RESEARCH
ON AIDS BENEFITS EFFORTS AGAINST OTHER DISEASES prepared by
the NIH Office of AIDS Research
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Introduction
Because of the unique nature of HIV--the way the virus enters a
cell, causes infection, affects every organ system, and unleashes
a myriad of opportunistic infections and cancers--and the pace at
which the knowledge base has been expanded, AIDS research also is
unraveling the mysteries surrounding many other infectious,
malignant, neurologic, autoimmune, and metabolic diseases. In
addition to its direct and indirect medical applications, basic
knowledge of the biology of HIV infection and the processes by
which it causes AIDS benefits other areas of basic research
including immunology, virology, microbiology, molecular biology,
and genetics. The study of drugs to treat HIV infection and its
complications also has helped to establish new approaches for the
design and conduct of more rapid clinical studies, as well as
those that address the special recruitment requirements of women,
minorities, and other underserved populations. In addition to
learning more about the special recruitment requirements of these
populations, the investment in behavioral and social sciences
research has provided effective strategies for intervening in
other diseases modified by individual behavior.
Effective drugs to treat other
infectious diseases
The investment in AIDS research has provided a new paradigm for
confronting viral diseases in general. Prior to the development of new
potent antiviral drugs, virtually all efforts to combat viral diseases
involved prevention (using vaccines) or palliation (treating
symptoms). Few effective treatments were available for most common
viral infections. The AIDS drug development experience has not only
benefitted development of treatments for other viral diseases, but
also will hasten drug development efforts for bacterial, mycobacterial
and fungal diseases.
- The successful development of four classes of drugs that limit
the replication of HIV, nucleoside reverse transcriptase
inhibitors, non-nucleoside reverse transcriptase inhibitors,
protease inhibitors, and nucleotide analogs, represents a landmark
in drug development for the control of viral diseases. The first
drug in a new class, fusion inhibitors, was just approved by the
Food and Drug Administration (FDA).
- The identification of several new viral and host/cellular
targets will permit the development of new drugs for HIV and other
viral infections such as integrase inhibitors, assembly
inhibitors, and zinc finger inhibitors.
- The successful development of powerful multi-drug
combinations capable of inhibiting viral replication in different
stages of the virus life cycle represents an important approach to
potentially controlling other viral infections and delaying
disease progression.
- Experience gained from characterizing the HIV protease enzyme
and developing protease inhibitors also is being applied to the
design and development of potential agents against the coronavirus,
which has been identified as the causative agent of severe acute
respiratory syndrome (SARS). An antiviral agent against this virus
may inhibit viral replication, halt disease progression, and
prevent the high mortality rates associated with this disease.
- The drug lamivudine, (also known as 3TC, an inhibitor of the
HIV reverse transcriptase enzyme), initially developed to treat
HIV infection, has been shown to be effective for the treatment of
chronic hepatitis B infection, and it has been recently approved
by the FDA for this purpose. Prior to the availability of
lamivudine, HBV could only be treated with injections of
alpha-interferon, and many HBV-infected persons proceeded
inexorably to cirrhosis, liver failure and liver cancer.
Lamivudine is more effective than alpha-interferon in producing
HBV disease remission and provides the important new option of an
oral drug for the treatment of a disease that affects 300 million
people world-wide. In addition, lamivudine represents a "lead
compound" that should expedite the development of even more
effective therapies to treat, and perhaps even cure, chronic
hepatitis B infections.
- Another antiviral agent, adefovir divipoxil, (Hepsera), which
failed as an HIV treatment due to kidney damage, was found in a
much lower dosage to suppress HBV without damaging the kidneys,
and was recently approved for treatment of chronic HBV disease.
- Development of combination therapy for HIV infection stimulated
interest in utilizing combination therapy to treat hepatitis C
infection. Pegylated interferon, initially tested on HIV-infected
patients with Kaposi’s sarcoma, later was shown to be effective
for the treatment of HCV infection.
- Experience gained from the development of protease inhibitors
also is being applied to vaccinia virus (smallpox) research. There
is currently no antiviral drug to fight smallpox. An antiviral
drug might act as protease inhibitors do in HIV-infected
individuals, preventing viral replication.
