populations are entered into specific clinical trials that are evaluated by teams

of biostatisticians.

The necessary expertise and experience for design and execution of these trials exist today. It takes but the desire and the funding to turn this apparatus toward the therapy of AIDS.

Development of therapeutic programs are expensive, for in addition to research they require patient care. Once such programs are established, caution must be exercised to assure that the trials of new drugs do not consume all of the available AIDS research funds. The needs of therapy always appear to be immediate because patients are dying. However, the needs of fundamental research and for vaccine development are equally important as it is only through these efforts that the disease can be prevented and ultimately cured.

Progress in development of effective AIDS therapies might also represent progress toward chemical prophylaxis. Drugs that stop virus from producing once infection has been established might also prevent infection ab initio. Such drugs in combination with vaccine preparations might be particularly effective.

An extremely large market beckons successful manufactures of such drugs. A patient population numbering several millions will require daily adminstration of

these drugs. An even larger population is likely to be interested in chemical prophylaxis. Given this opportunity, it is surprising that most major pharmaceutical firms appear to be inactive in this area of pharmacology.

The overall picture that emerges regarding AIDS research is disquieting. It is an image of growing concern but little action. What progress has been made to date should not provide comfort that we can with a similar level of effort solve the problem of AIDS. It is most likely that given our current level of effort this problem will be solved soon, no matter how brilliant or industrious the scientists work in this area might be. We cannot even be sure that given a major commitment and mobilization of much of the biomedical research resources

or therapy will be forthcoming in the near future.

, a vaccine

Why such inaction in view of the mounting disaster?

Part of the answer probably

lies in the facts that AIDS was first evident as a major problem in the homosexual

population. It is also a venereal disease and one contracted by drug users. As such, there is a repugnance felt by many parts of our society for this disease. I believe that the problem in approaching this disease lies deeper still. No one likes bads news. The worse the news is, the less we like it. The AIDS epidemic is the worst of news. Our first "eaction is to deny the reality of the problem. We who work with this disease daily must still remind ourselves that this disease is for real. The palpable human suffering as well as the cold logic of the numbers of affected people that we see growing daily prevent us from forgetting that this is a disease that demands our attention. But not everyone lives with this reality. So many bad things happen in our lives - airplanes crash, bombs explode, earthquakes destroy cities, friends die of cancer. Most people simply do not want to think about yet another piece of bad news. But AIDS is a problem that will not go away. Everytime that we look at it, it looms larger so that now the shadow of this disease has begun to darken all our lives.

It is also the natural human response to hope that we ourselves will be spared from this disease. We can tell ourselves that the disease happens to others but may not happen to us. Albert Camus provided a searing description of the mentality in the At first plague. people thought the disease was only a problem for rats, then for the dirty people who lived across town.

The fear came

home when death visited someone next door. What many interpret as homophobia regarding the AIDS problem may be that, but also at work is a desire to define any -group as "them" not us. It is becoming increasingly harder to define

those with AIDS as "them". "Them" now includes not only Africans, not only homosexuals, not only Haitians, not only drug abusers, not only hemophiliacs, but also soldiers and Johns or Johns' wives. I am confident that we will awake to ?

realize what problem is in our midst, but when, and how late in the day will it be?

And always

we may ask the age old question, why are we visited with this

pestilence? One answer offers itself as we look back into the origin of our species, an answer anticipated by William McNell is his classic work of the effect of disease on our species and our history, Plagues and Peoples. It is thought that mankind evolved over a period of several million years in Africa. Along with our species evolved our parasites, parasites that are adapted not only to us but to our primate relatives. Much of humankind has now left its historic home in the wet tropics of Africa. In our migrations, we have separated ourselves not only from our ancestral parasites, that remain for the most part bound irrevocably to the

tropics, but also from our primate cousins. These parasites still flourish in the rich brew of tropical climate and primate speciation. We who have been separated from these parasites for tens of thousands of years are no longer

the ravages of the diseases they may cause.

resistant to

Recently the shape of the world has

Such has been the case for thousands of years.
altered. Dakar in West Africa is now a six hour plane ride from New York City. We

are once again knit to our African heritage, once again in touch with those
parasites that evolved with
parasites that are still present in the

of

us

primates of Africa. We peoples who have separated from Africa are now in a
position
when they first encountered the

: the American Indians

Το

Europeans, We are no longer resistant to diseases widespread in the old world. compound this problem, the African continent is itself in turmoil. The past forty years have seen massive population migrations to urban centers, rerouting of waterways, and in some cases deterioration of health care systems as the result of political upheaval. The health status of many parts of Africa appears to be worse now then it was before World War II.

