The History of HIV and Current Epidemic

this program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest UC TV programs by I'd like to welcome all of you to the UCSF mini medical school the topic being HIV past present and future my name is Diane Hoefler and I am professor of medicine at UCSF and I run the hiv/aids program at San Francisco General Hospital I wanted to start out with a couple of thank-yous first of all I want to thank all of you for signing up for this course I'd like to thank you CSF for allowing us to feature HIV in the mini medical school I like to thank our technical folks Kyle and John who are at the back of the room and if I'm waving like this it's because they're giving me signals and I'd also like to give start out by giving a big round of applause to the physician who has organized this program who's going to be our first speaker for this evening dr. Monica Gandhi so a big round of applause for dr. Gandhi so we're a little biased in the hiv/aids field but AIDS is like no really other story in modern medicine AIDS HIV is a story of despair it's a story of discovery it's a story of fear it's the story of courage it's a story of medical triumph and a little bit sadly for me to say right now it's also a story right now of complacency and I'm really delighted to see all of you here because hiv/aids still is a global public health emergency in a 34 million people living with this disease and over two million new infections every year and somehow it's fallen a little bit off the public radar screen but there's so much work to be done we here in San Francisco are very unfortunate are very fortunate to have the cutting-edge leaders from all around the world who are you going to hear about in this course so this evening we have a two-part program the in the first part of our program we are going to I'm here a lecture on Monica Gandhi is going to tell us about the origin of HIV and the entry into human populations this is something that people always ask how did HIV start where did it come from and to be honest there's lots of myths about that but our mythbuster Monica Ghandi is going to set the record straight this evening so one of the goals that we have in our mini medical school course said after you leave this evening you feel like you have a firm understanding of really the origin of HIV so our first speakers I said is dr. Monica Monica Ghandi dr. Gandhi is hails from Utah she went to the University of Utah and then she went to Harvard Medical School I'm somewhere in between she got a degree in British literature from Cambridge which we always find very interesting about Monica and fortunately she came over to the west coast where she specialized infectious disease and then she has been a faculty in the hiv/aids division interestingly her brother also works in infectious disease and HIV in the other institution Harvard but we have Monica here and it's it's really a delight she is truly one of our premier educators in our program and you'll see why when you hear her lecture this evening so Monica thank you so much an introduction and thank you all so much for being here I look forward to spending the next six weeks with you so I want to talk about where HIV could have entered human populations and when and we think we have a good idea of this but but I think this often generates a lot of questions so I look forward to those at the end so you know the history of HIV is that one of the first reports of this ever described from Africa was published in kind of a premier Medical Journal that I'll be talking about further in this talk called The Lancet and at that point I want to read you a quote which was that it all started as a rumor then we found out we were we were dealing with the disease then we realized that it was an epidemic and now we have accepted it as a tragedy and that was the chief epidemiologist in Kampala Uganda speaking 1992 and the description of the disease at the time because people were so wasted from it was called slim disease the first reports in this country and we're going to have a lot more on this history later in the course but the first report of this epidemic that was called AIDS were in the what's called the MMWR one of our journals around surveillance in this country and these were both published in June and then one follow up in July and these are well known to us we commemorated a couple years ago the thirty year anniversary of these two reports and one described an outbreak of Pneumocystis pneumonia among gay men in LA and then the second described in other cities around the country Kaposi sarcoma another infection associated with advanced AIDS and these were the first reports in this country and that's the first clinical report of this cluster so I want to take a step back and say okay how do infectious diseases enter human populations when we talk about HIV how does this happen with all pathogens I'm going to use the word pathogen and microbe so microbe being a tiny little organism a virus a bacteria fungus a parasite that comes into human populations and I'm going to use that word microbe and pathogen sort of interchangeably and most mostly in the world actually because organisms have to live microbes are sitting happily in the organism and and living very well within that organism so for instance we have a number of different organisms that are incorporated and even into our very fabric of our DNA are all over our body our lining our gut and most microbes live in harmony with their hosts and in fact there's well-known examples of commensal relationships this is an example of a crab in a coral and they live very happily together and the crab eats the mucus that secreted off the coral and all the detritus that comes into the coral and then the crab protects the coral from predators so this is an example of a commensal relationship but what happens is that when coexisting microbes in your body can evolve and can become more virulent or can start causing human disease in the human body or a new pathogen from the environment can come into and enter the human host and these are the two ways that emerging diseases occur that a new disease is observed in human populations and it's actually human output activities in quotes but human sort of interference with the environment that can lead to the emergence of new diseases in humans so for instance global warming is a good example that as the earth warms up microbes that previously could only exist in one environment can now exist in another environment and then they're exposed to new hosts and can go crazy with those new hosts we'll be talking about this second one which is interaction with animals either hunting or eating or keeping animals as pets this process by which microbes or pathogens go from a nonhuman to a human host is called zoonosis and HIV we think is a zoonotic illness there's also changes in agricultural patterns so as you farm new crops that attracts new pests that can infect a farming community as we encroach on animal habitats animals are crowded more densely together in animals that shouldn't be so close together are very close together and they can mix microbes and new microbes can emerge and also if we go into habitats that we've never been together we are exposed to new microbes as urbanization occurs of course humans are crowded into small spaces and that's delightful for contagious diseases and then modern transport of course that jet travel makes it so that organisms can go in a day from one place on the earth together to the other even when someone feels quite well or ships can of course carry unintended passengers in the forms of microbes and then of course there's war and famine and all the other human activities that can contribute to disease so let's talk about HIV then specifically once we have a larger framework of how diseases enter populations HIV itself is a a type of virus called a lentivirus and that is a subgroup of viruses called retroviruses so I'll explain what retro and what lenta is retro means that these viruses use RNA as their genetic material and eventually that RNA we have DNA as our genetic material but that RNA eventually has to convert to DNA once this virus enters the human host to cause more mischief lentivirus that lenta part means slow and that means and this is very clever of this virus but that means that there's a long interval between the initial infection and the time that someone gets sick and that long interval is the time in which a person can spread the disease even though they feel quite well and so the length of viruses are a subclass of retroviruses and were there ever anything in in the animal kingdom that we knew