- Current therapies for cytomegalovirus (CMV) are toxic and
expensive. Using techniques developed to derive inhibitors of the
HIV protease, new candidate drugs have been designed that
represent promising leads as agents to treat CMV infection.
- Using techniques successfully validated in the course of HIV
drug development, progress has been made in targeting a number of
steps in the influenza virus life cycle for inhibition.
- New animal models of viral diseases that have been developed by
AIDS researchers will facilitate studies of other infectious
agents and the diseases that they cause.
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Advances in methods for drug design
AIDS therapeutics research, particularly the development of
protease inhibitors, has convincingly demonstrated the importance of
structural analysis in rational drug design and has resulted in a
new generation of powerful inhibitors of HIV replication. Progress
in this area depends on the identification of a promising molecular
target for drug therapy, determination of the three-dimensional
structure of the target molecular using sophisticated X-ray
crystallographic methods, and structure-based drug design aided by
the techniques of structural biology, optimization of ligand
affinity and selectivity, and computer-based molecular modeling. HIV
research has benefitted from the availability of these individual
methods and, concurrently, has fostered significant improvements in
each of these critical technologies, including X-ray
crystallographic methodologies, nuclear magnetic resonance
techniques, and computational approaches to medicinal chemistry. The
continued support of these technological advances will benefit
efforts to develop new drugs for other diseases. A number of the
most promising anti-cancer drug candidates currently in clinical
trials, including the mechanistically novel inhibitors of matrix
metalloproteases, have been developed with a similar iterative
structure-based approach to drug discovery. Structure-based drug
design may also lead to the discovery and development of lead
compounds against the coronavirus associated with SARS
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Treatments for opportunistic infections
Individuals who receive drugs that intentionally or
unintentionally suppress the function of the immune system are, like
HIV-infected patients, at significantly increased risk of infection
with microorganisms that generally do not pose a hazard to those
with fully functioning immune systems. Many forms of treatment for
cancer involve the use of drugs that suppress the immune system.
Transplantation of solid organs to treat organ failure (e.g., heart,
liver, or kidney) and bone marrow transplants to treat malignant
(e.g., leukemia) or hematologic diseases (e.g., immunodeficiency
syndromes or genetic disorders of hemoglobin production such as
sickle cell anemia) necessarily involves the use of drugs that
suppress the immune system to prevent rejection of the transplanted
organs or tissues. The development of effective drugs to prevent and
treat many of the microorganisms that cause such opportunistic
infections (OIs) promises real benefit to those undergoing cancer
chemotherapy or receiving anti-transplant rejection therapy.
- Clinical research to delay or prevent life-threatening
AIDS-related opportunistic diseases has helped to stimulate the
development of effective drugs to treat these pathogens in
immunosuppressed persons, such as Pneumocystis carinii,
cytomegalovirus (a cause of blindness in people with AIDS and
life-threatening pneumonias and serious gastrointestinal
infections in bone marrow and organ transplant recipients), and
a variety of serious fungal infections that cause meningitis or
disseminated infections.
- Research on AIDS therapies has helped establish the concept
of "prophylaxis" of certain infections in
immunosuppressed persons. Providing regular, low doses of drugs
that are intended to prevent development of disease
decreases the risk of opportunistic infection. This approach
recently has been shown to be highly cost-effective in the
course of treatment of HIV infection. Prophylaxis of OIs is now
standard practice to prevent infections caused by a variety of
bacteria, viruses (such as CMV), and fungi in immunosuppressed
patients. However, it should be noted that the overall incidence
of OIs has declined with the use of antiretroviral therapy
(ART), and ART is now considered the most effective approach to
preventing OIs.
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Understanding the origins and manifestations of malignancies
One of the cardinal manifestations of AIDS is the predisposition
to develop specific types of cancer, including Kaposi's sarcoma and
non-Hodgkin's lymphomas. That these cancers arise in the setting of
host immunodeficiency provides strong support for the notion that
the immune system can play an important role in suppressing the
development of cancers. Because HIV suppresses the immune system and
most AIDS-related malignancies are strongly associated with viruses,
HIV infection provides a unique model to study the interplay of
viruses, the impaired immune system, and the development of cancers.
