blood transfusions, especially in Eastern Europe, but now it can be said that this mechanism has been successfully eliminated.

It is estimated that approximately 80 million people have contracted HIV, most of whom have died. Each year there are approximately 30 million-40 million people of various ages living with HIV worldwide. Around 1 million-2 million people become newly infected each year, especially in epicenter areas such as Africa. There have been more than 30 million deaths in 40 years. By comparing this with COVID-19, we can see the progress of medical science, as despite the extraordinary speed of transmission, deaths from the coronavirus have been kept below 3 million.

The first antiretroviral (ARV) medication for HIV, codenamed AZT, was developed in 1987. There was a period of six years when people with this deadly disease had absolutely no hope of a cure. Since then there has been a rapid increase in the types of ARV drugs to treat the disease. Experts know that one kind of drug is not enough for HIV. Currently the best combination uses at least three drugs, known as highly active antiretroviral therapy (HAART). It could be said that ARV medication for HIV is the strongest antiviral medication in the world today. This is a great achievement considering that developing antiviral drugs is very difficult.

On the other hand, in terms of vaccines as a preventive measure, the world of science has not succeeded in making a vaccine for the HIV virus. In fact, about 500 candidate vaccines are being studied, a world record in vaccine production efforts. The problem is the HIV virus is a difficult target mainly because the mutation rate is about 100 times higher than the SARS-CoV-2 virus.

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In vaccine theory, Covid-19 is actually a relatively easy target. Only one HIV vaccine has been able to arouse any hope, namely the RV-144 vaccine, which was tested in Thailand around 2003. The demonstrated efficacy was only 30 percent, but it was the first time people were able to prove that immunity to HIV can be raised. Unfortunately, the vaccine only provides protection for one year. Last year, the last vaccine to be clinically tested on a large scale was also discontinued due to disappointing results. It is very difficult to make an HIV vaccine.

At present, the HIV situation in developed countries is relatively under control. People who are sick (people with HIV AIDS/PLWHA) have access to good treatment and life expectancy can be increased. This disease has become a chronic disease and perception of it has changed, no longer being seen as a killer disease.

Prevention in developed countries is also extraordinary. Several countries have succeeded in eliminating one of the main sources of transmission, namely from mother to child. Prevention through sexual intercourse is currently carried out in various ways with high success. The principle adopted is "ARV drugs are the main prevention".

KOMPAS/BAHANA PATRIA GUPTA

Campaign to commemorate World AIDS Day in the Car Free Day area, Jalan Darmo, Surabaya, Sunday (1/12/2019). The activity is to raise awareness about a healthy lifestyle and knowledge about HIV AIDS.

Cannot heal yet

Even though the progress of treatment and prevention has come a long way, medicine has not succeeded in curing HIV sufferers. The main problem is the ability of the virus to hide in locations that ARV drugs cannot reach. This is what is confusing and one of the priorities to be overcome. What is being done is trying to find new types of drugs and drugs or materials that can dismantle the "grave" of the virus in the body.

Only one HIV patient has ever recovered: Timothy Ray Brown, aka the Berlin Patient. Last year he died. His recovery happened unexpectedly. A bone marrow transplantation from a donor who had a genetic mutation in the virus coreceptor made it unable for the virus to survive. This rare case only happened once. There are currently two other patients who may have experienced the same thing, referred to as the London Patient and Dusseldorf Patient. Experts are closely observing these two patients before making a final conclusion.

Indonesia’s target

In Indonesia, HIV was first discovered in Bali in 1987. The number of people with the disease fluctuates every year. In 2019, there were around 50,000 people living with HIV and 7,000 AIDS sufferers. By mid-2020 there were nearly 700,000 people living with HIV in this country. The four major provinces of Java are the main regions, plus Papua. When Thailand and Malaysia were declared free of mother-to-child transmission, in Indonesia, testing for pregnant women could only be carried out on about 60 percent of pregnant women. Diagnostic tools have been widely distributed, but reaching and inviting pregnant women is often a problem.

Testing for HIV is different from other diseases, it needs the consent of the person concerned. There are still quite a number of people who are afraid to hear the word HIV and refuse to be tested. The limitations of ARVs are also felt because of the six classes of drugs, practically we can only access the three oldest classes. In the era of the dual pandemics the world is experiencing due to HIV and Covid-19, the situation is even more difficult.

In people with HIV, the mitigation of Covid-19 is more difficult because there are more comorbidities and the ability of drugs is increasingly limited. The Covid-19 vaccine has also experienced a decline in ability. Many programs for HIV were also disrupted during the Covid-19 outbreak. Some patients experience delays in treatment so that routine procedures are interrupted, including ARV drugs. In fact the rules on ARV consumption are very strict. It is understandable that HIV experts have been very concerned in the last two years.

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Another serious problem surrounding HIV is the issue of stigma. People\'s views and treatment of people with HIV or anything related to HIV is really confusing. This is not a monopoly of any particular group. There are students who are infected with HIV who would be expelled from campus simply because they are PLWHA. Even though it is very minimal, there are still health workers who do not want to come into contact with PLWHA, even though it is clear that transmission through touch cannot happen.

Seeing that the majority of sufferers are housewives, this unfair treatment needs to end immediately. Many of them do not even know anyone other than their husbands. The same applies to children who are infected with HIV. Regardless of their academic achievement, they are ostracized, expelled from school and experience bad stigma, even though they are 100 percent innocent. Solving medical and non-medical problems is certainly equally difficult.

The current world target for HIV is 90-90-90. We should be able to diagnose 90 percent of the infected. Of those diagnosed, at least 90 percent must be treated, and 90 percent of those who receive this therapy are expected to show good results.

ARSIP PRIBADI

Dominicus Husada

For us this target is far away. In the Covid-19 situation, this target is definitely more difficult. It needs hard work, sincerity and extraordinary cooperation from all parties to be able to achieve it. The struggle of our nation has been proven time and again throughout history. Armed with this long history, we should once again prove that we can indeed overcome this dual pandemic problem.

This article was translated by Hyginus Hardoyo.