about that was comparable to the lentivirus of HIV and human populations well indeed there's a completely almost analogous bunch of viruses that live in primates and these are called these Lenti viruses that live in primates just like human immunodeficiency virus spells out HIV these are called simian immunodeficiency viruses SIV strains and there are many many SIV strains that live very happily with their primate hosts so again I told you that there are many microbes that live happily with their hosts and it's only when a microbe like SIV gets away from its host that it's living commensal E and fine with to a host that it's not supposed to be in like humans that disease can occur so many of these primates for centuries have lived with their SIV strains and not gotten sick and their SIV strains found in chimpanzees gorillas monkeys African green monkeys baboons mangabeys sykes monkeys many many primate species so let's think about first I'm going to tell you about which strains of SIV most look like our strain of HIV and then we'll speculate on how that cross over from the primate to the human occurred so let's do a little bit more background about what are the types of HIV that are found in human populations it's pretty easy there's actually just two major types of HIV strains in the world hiv-1 and hiv-2 it does get a little more complicated because from there there are some groups of HIV one there are four different groups group m n o and P and then group M HIV is that pandemic strain so that is the strain that causes over 90 percent of all human infections HIV one group M and group M has a number of different subtypes that we actually call clades and just I'll point out there are different clades there's not an e but a B C D F G and so on and clade B is the strain that's found in the u.s. so this map below is kind of small but you can see that B is the strain that's predominantly found in the US so when we think about HIV and which strains are homologous to SIV strains let's just focus on hiv-1 and hiv-2 so it if you just look at and I'm not talking about how the crossover occurred but if you just look at what strain looks like the other HIV one the major SIV strain that closely read most closely resembles SIV most closely resembles HIV one is the particular SIV strain found in the common chimpanzee and this subspecies is called Pantry oddities trial oddities and there's an example in the San Francisco Zoo and poor guy he's all by himself but he often sits up on a tree and he I have to go to the zoo a lot because I have these children but but he this is this SIV strain looks like if you sequence it if you actually look in a laboratory and look at what it looks like it looks most like HIV one the one in the common chimpanzee HIV to it SIV strain that it most closely looks like is an SIV strain found in mangabey 's and this illustration is from a really nice paper and I've included the papers if you want more information down at the bottom but this illustration shows a group of researchers that were to East Cameroon and they would collect fecal samples from all the different primate species that live in these Cameroon and they could see which SIV strain from these samples looked most like HIV one so it's actually quite simple then so HIV one group n m and O all look most like the SIV from the common chimpanzee group P and this is a very rare strain and was first reported out of Europe but it was an immigrant from West Africa group he actually is a strain that most looks like an SIV that is found in gorillas and then HIV - as I told you looks most like the SIV strain from mangabeys so that just tells you what the strains look like that doesn't tell you how this jump was made from primate to human so how did we get the viruses from these primates these SIV viruses that are living in these primates how did they jump into human populations well one of the first theories that was propounded on this was published in by a journalist named Edward Hooper and this publication was called the river a journey to the source of hiv/aids and the back story here was that in the late 50s there was a competition for the vaccines that were going to be used globally so there was the oral vaccine that had been designed by Sabin and then there was an injectable vaccine that was designed by Salk and there was a Polish scientist named Hillary Khabarovsk II who was actually competing with Sabin for the development of the first oral polio vaccine and the National Institutes of Health in the late 50s held a special committee to say okay which one's more effective which one's the most safe and Sabin won out as the developer of the oral vaccine but corporal Skee who was in affiliated with Belgium at the time went on despite this recommendation to administer his vaccine to a million people in in territories that were controlled by Belgium at the time so at the time this was called the Belgian Congo now called the Democratic Republic of Congo Rwanda and Burundi and so 100 million or more of these oral vaccines were given and the theory was and this theory was propounded by Edward Hooper and then actually published by the Rolling Stone which gave it a magazine which gave it some popularity was that Kapowski was responsible for this the I'm sorry that these slides are cut off a lot of them are but there was a lot of reasons why this theory didn't actually hold up one is that the cultural media and the compile ski used to make these oral vaccines actually were not in cells from chimpanzees and we again know that HIV one em is most closely related to chimpanzee cells they were using African green kidney monkey cells to and I'm going to talk about that the timing didn't fit of 1957 to 1960 was the time that he was administering these vaccines it didn't fit for later on when we think that HIV entered human populations so Kapowski sued rolling stones for defamation and he got a dollar in damages so what was that crossover event and I would make a request that these slides are cut off by the way they're formatted but if you guys are okay with it I'm just going to proceed but there are going to be a lot of cut-offs here but what was the what was the crossover event you know the most common prevailing theory and I'm going to give a little bit more evidence about this is that is that the possibility of crossover was frequent contact between humans and non-human primates that really occurred in the beginning of the 20th century sort of late in the 19th century and that was through the medium of the bush meat trade the bush meat trade actually refers to hunting wildlife not just primates for food or for exotic purposes but a lot of the focus has been on the hunting of primates and a lot of this theory came I'll refer you to a popular author and a scientist named Nathan Wolfe who looked at these hunters and all the all the SIV strains that they're exposed to so if you take one of these push meat hunters and look at their DNA it's actually littered with all these SIV strains that they probably were exposed to from different primates that they were hunting from the blood exposure to those primates and so that was the crossover event and the spread was probably something to do whereas I'm going to talk about more with social disruption colonization the sex trade and history so this is an example of a nice article that summarizes the bush meat market and this unappetizing look at the bush meat market in West and Central Africa with again not just primates and the reason that this trade grew up so much more at the turn of the century was really access to modern firearms they were logging roads that were created between forests and cities and really at this point the extinction of some primates are really threatened and this is an example of Nathan Wolf's work that I indicated to you before but this is for example the percentage of HIV positive persons this is a paper in rural villages in Cameroon who report contact with wild animals as represented by the dark lines here and contact with non-human primates is represented by the wider bars and you can see that a very high proportion of people eat wild species or eat non-human primates a large proportion up to 80% Butcher wild species or butcher non-human primates up to 60% hunt and then also there are some keeping of non-human primates as pets and this is a little bit technical and there's no reason to understand this fully I want to just give you the gist of this is that if you look at the same 14 world villages in Cameroon HIV infected people in those villages not only have the common strain that spread from human to human in that region but there also have again in their in their