The HIV model also provides a unique opportunity to test novel
approaches by which immune responses can be modified to help treat
established malignancies.
- AIDS research has helped to broaden the understanding of the
types of viruses potentially involved in the development of
cancers. The discovery of the likely cause of Kaposi's sarcoma,
the herpes virus known as HHV8, provides a model for using novel
techniques of molecular biology to search for infectious
cancer-causing agents in any type of cancer. Studies involving
HIV-infected persons are now serving as the model to identify
potential infectious etiologies for several common malignancies.
- IV-infected women who also are infected with human papilloma
virus (HPV) are at increased risk of developing cervical cancer,
suggesting that the immune system also plays an important role
in controlling HPV disease. A link between HPV infection and
cervical cancer also is seen in women not infected with HIV.
Studies of HIV-associated cervical cancer have stimulated new
areas of research and therapeutic strategies to treat this
disease, which will likely benefit all women at risk of cervical
cancer.
- Wasting, the intractable loss of weight, is a common clinical
manifestation of both cancer and advanced HIV disease. New
therapeutic approaches developed to treat HIV-associated
wasting, such as recombinant human growth hormone, nutritional
interventions, exercise, testosterone replacement, or anabolic
steroids may prove to be of benefit to persons with cancer
cachexia.
- The field of HIV-associated wasting syndrome research is
rapidly changing as a result of the introduction of
antiretroviral therapies (ART). New-onset diabetes, a series of
metabolic abnormalities, and abnormal fat distribution have been
described in HIV-infected individuals taking ART. Peripheral
insulin resistance (the failure of target tissues to respond to
normal levels of circulating insulin) is a major component of
type 2 diabetes and obesity, and more recently has been
implicated in the pathogenesis of the metabolic abnormalities
associated with ART. Studies elucidating the pathogenesis of the
metabolic abnormalities associated with HIV disease and ART may
provide crucial insights into the underlying mechanisms of
insulin resistance and may prove to be important in
understanding the pathogenic processes operating in type 2
diabetes and obesity. Moreover, type 2 diabetes, central
obesity, and metabolic abnormalities associated with ART are
characterized by alterations in lipid profiles that may confer
increased risk for cardiovascular disease. Elucidation of the
mechanisms underlying these changes could be very important for
designing interventions aimed at preventing cardiovascular
disease in patients with type 2 diabetes.
- Research on anti-HIV drug resistance is providing important
information for the design of more effective regimens with
minimal drug resistance. Insight gained from these studies may
be useful in better understanding the basic mechanisms involved
in the development of single- and multiple-drug resistance and
ultimately lead to the development of better treatment regimens
for other infectious diseases.
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Advances in the ability to diagnose infection and monitor the
efficacy of therapy
AIDS research has provided new paradigms for the diagnosis of
infectious diseases and for monitoring the efficacy of therapy.
Molecular diagnostic methods use sensitive techniques to detect and
quantify the pathogen in an infected individual. These methods now
permit more rapid diagnosis of infectious diseases, facilitate
earlier introduction of effective therapies, permit the design of
faster, more informative clinical trials, and allow the
individualization of optimal therapies.
- Among these new technologies is the polymerase chain reaction (PCR)
test used to diagnose HIV infection or the viral load assays used
to assess disease progression and efficacy of anti-HIV therapies.
The development of these approaches and their validation in the
course of AIDS studies have helped speed the process of clinically
testing candidate AIDS therapies, and similar approaches are now
being employed to study treatments for other infectious diseases.
PCR-based tests are now routinely used to rapidly diagnose a
number of important infectious diseases including hepatitis C,
tuberculosis, chlamydia, Lyme disease, and a variety of fungal
infections. In hepatitis C treatment, just as in the management of
HIV infection, PCR technology has proven to be useful in
monitoring the impact of therapy.