From this perspective, it is no coincidence that this latest scourge is of African origin. I count four major diseases that have emerged over the past 25 years from Africa Marburg agent, assa Valley Fever, Ebola Fever and now AIDS. This pattern of thought is not new to us who have been working with the human leukemia retroviruses.

Here we see evidence for that these leukemia viruses emerged from Africa along with the slave trade and European exploration. The lesson of African origins is one we should all heed. It reminds us in the words of John Dunn that "No man is an island entire unto himself." These diseases remind us that the definition of others as "them" is folly. This may be the worst epidemic to emerge from our ancestral past for many generations, but it is unlikely, given current AIOS conditions worldwide, that it will be the last one.

demand our full attention.

and the epidemics to come

The HTLV III Epidemic: An Appraisal

A new lethal epidemic of HTLV-III infection is rapidly spreading throughout the United States and the rest of the industrialized world. The epidemic is

well established in Central Africa as well. The magnitude and nature of the problem is summarized here.

HOW BIG IS THE PROBLEM?

More than one million Americans are now infected with HTLV-III virus. The virus was virtually unknown in the United States prior to 1978. Official estimates are that one in ten Americans will be infected with the virus in the foreseeable future.

WHAT ARE THE CONSEQUENSES OF INFECTION BY THE VIRUS ?

Infection by the HTLV-III virus is highly lethal. New studies reveal that symptoms associated with virus infection include:

1. Destruction of the immune system (AIDS), a fatal result of the infection.

2. Destruction of the brain by virus infection. Serious motor, neurologic, and psychiatric consequences are the result of direct infection of the brain by the virus.

3. Destruction of lung tissue (occurs mostly in children). This manifestation of virus infection is called lymphoid interstitial pneumonitis

(LIP).

4. Predisposition to at least three types of cancer, Kaposi sarcoma, B-cell lymphoma, Hodgkin's lymphoma.

5. Persistently swollen glands (ARC).

HOW MANY PEOPLE INFECTED BY THE VIRUS WILL BECOME SERIOUSLY ILL ?

Originally it was thought only a small fraction of those infected would became ill. It is now thought that a sizeable fraction (more than 50%) of those infected will become ill with one or more of the symptoms (AIDS, ARC, LIP, brain disease, cancer). Once infected, a person probably remains infected for life. The incubation time for serious disease is measured in years. One half of the people infected six or seven years ago are now ill. The long term survival rate, 10 years or more, is unknown but may be very low.

HOW IS THE VIRUS TRANSMITTED?

Transmission occurs either sexually or by needle. The virus can be sexually transmitted from man to women, man to man, and women to man. The virus can be transmitted by use of shared needles by intravenous drug users, and by blood and blood products via tranfusions. The virus can be transmitted by semen or by organ donors. The virus can be transmitted from mother to unborn child. The virus is only transmitted by intimate contact and cannot be transmitted by casual contact or by routine patient care. The virus is not transmitted in laboratory settings as no infections of laboratory workers are known.

CAN THE VIRUS BE TRANSMITTED BY KISSING OR OTHER CASUAL CONTACT WITH INFECTED CARRIERS ?

It is thought that the risks of catching the HTLV-III virus by casual contact are very small. It is unlikely kissing without exchange of saliva would transmit the virus.

WHY HAS THE VIRUS SPREAD SO RAPIDLY ?

It appears that most if not all people infected by the virus are carriers of the virus. People can appear to be entirely healthy yet transmit the virus. Infected people are carriers for at least one to two years before they become ill. The vast majority of poeple who spread the infection throughout the population are healthy carriers.