genomes or in their very fabric of their DNA which HIV we know likes to knit itself into our DNA and mold talk about that more in a couple weeks when we talk about therapies HIV these these villagers who are exposed to non-human primates at such a high rate not only have a predominant strain but have many many many other strains that resemble SIV strains in different non-human primates including some that we've never even identified so the message is really that HIV genetic diversity is commonplace in villages with frequent contact with non-human primates and this is at this point at this point the prevailing theory of how HIV crossed over so the next question then becomes when did HIV cross over when did it get to human populations and I told you that the first description in the United States was in the MMWR and June 5th 1981 there hadn't been previous reports from the region of origin if we think the region of origin is namely specifically West Africa there had not been previous to 1981 outbreaks of diseases that we usually think are associated with having advanced immunodeficiency but this is difficult to describe in an area where there may be a number of other competing diseases and tropical diseases and a number of other outbreaks of other things and so that may not be the focus there was a case report that created quite a bit of controversy that was published and again one of these big medical journals called The Lancet in 1959 of a 25 year old man in the UK who was a naval seamen and he came in severely emaciated they used these sorts of terms in 1959 so remorseless anal lesion and also eating into this upper lip which is illustrated here and the postmortem in 1959 this case report revealed in his lungs Pneumocystis and cytomegalovirus to a virus and a fungi that are that are associated with HIV or advanced immunodeficiency and later in 1983 the pathologist from the Manchester Royal Infirmary took his specimens because he had post-mortems available and claimed that they were positive on on what's called polymerase chain reaction for HIV and that created a lot of controversy because they didn't report their methods well and and they wouldn't release any of his specimens for anyone to verify that so that's still very very debatable and Edward Hooper the same writer who gave us the river did call publicly for an apology to the family and his fiancee for this report so a lot of these are cut off but I'm I but I wanna I want it to go to the next idea of where we got this idea of when HIV could have entered human populations well the only way to truly know is to have in time human specimens so if we had human specimens from West Africa from the 1800s then we could understand if HIV had been present in human populations in the 1800s but there are no human specimens they're not plasma specimens they're not lymph node specimens or not tissue samples sitting around from which you can identify HIV that go back very far some of the oldest known stored specimens from Africa were 1,200 plasma specimens that were stored at the University of Washington in Seattle that had been collected in 1959 from what was then called the Belgian Congo now called of course the Democratic Republic of Congo in the city of Kinshasa Leopoldville at the time and these specimens can be let been collected for an entirely different purpose they'd been collected for to look at the relationship between something called g6pd deficiency and the development of malaria but they went back to those specimens collected in 1959 and analyzed all of 1213 for HIV and HIV was found in one patient in 1959 and this desire of 59 strain than it was thus called was intensively studied and and essentially the way that they could study desire 59 strain is a couple of ways they could look at it sequence it and say how much it differed from the chimpanzee SIV strain which we think HIV one came from and also you could look at zr zr 59 and say how much did it differ from the modern HIV strains that were in human populations at the time of this paper which was in the year 2000 and you you can see by the illustration the desire 59 is there and it closely resembled some of the strains that we find a clades that we find in human populations B D and F and they did these kind of complex what's called phylogenetic analysis and said you know sine 59 is so close to BDNF it probably could not have entered human populations much much before this 1959 and so the estimated date at this point as of 2000 when this paper was published in your slides the full slide will be published at this point we thought HIV entered human populations around 1930 and then another specimen was found because again that's really the only way to know when HIV was in human populations and a lymph node was found from an adult female who had lymphoma in Kinshasa and it was embedded in paraffin and this was found from 1960 and this strain she had HIV and this strain was called DRC 60 so they thought okay DRC 60 is going to look a lot like zyre 59 because SIV crossed over into humans around 1930 this is now 1960 it had about 30 years to evolve in the human host so it shouldn't look - they shouldn't look too different from each other and then 1960 to the year 2008 which is when DRC 60 was found we know that evolution occurs at a certain rate in the human host so we thought that that this would just verify the hypothesis but in fact DRC 60 actually looked a lot different than zyre 59 and they were different enough that it looked like there was probable probably a longer time for HIV to be evolving and growing and mutating in the human host and so the estimate from this new sample that was found is that it looked like the ancestor of HIV 1m crossed into human populations probably around the turn of the 20th century anywhere between 1884 and 1924 is their estimate and 1908 was their median so that's when they think by this latest data that HIV entered human populations and then everything that occurred from there was history was West African history was the history of colonization and a social disruption of what Western countries did in in West Africa that disrupted West Africa so much to create the growth of this disease so if we think that HIV entered around the turn of the century if you look at now a map of western Africa at the time there was no city in the region no city in the region at the time that had a population before 1910 of greater than 10,000 people enter colonization and to Belgium enter all that was happening in the setting of colonialism including this establishment of the sex trade and an creation of larger cities and-and-and cities in which trade was occurring and so at that point once colonisation at colonialism occurred in Africa cities became larger and by the second half of the of the night of the 20th century you can see that populations were growing in size and by about 1960 Kinshasa had reached greater than a hundred thousand in population so the idea here was that it's possible that HIV was percolating in human populations around the turn of the century and the first half of the 20th century relatively undetected there were people were far apart there was not big cities there was not people crowded together and importantly there wasn't a sex trade that was established by by colonists who came and established this and so and so probably what happened was it was the superimposition of that history on top of a low-grade percolating virus in the community - led to the spread of HIV and I will refer you to this article because it's a nice article if you want to sort of understand all of this this was published again in a Lancet in 2011 but if you look at the chimpanzee on the right again we think that the Panter quantities to quality strain passed over into human populations in the 1900s the gorillas strain which was a group P probably passed over in the 1920s the mangabey strain probably passed over the 1930s and then evolution occurred within the human host as it spread within human populations and then all you have to do is then look at Western African history and then go to Eastern African and Southern African history to understand what happened from there I do want to bring up one tiny point because I don't want to dwell on this this is a this is provocative but I do want to refer you to an interesting paper that dr. Heywood actually sent my way in December it was just published in December 2012 but this this was a study which looked at needs to be replicated only group that's ever looked at this but looked at specifically the Bayaka Western pygmies in West Africa and this particular population is exposed most to this common chimpanzee and specifically