- The application of these technologies to other diseases
potentially caused by infectious agents, such as chlamydia linked
to cardiovascular disease, has made it possible to screen large
sample sets in a very short period of time to identify potential
causative agents of poorly defined chronic illnesses.
- The development of tests to screen blood donations for the
presence of HIV infection has stimulated advances in technologies
that are currently being used to screen the blood supply for the
presence of other important infectious diseases, such as hepatitis
C virus, hepatitis B virus, and HTLV-1 and 2 viruses that are
associated with the development of leukemia and serious neurologic
diseases. As a result, the safety of the blood supply has been
substantially improved.
- Rapid assays developed for the detection of HIV infection
enable more HIV-infected individuals to learn their HIV serostatus,
allowing them to take measures to prevent the further spread of
the virus, as well as to seek medical care for treatment of their
HIV disease. These assays are being developed for detection of HBV
and HCV and may result in improved protection of the global blood
supply.
- NIH-funded studies also are developing and testing innovative
approaches for inactivating HIV and other blood-borne viral and
bacterial pathogens such as hepatitis B virus and hepatitis C
virus to ensure that blood and blood components are safe and do
not result in transmission of diseases.
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Insight into the function of the human immune system in health
and disease
The investment in AIDS research has enormously speeded the
development of our understanding of the human immune system.
Research on AIDS has led to major advances in our understanding of
and ability to manipulate human immune responses. This research may
allow more effective approaches to treat diseases in which
dysregulated immune responses are either the actual cause of, or
substantial contributing factor to, the fundamental disease process,
including allergies, multiple sclerosis, juvenile diabetes, heart
disease, rheumatoid arthritis, and systemic lupus erythematosus.
- Promising immunologic approaches currently being investigated
to control cancer include the use of cytokine therapy to boost
anti-tumor immune responses, the use of genetically modified
tumor cells that express cytokines or other gene products
intended to re-direct host immune responses to more effectively
fight the resident tumor cell burden is another by-product of
HIV research on the human immune system. The expansion (in
tissue culture) and transfer of immune cells that can recognize
and kill tumor cells (activated T cells or cytotoxic T cells)
has already been tested in the treatment of certain solid
tumors, in conjunction with chemotherapeutic agents. Similar
approaches have been actively pursued in the course of research
on HIV therapies, and experience from studies in HIV-infected
individuals has helped accelerate the development and testing of
these treatments in the context of cancer therapy.
- New approaches developed for AIDS research have demonstrated
specific genetic variations affecting immune system cells that
protect against atherosclerosis. Establishing a link between a
specific cell receptor and heart disease will permit the
development of drugs targeted to this receptor in order to block
its action.
- New technologies developed through AIDS research to measure
the in vivo functioning of the immune system are radically
changing the field of immunology. These include: a
non-radioactive endogenous labeling technique to directly
measure the kinetics of circulating T lymphocytes in normal and
disease states; a technique to assess changes in thymic function
with age and during illness; and a methodology to assess the
number and distribution of antigen specific cytotoxic T cells,
which are among the most important players in clearing viral and
other pathogen infections. The availability of these techniques
is affording medical researchers the opportunity to effectively
measure immune function in both healthy and infected
individuals. These findings have far-reaching and important
implications for our understanding of the pathogenesis of immune
diseases and the development of effective vaccines against
infections.
- New methodologies developed in the context of AIDS research
are radically changing our thinking about the function of the
thymus throughout the lifetime. The deletion circles technology
that enables the identification of T cells recently emigrated
from the thymus was instrumental in demonstrating that the
thymus remains active late in life and contributes a diverse set
of functional T cells to the peripheral circulation. This
knowledge is of fundamental importance in understanding the
biology of the human thymus, the role of the thymus in
reconstitution of the immune system in adults, and the role the
thymus plays in post-natal production of auto-reactive T cells
in autoimmune diseases.
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New approaches to the design and conduct of drug trials
NIH-sponsored AIDS research programs have brought about
unprecedented cooperation among federal, university, and
pharmaceutical industry scientists in the design, development, and
testing of potential therapeutic agents and vaccines. AIDS research
has resulted in new approaches in the design and conduct of clinical
trials, as well as in recruiting and enrolling patients, especially
women, children, IDUs, and minorities in these studies. These models
are now being applied to test treatments for other diseases in
faster, more efficient, and more inclusive protocols.