that's that that chimpanzee the Pan troglodytes are qualities that has the SIV strain most closely related to our HIV strain and when they looked at the genome or the genetic structure of this particular sub population beocca Western pygmies they had evolved genes within the human genome that were protective against HIV they had genes in their genome that are only seen in for instance Western European populations that were possibly involved protection from HIV HIV as a happy accident to evolving protection from smallpox they had genes in their genome that we not would not have expected in western Africa but they were all associated with being protected from HIV infection and this is I'm going to leave you with that the their idea is that HIV may have crossed over into human populations at least human populations with a lot of exposure to this particular primate a long time ago and may have even led to changes in the human genome in this particularly isolated population leave you with that so so let's go back to history so what happened from western Africa so if I if we think that that I told you that Kinshasa started essentially burgeoned in around 1962 a large population sighs there was still long distances between cities in western Africa difficulty and travel there was insecurity and violence at the time as as as colonialism was being fought and but what needed to happen for this virus to spread successfully was that it was carried from Western to Eastern Africa probably in the 70s and at that point the spread was rapid if you look at for instance the five countries that border Lake Victoria in East Africa Uganda Rwanda Burundi tanzy Tanzania and Kenya we know by the mid-80s that the epidemic had reached really frightening proportions already by the mid-80s at that in those countries so there were lots of factors that led to this there was labor migration and by 1988 35% of truck drivers in Uganda were positive for HIV there's a high ratio of men in the urban centers in East Africa in these countries at the time there was a relatively low status of women circumcision seems to be protective and there were low rates of circumcision in the region there was a high rate of sex trade and the sexually transmitted infections and by 1986 85% of sex workers in Nairobi were infected with the virus and then the virus had to just travel down to South Africa by the tanzamarie and by the mid and late 80s sub-saharan Africa and South Africa was really the focus of this pandemic and I'm going to show you a series of maps and then we're going to end that that illustrate this this this incredible spread and this devastation but this is the map from UN aids from 1985 where you can see the darker areas are showing regions of high prevalence of HIV infection so again Western and Central Africa predominate by 1995 we have spread all over Africa very deep red areas in South Africa sub-saharan Africa and over in Southeast Asia and then this is 2005 really concentrated epidemics in sub-saharan Africa spread to the former Soviet Union and darker areas as you can see in South Asia and over to the United States this is a again from that same article that I refer you to if you're interested in really exploring how each particular strain went from place to place to place but just to focus in on the United States we think that this clade B that's the most predominant strain in the United States was introduced from Haiti around 1972 and that's the circled area there and this is the current map that will come up again and again in throughout our course HIV past present and future because this is the total number of adults and children estimated to be living with HIV as of the end of 2011 30 4.2 million people infected and as Diane already told you 30 4.2 million infected but 2 million new infections I just want to present a teaser for what's going to be coming up in a couple of weeks when we focus on HIV infection and women and children but if you look at the purple line here that represents the percentage of adults worldwide who are living with HIV who are female and you can see the purple line globally the 50 percent mark was reached quite a number of years ago and we're now in 2010 you know definitely at a pandemic that affects men and women equally and in fact in regions of the world where the epidemic is most concentrated like sub-saharan Africa which is the Green Line you can see that the epidemic is most pronounced in women in fact with up to almost 60% of women being infected 40 percent of men in densely affected regions and one comment on children but we're going to go over this a lot more but at this point Africa has 15 millions AIDS orphans and and this is defined as children who have lost one or more parents to AIDS and I do want to point out that there's a character in the Sesame Street in South Africa who's designed he's tapped Mikami is actually both an AIDS orphan and HIV infected himself and and he is literally present in the in South Africa tackle any sesame which is the Sesame Street equivalent to teach children about HIV and when Connie tried to come over to the United States the u.s. traditional use coalition in the Senate said that that would he would encourage homosexuality but I don't think he's gay I think he's just a little kid so stop aids make the promise so thank you so much and I'll take questions now on the origin or when it entered human populations and then we'll move to our panel please introduce yourself if you're ok with that when you ask a question so the spread of the question was that the spread of HIV did it start from the 1970s so the theory is that it entered human populations way before that probably around the early 1900s but that in 1970s is when cities and so that he that HIV was probably sitting there in human populations at a low rate in West Africa and Central Africa without causing major outbreaks it was really the the theory of history superimposed on top of the crossover is that it was when cities developed that were large and concentrated in the setting of urbanization in the setting of social disruption that occurred with colonization and in the setting of an establishment of a sex trade where HIV could be Strad sexually that HIV started to spread more quickly and that at least in history if you look at Western Africa and specifically at the Belgian Congo at the time what it was called that mainly occurred in the 60s and the 70s and then as I showed you as cities became bigger and as the sex trades grew it seemed like the spread again the manifestation of the disease was more obvious in in in the later decades 80s and 90s but no we think that HIV probably started and came into humans earlier but it was it required a certain population density to manifest yeah sorry I should have yes yes I should have explained this better what this means what this is indicating of all HIV infected people in a country the percentage who are female seem to be 57% and the percentage are male in that region would be 43% so of that 30% who are actually infected this is the breakdown by sex so not of the entire population right right but but obviating factor now in this country word about and again this is this is limited by our surveillance in this country but in this country right now of all the people who are infected in the United States there's about 26% of them are female so it really depends on the setting so I quoted you from 1986 that 85% of sex workers in Nairobi were infected but there have been major strides in prevention in sex workers in a number of different countries in Africa and there been great strides in India for example so those overall percentages have come down if anyone has the exact percentage in Nairobi at this point among sex workers and welcome input from any of the faculty but I don't know where we are right now but it it couldn't have gotten worse than eighty five percent and with prevention efforts it's probably much better than that and one important point about that is is there regions where there's what's called generalized epidemics and what's called concentrated epidemics so there are places in the world where we think HIV just seems to be in specific high-risk groups but in countries that are hardest hit we call them generalized epidemics because the HIV rate may be higher in groups are at more risk like sex workers but the HIV is spread to the general population and that's called a generalized epidemic and we can talk more about that after the so that is a great question and will be covered more the last day of the course when Peter Hunt talks about immunology of HIV and jay levy will probably approach this a little bit next week there are a number of reasons why some people tend to progress take a longer time to put to progress to get sick and there are some people who can even control their their own virus and you're right it has to do with their own immunity and their Oh host ability to do that and there's more details on that to come and I would refer you to those talks yeah this is a great question so the question is um I hope everyone heard the question because I want to explain it a little bit so in populations that are highly exposed like a bush meat hunter population they actually have probably multiple crossover events so multiple strains because they have the blood to blood exposure you're absolutely right there have cuts on their hands they're using knives they're exposed to the blood products as they butcher the animals so there is absolutely blood to blood exposure like you said and they can have host a number of different HIV strains but in the general population it's the strain that's most efficiently transmitted from human to human that goes crazy they get spread across the world and so somehow HIV group am you know HIV one group em is most efficiently transferred otherwise we'd have the gorilla strain everywhere which is group P we'd have the N strain which is very rare everywhere the O strain so there's something about the M strain and there's different reasons for it that it just most efficiently transfer it's spread from human to human so this is a great question and this is also around sort of life cycle and the mechanism of HIV infection which will be most revealed when we talk about treatment of HIV because to talk about treatment of HIV and George baby will be doing so we're going to talk about the life cycle of the virus and you're absolutely right the virus enters and encodes and makes itself into DNA and eventually integrates into the human cell chromosome but this aspect that you said that how can you get it out of the chromosome that question which you're referring to the possibility of cure is going to be it's going to be talked about in the last day of the course so I would really encourage you to come in here Steve Deeks dynamic talks I can't cover that that all here but there's he's going to do a great job talking about the immunology and and and the possibility of cure any other and then I think we'll just take just two more okay right here please no it's in its excellent question and you know to give the most simplistic example there's a they are resistant partially to HIV because they have mutations in a gate called the ccr5 receptor that allows HIV to enter human cells and if you have mutations in that gate or better yet you don't make that gate at all you can be exposed to HIV as much as you want you'll never get infected and so that experiment that you're proposing to bring that mutational gate into other humans to help them resist HIV infection is the very topic again of the last day of the course where we're going to talk about here and we're going to talk about those very ideas so it's an excellent thought to hold that question yeah that's a really good question about natural hosts being getting sick when exposed when they are infected with SIV because for instance the macaque is not supposed to have the SIV mangabey strain in it and so the actual model that we use in a laboratory the primate model for HIV 2 infection is we've taken the SIV SM mangabey put in macaques and then the macaque gets sick and that's the primate model but we used to think that s IVs didn't make their primate sick and there's some very very recent data that that made that may not be true and this was specifically in that gorilla model not model but the gorilla and it was the SIV gorilla strain that if present and gorillas seem to sick in the gorillas more than gorillas that don't have that SIV strain so the lentivirus is so slow that it's possible that it is actually affecting ultimately its own primate but there's so many competing diseases and so can meet many competing illnesses that it may have been that other things got to the primate before that occurred and I'll definitely send you that reference if you email me I'm on the global server and I'll send you that reference that's true of HIV as well if it's in low level in human populations if and and in places where there a lot of tropical diseases you could be getting sick from other things and dying from other things before HIV had a chance to make you sick I think we should stop because we have a very exciting panel so I'm going to allow Diana to come here so thank you so much I'm sorry about these slides being kind of messed up but I will email you these slides the updated slides later this week thank you so thank you Monica for the terrific talk and thanks to the audience those were really excellent questions a lot of them are going to be addressed during the the course so now we're going to talk about the the history of the AIDS epidemic and I don't think any community is ever quite ready for an epidemic and that was certainly the case in San Francisco in the knurl the early 1980s when HIV appeared apparently precipitously I think the city was on the heels of the the Harvey Milk assassination in the George Moscone there was a lot of bursts of sexual freedom and there was a whole confluence of events that happened that allowed HIV really to just erupt particularly in the MSM community in our city I would refer you in terms of the early years of the HIV epidemic to a book which is called and the band played on by Randy Shilts in fact I was thinking at the end of the course always got extra copies that this movie will raffle off a copy for those of you who make it to the end of the course it's really great reading and it goes into the very early days of the HIV epidemic particularly Los Angeles New York and San Francisco on our curriculum we had dr. Paul Volcker ding who is featured heavily in the band played on as a speaker for the second part of our mini medical school this evening dr. Valle birding sends his regrets and he was unfortunately unable to attend this evening however in his place and I hope you will not be disappointed we were all thinking well what is the best way for us to come vait the history of HIV epidemic here in our own city and that's by asking people to talk about who were here and who were experiencing the epidemic so what we have done is we're going now to move to a panel discussion and I'd like to invite the panelists to come up to the table and for this segment of the course what we'll do is I'll ask the panelists a couple of questions and then dr. hare is going to give us a brief overview of the epidemiology currently in San Francisco and then we will open it up to a piano discussion so I am going to let the panelists really share with you their story and they will individually be introduced as I ask them questions as opposed to going through a lengthy introduction so I'm going to start with asking a question to our first panelist mr. Lu Grosso one of the things that we do in medical school and in medical education is we invite patients to talk about their disease and their disease experience and I have colleagues who work in various different fields and they say you know how did you guys make so much progress in aids and how do things go so quickly and frankly it's never been quickly enough for us but I can tell you the key secret ingredient is the community and we in San Francisco have had a community of people affected with this disease we would never have made as much progress that we've made and one of the individuals who really to me is emblematic of giving their time talking to people about HIV being a really true Crusader is mr. Lu Grosso and I like everyone really to give Lou a round of applause for joining with us this evening so I thought we could start out by asking Lou just to share his story about what happened in the early years of HIV epidemic for Lou thank you well and I guess my story started I was born in know in 1986 I came back from a two and a half year stint in Germany and while I was there I found out that the last person I had had sex with before going to leaving for Germany so that would have been June 1983 had died of AIDS while I was in Germany he got sick and died of course I didn't know he had it so I the first day I got I arrived back home in San Francisco on January 1st and I had an appointment with my doctor on January 3rd and I was tested and kid came back that I was HIV positive and he sent me to a doctor who was then the so-called expert dr. Robert Armstrong I think it was his name he was down in Los Gatos and he determined that my t-cells were really low they were like around 