- New approaches for conducting clinical trials have been
developed, including community-based trials, which capture the
expertise of community physicians. NIH-sponsored AIDS clinical
trials have demonstrated the importance of providing ancillary
services, such as general health care, transportation,
obstetrical care, day care for children, and other related
services, to recruit and ensure the continued participation of
women, children, adolescents, and minorities in clinical trials.
- AIDS clinical studies pioneered the development of community
advisory boards to assist clinical trial sites in ensuring close
cooperation with community constituency groups. These strategies
are now being applied in the study of treatments for other
diseases.
- The "parallel-track" mechanism has been shown to be
consistent with the conduct of effective clinical studies of
candidate therapies and will benefit persons suffering from all
types of life-threatening diseases for which existing therapies
are either ineffective or have failed. This mechanism permits
access to promising drug treatments, prior to their formal
approval by the FDA, for individuals who would not otherwise
qualify for participation in specific clinical studies.
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Advances in the study of neurologic manifestations
Research aimed at understanding how HIV enters the central
nervous system (CNS) and how it results in neurologic disease has
yielded important knowledge regarding the role that severe
inflammatory processes within the CNS can have in neuronal
degeneration and impairment of cognitive and motor functions. AIDS
research has provided direct insights into the mechanisms by which
neurotoxic molecules released by inflammatory processes in the brain
induce neuronal injury and death.
- The recent discovery of chemokine receptors has opened new
avenues of research that will probably lead to a better
understanding of the nervous system in both normal and disease
states. Research on chemokines and chemokine receptors has
already stimulated investigations into trafficking of immune
cells into the brain, provided in situ examples of
blood/brain barrier (BBB) permeability, challenged old concepts
of the brain as an immune-privileged site, and provided
suggestive evidence of a possible role for chemokine receptors
in the developmental formation of neural circuits in the
hippocampus.
- Studies on the mechanisms involved when HIV crosses the BBB
to infect cells within the brain and how drug therapies can be
delivered to the brain and CNS have led to a better
understanding of the mechanisms through which this barrier
functions and how it may be circumvented.
- Neuro-AIDS has become a fertile area of investigation for
multiple neurologic diseases since it reflects numerous ways in
which the nervous system can be susceptible to infection, to
inflammatory processes, and to ways in which viruses can remain
latent for years. As such, the results of these studies have
important implications for research on Alzheimer's disease,
dementia, multiple sclerosis, neuropsychological disorders,
encephalitis, and meningitis.
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Expansion of basic science knowledge base
The investment in AIDS research has enormously facilitated our
progress in many areas of basic science. Indeed, this effort has
been a major contributor to the knowledge base upon which the
biotechnology industry has been built. Biotechnology companies are
capitalizing on new basic biomedical information provided by AIDS
research, most notably new findings regarding chemokines and novel
proteins as targets for drug and vaccine development. The discovery
of a series of chemokine receptors necessary for HIV entry into a
cell has opened new research opportunities for studies on virus/host
interactions and research on receptor biology. Findings from these
studies may lead to novel therapeutics that can block cell surface
receptors, thus potentially preventing further spread of viral
infections and disease progression.
- AIDS researchers have reported using a large protein
molecule to kill HIV-infected cells. A similar mechanism may
also be useful in destroying cancer cells and cells infected
with hepatitis C virus, herpes virus, and other infectious
agents.
- Basic research on HIV has elucidated the mechanism the
virus uses to infect target cells. This mechanism, which
includes the virus injecting its genetic material into another
cell, may potentially be used to deliver gene therapy for
hemophilia and other genetic diseases.