200 or so and therefore by definition I had AIDS and that I probably had three years to live and that there was really nothing much I could do just stay healthy be say come in for check-ups so of course being young kind of said yeah okay and went on with the rest of my life and what I did experience one real issue which I hadn't told anybody about I had a dentist appointment in late 1986 and I went into my my dentist who I known her a long time and I told him my head aids and he had a real hissy fit and threw me out of the hospice I mean literally yelling screaming and just threw me out and that was just well okay I guess I can't be open about my HIV status anymore so much for medical community helping you out but after after that experience um I tried keeping it all to myself as much as I could didn't really tell anybody didn't go out 1989 came and well I'm supposed to die so I better get on with the rest of my life and I started I moved to San Francisco moved in with a couple got a new job in a new industry I became an office manager at a law book store of all things I was my profession before this was fasten your seat belts I was in bowling I was a bowling center manager of bowling center mechanic I taught bowling I anything to do with bowling so I moved to the city and got a Java as an office manager at a law bookstore and start a new beginning because my life was supposed to end so new beginnings then the partner my roommate started getting sick hich found out he had HIV which but he wasn't sick with AIDS and he started having problems then I helped him with legal issues and I started taking him to doctors appointments and we became close and he got real sick in 1993 November 3rd I remember I took them to San Francisco General and they did a bunch of tests and they came back and said that he had cancer and probably had about six months but they really weren't sure their test was showing cancer but they were couldn't be more specific on that so they admitted him to the hospital and six weeks later he was in the hospital for six weeks and they came back and said to him um we know you're sick we know you've got cancer we can't locate it we don't know where it is so we're going to say you have AIDS it was the he just fell through the all the slots and look we can't figure it out so you must have AIDS and they sent us over to ward 86 San Francisco general the outpatient clinic and got in touch with the terrific doctor dr. Donald Abrams and who is also he was an aged doctor and an oncologist and we got it all figured out and he did have cancer he had and had KS in his colon and no markings of chaos anywhere on his body it was all in his colon and I fell in love with with Donald Abrams and he became my doctor too and Dan died in June and June of 94 and Donald and I I was his patient for many many years until 2004 and that's when I met four at Brad became my doctor you know and when I I was exposed to HIV like I could have been as early as 1979 or as late as that June 1983 date my the medicine I took I had one point in 1989 I started taking AZT it I didn't have any problems with the meds at all I didn't affect me I didn't get sick from there was no side effects it did nothing for me as far as my number stayed the same in 1998 I think it was I get started the the new drugs my t-cells went up a little bit they went from 200 to 300 I feel like I'm one of those people that there's some keeping me alive I don't know what it is but something's doing it and I that's why I participate in as many studies as I can as often as I can because I want them to figure out what's keeping me alive so that's about it our next panelist is Deon Jones who is a nurse who was raised in France did Peace Corps in Togo and then made her way to San Francisco and she's going to tell us how actually she got that job and what she's been doing since but Dionne what I'd like you to do is to to to share with the with the students what it was like is a provider in the very very early days of the HIV epidemic particularly in San Francisco General Hospital okay thank you I have some sister nurses out there and probably brother nurses too so thanks a lot Lu now mark leaned over and said you dumped Donnell Abrams for a younger man disappointed live so so going back to a Monica story in her timeline so think back like you know early 1980s in San Francisco and in preparation for this panel yesterday I got I watched this new documentary that's called how to survive a plague which is nominated for the Academy Awards in the documentary section and it's really about the history of act up primarily on the East Coast in New York and it's a really interesting film for people who are interested in the history of HIV some very incredible and moving archival footage and I think that what it reminded me of is that every community around the world has its story about HIV and we have our story here in San Francisco and we've hosted at San Francisco General many visitors from all over the world that collaborated with on research projects and and and travel back and forth and they always I always ask them I tend to be the person to have to do the who are our patients and why is our HIV epidemic so different here in San Francisco than it is in Tanzania or South Africa or China or Japan and every place has its story of how this epidemic evolved in our story really in the 1980s started with it with this epidemic in this virus really locating itself and finding a host within the gay community through in the United States in the major urban centers going back to Monica's point particularly Los Angeles San Francisco and New York and for those of you that are old enough to remember this was an incredibly vibrant time in the gay rights movement coming after 30 years of a really growing and maturing civil rights movement that started in the african-american community in the 1950s and then got picked up in the women's rights movement and then its natural progression was it came upon the lesbians and gay men fighting for civil rights it was a straight-up civil rights movement and in San Francisco we had a very mature it was a very political City since since a long time and we had a very mature gay rights movement with institutions and as Dian referenced we had elected our first openly gay elected official Harvey Milk we had been through the tragedy of his assassination and that of the mayor of our city and it was a mature movement and with a lot of people coming from all over the world and all over the United States in fact in the early 1980s the estimate of the number of gay men living in San Francisco was close to 200,000 people and then you have this this HIV virus it's a sexually transmitted disease and and just like the women's movement really took up the issue of women's rights and the issue also of control over our sexuality the issue of in the lesbian gay rights movement was taking up the issue of sexuality and the right to have sex and so here you have a sexually transmitted disease in this virus that is entering in our city at a time when people are having a lot of sex and and so very quickly it emerged these patients these people were writing very sick who had previously been well they were very young for the most part and our institutions our health institutions were really overrun so I started working at San Francisco General in 1982 I just graduated from nursing school at City College and and I was assigned to a medicine ward and I would say close to a third of the 34 patients were people living with it living with AIDS and dying of AIDS so back in those days HIV disease was a combination of caring for extremely ill patients sort of intensive care nursing and also caring for people who are dying and so you had this to things that you were holding at the same time of trying to keep people alive who are extremely sick and at the same time caring for people as they're dying and really learning how to do that with a population where you're not expecting to be having to do end-of-life care with a 21 year old or a 22 year old who just found out three months ago that they had this thing called AIDS which back in those days we didn't even know what caused it so by 1982 we knew we we knew what AIDS was AIDS was defined we were calling it gay related immune deficiency anymore we knew most likely that it was a sexually transmitted disease and so blood-borne meaning we had to protect our blood supply and we had to understand how drug use was facilitating the transmission of this virus but we still didn't know what caused it and in the city really and this is one of the wonderful things about this documentary the how to survive a plague is that at that