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Expansion of clinical science research
Support of basic cancer research in the 1960s and 1970s provided
several key tools and techniques for identifying subsets of human
lymphocytes and retro/lentiviruses that made it possible to identify
HIV and to elucidate the AIDS disease syndrome. Seminal research in
basic immunology that identified mouse T-lymphocyte subsets led to
parallel studies in human blood and lymphoid tissue. By 1980, the
reagents that were needed for characterizing human T cells permitted
the rapid characterization of severe lymphocyte loss in
immunodeficiencies and the rapid comparison of the acquired
immunodeficiency syndrome that initially appeared to be affecting
gay men, infants, and blood transfusion recipients. In turn,
clinical research in HIV-infected patients has generated a large
knowledge base on lymphocyte subsets and immune activation markers
that is being applied to autoimmune diseases and infectious diseases
of both children and adults.
- The need for sample assessment in AIDS clinical trials
drove the improvements in technology to permit rapid, high
quality, multiparameter assessments of blood cell subsets using
small quantities of blood samples. These assessments are now
being applied to a wide range of genetic and infectious
diseases.
- The need to define and understand a correlate of immunity
for HIV vaccine development has rapidly translated basic
research from studies in mice to studies in HIV-infected
individuals and HIV vaccinees. Studies on the specificity of
T-cell responses in asymptomatic HIV-infected individuals have
resulted in the development of new tools such as Major
Histocompatability Complex (MHC) tetramers and T-cell receptor (TCR)
spectrotypes and explored their application to understanding the
efficacy of such responses to control virus replication in
vivo. In the pressing need for a safe and efficacious AIDS
vaccine, these novel technologies are being applied to
understanding whether AIDS vaccine candidates are inducing
specific T-cell responses. As a result of the unparalleled
explosion of research in this area, there currently are more
well-defined epitopes of HIV than any other infectious agent and
the nature of immune responses to many viruses are being defined
for application to other viral diseases. This has major impact
on the development of vaccines for other viral diseases.
- The samples collected from cohorts of HIV-infected persons
also have been used to explore the genetic factors (i.e., the
distribution of mutant allelic forms of chemokine receptors in
human populations) associated with infectious diseases. This
research would not have been possible without the
epidemiological and clinical studies to identify the causes,
susceptibility, and progression of disease in HIV-infected
individuals.
- The preclinical and clinical testing of new vaccine
adjuvants in candidate HIV vaccines in uninfected HIV vaccine
volunteers was a major step that demonstrated that there were
limits to the direct application of data from vaccine testing in
various species of rodents. Complementary basic research
supported by AIDS funding has led to the molecular assessment of
the differences in cytokine stimulation between rodent and
primate species.
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Insights into the impact of human behavior on public health
Basic behavioral and social science research has yielded
information about the interpersonal dynamics and social settings in
which HIV-related and other risk behaviors occur and the impact of
the HIV/AIDS epidemic on individuals, families, communities, and
societies.
- Ethnographic studies of drug-using networks led to the
revelation that HIV was being transmitted through the sharing of
syringes, needles, cottons, cookers, and other drug paraphernalia
and through identifiable webs of social and sexual relationships.
In addition to its relevance for other chronic, infectious
diseases endemic in the IDU population, including hepatitis and
STDs, this information, and the qualitative and quantitative
techniques used to obtain it, have contributed to our general
understanding of disease transmission within defined social and
geographic spaces.
- Scientifically rigorous national probability surveys among
adults and adolescents conducted in the context of HIV/AIDS, have
increased our knowledge of human sexual behavior, including the
dynamics of partner selection, peer and family influence,
and the role of drugs and alcohol in HIV risk behavior. These
surveys also have provided the first accurate picture of the
sexual behaviors in which people are actually engaging. This
knowledge is important for projecting not only HIV transmission
among different groups but also fertility and family planning
trends.
- HIV-related interview and survey research has revealed that
often a constellation of physiological, psychological, and social
factors make certain people and groups more vulnerable than others
to co-occurring diseases and conditions. The term "syndemics"
has been coined to characterize the synergistic relationship of
such co-occurring epidemics as HIV, hepatitis C, tuberculosis,
drug use, mental illness, poverty, and childhood sexual abuse (in
various combinations) that have been documented among groups of
injecting drug users, women, and gay men. Better understanding of
the nature of these syndemics and their contribution to risk of a
number of diseases and disorders will lead to more effective
public health interventions.