point in time you had these major building blocks of a city so you needed the science and you needed the medicine and you needed the policy people and particularly the public health policy people and you needed the politicians you needed the healthcare workers and most importantly what we had as Diane referred to is really what we had was this community of activists some of whom were infected many who were not who were at the table demanding that the services be provided and that we figure out how to do this how to do it right and how to do it well and I think that that was what was so unique in in a place like San Francisco that that we could do that and many mistakes were made and there were many many hard discussions where weighing the public health on the civil rights issues for example the whole issue of closure of the bathhouses these are extremely complicated issues we face comparable issues today and and the whole city was really involved and engaged in this and our physicians and nurses who were by day taking care of patients were at meetings at night with act up or at the Health Commission or at public forums trying to answer the questions about what is going on and and I think that that's one of the things that in San Francisco you have to really appreciate is that the strength of a response is really in direct proportion of the strength of the institutions and so one of the unique things in San Francisco is that people in San Francisco support their public health department they do it every time a ballot measure is on the ballot to rebuild Laguna Honda hospital or rebuild San Francisco General where they're essentially voting against the financial self-interest we're agreeing to tax ourselves because we believe these institutions are really important we believe in the strength of community organizations and we also had to figure out how to have these conversations at the table where scientists some of whom you're going to hear from in this course are for the first time sitting across the table with patients and having to have these conversations about how to take care of this illness how to do it right and how to do it well and you know for me when I came to San Francisco General in 1982 my goal in life was to become a midwife so here I am 30 years later and and I found myself you know after the first ten years of like okay how did I go from wanting to be a nurse taking care of women giving birth to being a nurse where I'm primarily taking care of men who are dying not exclusively men by then but but I think there's something about for me as of all of these different these different institutions and different parts of society that have to come together to respond and to how to survive this plague that was that was so compelling that that I couldn't leave and so I Here I am 30 years later and and I think some of those is some of the reasons are the same now and I think as the course goes on and we talk about HIV today and the reasons why we can be hopeful and we can be talking about a cure the reasons why somebody like Lou is here with us tonight so that we can really celebrate what his ongoing and continued contribution is to continuing to figure out how to do this well and how to do it right is is a really compelling story and I congratulate you all for coming to this course and really I think you'll enjoy the speakers over the next few weeks because it's an exciting and very compelling story thank you Dan you really want to thank you personally for all you've done in the epidemic and you make the nursing profession proud Dion is a frequent speaker in NPR she thought she's often interviewed just about our clinic and what's happening there and which it's been really wonderful to have her our next panelist I wanted to ask to comment is dr. mark Jacobson dr. Jacobson is a professor at UCSF an AIDS expert on our faculty who's been working in the epidemic and I'll share with you from the very beginning mark I was I think we've heard a lot of positive and aspirational things that we've done in San Francisco is a city but myself being a provider going through these early dark days can you comment a little bit on your experience but also what it was like and Lou eluded this to a little bit when we are trying to get care for our patients early on often what a challenge it was when within our own profession where people allegedly had a commitment to care sometimes that we had to overcome some obstacles so what you can talk about your your early years and for example when we would try to get procedures done and things like that some of the challenges that we have well I think I think at the beginning it would and I graduated from medical school here in 1981 just before those articles that Monica showed that CDC published and people had no idea what was going on and the way that doctors handled it was a full-court press and I as it became apparent that this was an infectious disease for which there was no effective treatment at all and it became more about just trying to make people comfortable and when it became apparent that people who took care of these patients were potentially at risk themselves from exposure to blood and doing procedures that's when a lot of people pulled back not so much in the Bay Area as other parts of this country we're very fortunate here but it happened here and in fact I remember I finished medical school I did a residency I went to UCLA for two years to study infectious diseases and then I came back and I was hired in 1986 on the faculty here and when I was hired here tear was and wertha Pietist there was the actually the head of orthopedics in San Francisco General Hospital was a woman who absolutely refused to take care of or operate on people who had hid and yes it was a woman yes Lorraine dead um is Lorraine here tonight oh I'm not good she said and but and and things got very polarized there were search into her at much greater risk right because they were more likely to cut themselves then then we were we were signal needles in people and sticking ourselves especially when we were inexperienced when I was an intern in 1981 I took care of a the first patient in the hospital I was training at who had a Pneumocystis and very very sick in the ICU requiring dialysis and on a ventilator and either every other day for like three or four weeks I had to put either a catheter in a deep vein in the neck or else a tube into his abdomen because we didn't have hemodialysis it was a different kind of dialysis and covered with fluids and and I was an intern and I was clumsy and I made mistakes little mistakes but sometimes cut myself and and that kind of fear grew once we understood everybody understood that this was a virus I mean at that point that was 1980 when people had no idea what this was but so there was there was a lot of fear and pushback there were a couple of health providers who one in particular not not here but I won't forget this this is a very young cardiologist at Hopkins who who is it while he was in training he had stuck himself a deep needle stick and he had small children and he died and just before he died he wrote a long very moving essay about his experience that was published in the New England Journal and I miss it was pretty devastating I don't know if that addresses the question no no we just wanted to share experiences so I want to come back just a little bit this week so I want to get back to the audience Dion we think of HIV as being an MSM disease in San Francisco what's the first memory of a woman that you took care of infected with HIV so pretty early on I think there's there were a couple of like myths around the storyline of like one of them was that initially it was a disease only of middle-class white gay men and then somewhere along the way it became a disease of poor people and the same true as the meth around women and in fact from the beginning it was a disease that affected all strata of society and so it's an Francisco General we had homeless people living with HIV from the very beginning and probably I think the first woman patient that we had on the HIV unit once it was open in 1983 was you know within six months and it was a very I think it was very shocking for people I mean logically by then we sort of knew why women could be at risk and we knew that women had been infected in newer cases another place of the world but then when it occurred it was very shocking and actually remember having a fight with Randy Shilts who at the time was a reporter with a chronicle and as you can imagine you know we as nurses and doctors that we had to learn how to deal with the press which was not part of our training and nursing school or medical school but it was an ongoing thing and and learn how to use the press in a way that could be helpful but off times that also meant having to protect our patients and their privacy and Randy Shilts was absolutely bound and determined that he was going to come in and interview this woman and there was no way in the world that she was interested and being interviewed for The Chronicle and no way that any one of us was going to let him anywhere near her and it was a very I think I think what ended up happening very early on and I think a lot of the work that Manik is doing now was really happened the beginning of it happened in those days is that that women started to find each other and support groups were created for women living with HIV and in fact a few years later at Ward 86 we really came to the realization that because the majority of our patients were men that the experience of women taken that elevator up to the sixth floor and sitting in the waiting room oftentimes is the only woman was a very alienating experience and so we created a women's clinic on Thursday morning and all of our providers see most of of women patients and the whole waiting room is only women and we have breakfast and we have support groups and and it becomes a much more a less scary and alienating experience and to this day and we're using some of that same approach for young young people and and also for our Latino patients it makes a difference when you walk in a waiting room if you see people who look like you or you don't and it's a very scary thing we I have many of my new new positive patients who tell me that it was scarier taking the elevator for the first time for the first patient appointment and coming off of that elevator than when I told them that they were HIV positive in the emergency department there's something about that first visit that's for this is agate this is for the rest of my life this is what's happened to my life and it's a scary experience so you have to create an environment that helps mitigate that alienation in that fear in in we're social animals and so the sense of community is really important in the sense of solidarity is really important great thank you very much I have so many more things I want to ask the pants but I also want the audience have a chance to ask questions what we're going to do now is I'm going to ask the panelists to go back to the to their seats doctor here our clinic director at Ward 86 we take care of over 3,000 patients is going to give us a quick run-through on the HIV epidemiology in San Francisco and then we'll wrap it up with questions from the audience all right thank you all for sticking it out I'm going to try to keep my remarks short but I do want to give me my role this evening is to give you a bit of perspective on what HIV is like in San Francisco so we've heard a bit about some of the the global numbers and I think to me you know every epidemic is ultimately local and understanding what happens in San Francisco is really important to how we take care of the people in San Francisco and these numbers are I think really are part of what makes San Francisco unique the prospective wise there's a new infection of HIV today every 12 seconds in the world every nine minutes in the United States and every day in San Francisco so we are in 2011 these are absurd doesn't project all that well but these are just some of the numbers so in San Francisco to date there's been over 35,000 infections and over 19,000 people have died in San Francisco of HIV currently we estimate somewhere between 15 and 18 thousand people in our city live infected with HIV and we're fortunate that the number of new cases has been going down in San Francisco due to a number of different factors great testing strategies linkage of patients to care getting people on treatment and making their virus undetectable through treatment which we now know as a very very effective tool to prevent spread of HIV so now we have about 392 new infections every year and I just put for comparison the numbers in California the US and the world it's some kind of almost incomprehensible to think of the origins that Monica outlined for us of those isolated transmissions from monkeys to humans and now thinking that over 72 million people have been infected in the last hundred years and some numbers that I think are really still quite staggering for people to understand these are current statistics in San Francisco if you look at the gay male population in San Francisco one out of four men gay men in San Francisco is HIV positive and that number for men who live in the Castro is greater than 50 percent the highest rates of new infections in our city is among transgendered injection drug users who are infected at a rate of 6% per year just staggering numbers for the rates of new infections this slide is a graph from a well site in New England Journal article really this was titled AIDS in America forgotten but not gone which looks the bars in the left or prevalence rates are the rates of infections and populations in the United States looking at certain isolated both global United States at the far left and certain isolated populations and comparing those to Africa we all hear so much in the news about AIDS in Africa and looking at the prevalence rates in some of these populations specific populations the United States how they compare to Africa and how they compare almost shockingly equivalently and I took the liberty of as of others of adding San Francisco's gay male epidemic on this graph and we still have prevalence rates of gay men that are really on par or surpass those in the generalized populations and at sub-saharan Africa so to break it down just a bit more so who are these 392 new infections in San Francisco well 88% are among men 2% transgender about 10% women so in San Francisco unlike other up it's the United States our epidemic still is primarily among gay men not exclusively and it's really important to remember it's not exclusively among gay men but these numbers would be very different if you looked in Oakland if you looked in Atlanta if you looked in New York of those infections the large majority are among men who have sex with men that's what MSM stands for our epic is still largely among white men but disproportionate to our city's population Latino and in particular blacks are over-represented in our city's epidemic and interestingly you talk about the aging of the HIV epidemic one of the new frontiers of HIV and about one in six new infections in San Francisco occurs in men over the age of 50 we also hear a bit more about AIDS in children but it's a testament to our prevention efforts in the city that there's not been a case of HIV and a newborn since 2005 so a tremendous early success in HIV with the prevention of transmission between mothers and children so we're in our city it is HIV reside so these are it's a picture of the neighborhoods in San Francisco the darker purple areas are areas with higher concentrations of the epidemic and the lighter purple areas are lower concentrations so probably not a surprise to people HIV centered around the Castro along the Market Street corridor down the Tenderloin in South of Market areas but also important areas infections in the south eastern parts of the states of the city sorry of Bayview and Hunters Point this is a slide that Dion added in I'm just going to orient you to this this is these are the San Francisco AIDS cases you can see the the number of AIDS cases there in green this is not HIV but a clinical diagnosis of AIDS there in green that have gone down with the advent of effective treatment the number of deaths in pink from a it's also going down but as a result the number of people living with HIV the yellow bars really have gone up so we're seeing a lot more people fortunately living longer lives with HIV but the prevalence in our city then actually stays high even though the number of new infections can go down so that's just a brief snapshot of what the epidemiology of HIV looks like in San Francisco and I wanted to highlight the uniqueness I think of our city and in that respect and how that shapes our city's response to HIV so that will turn back over to dr. Howell here thank you very much Brad for that nice overview I want to thank you for being a wonderful audience it's been a really terrific evening please feel free to come to the front and if not we'll see you at the next course which is on February 26 you

Channel: University of California Television (UCTV)

Views: 322,465

Keywords: HIV, AIDS, Monica Gandhi

Id: ph6_Z6NIx98

Length: 87min 39sec (5259 seconds)

Published: Thu May 16 2013