- HIV-related social and demographic research has revealed the
nature and extent to which infectious diseases can have a
devastating impact on family and household structure and function,
community stability, and even national security. Demographers
working in Sub-Saharan Africa and Thailand have documented the
ways in which HIV and AIDS have forced the elderly to care for
sick adult children and grandchildren (often orphaned) who
otherwise would be providing for them in their old age. The
implications of the demise of much of the working-age population
in many communities is profound, affecting food security,
productivity, and what meager social security systems already
exist. The ability to monitor trends in HIV/AIDS-associated
morbidity, mortality, and migration and their impact on such
heavily affected societies contributes much to our understanding
of the threat of other infectious diseases.
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Effective interventions to promote health and prevent disease
- Behavioral and social interventions formulated from an expanded
knowledge base have demonstrated efficacy in reducing HIV-related
risk behaviors--e.g., increasing condom use, reducing the number of
sex partners, delaying the onset of sexual intercourse, reducing
frequency of needle sharing among IDUs, referring IDUs to drug
treatment programs, etc.--and reducing HIV and STD incidence in a
range of population groups and settings. The development and
improvement of HIV-related behavioral intervention science has
benefitted all areas of health promotion and disease prevention,
including nutrition, smoking, alcohol and drug use, and pregnancy
prevention.
- Psychosocial interventions aimed at reducing HIV-related sexual
risk emphasize the development of behavioral skills, such as
self-efficacy and the ability to negotiate with partners over condom
use or sexual abstinence. These behavioral skills are important for
other health and social life situations, including pregnancy
prevention, avoidance of drug and alcohol abuse, and conflict
resolution/violence prevention.
- Outreach interventions that employ peer leaders and social
networks, such as those developed for out-of-treatment drug users to
deliver HIV-prevention messages and services, are applicable to
other health promotion and disease prevention efforts, such as
nutrition and exercise campaigns.
- A key strategy for preventing the onset of HIV-associated
opportunistic infections and further progression to AIDS is strict
adherence to prescribed regimens of anti-HIV medications. Experts
agree that the virulence of HIV infection demands nearly 100%
adherence to anti-HIV treatments for them to be effective. Research
on enhancing adherence among HIV-infected patients has produced a
number of new psychosocial and technological methods that are
applicable to other health arenas, especially those that involve
taking a number of different medications on different schedules. Key
among these are interventions that focus on the patient-provider
relationship, which have been shown not only to improve adherence to
medications but also communication and trust between parties in
general.
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Improved methodologies for measuring behavioral and social
factors
Addressing HIV transmission and prevention has required the
development of better methods of measuring and assessing sensitive
sexual and drug using behaviors within their social context.
- The development and refinement of computer assisted survey
instruments (CASI), such as the audio version (ACASI), has
allowed researchers to obtain information of a highly sensitive
nature from individuals in a more private manner than an
interview would allow. Self-reported information yielded from
these technologies is believed to be more truthful than that
obtained by other methods of inquiry. CASI and ACASI have been
used extensively to obtain information about patterns of sexual
behavior important to understanding the social dynamics of not
only of HIV/AIDS but also STDs, substance abuse, fertility,
family planning, and relationship formation.
- Qualitative and quantitative techniques for mapping social
networks have been instrumental in charting the movement of HIV
epidemics in different social groups and communities. These
include ethnographic methods involving careful observation of
behavior, and complex computer software that can provide
multi-dimensional images of social networks. These techniques
have important applications for social and behavioral
epidemiology not only related to HIV/AIDS but also to other
infectious and non-infectious diseases and to social and
cultural movements related to health risk and protection.
- HIV/AIDS-associated social and bio-statistical modeling
research has significantly improved our understanding of trends
in the epidemic and their impact at a population level. New
analytic and predictive tools have been developed that help
calculate past histories and future trajectories of disease
under different scenarios, including widespread implementation
of interventions, such as a preventive vaccine or microbicide
with a limited level of efficacy. Advances in cost-effectiveness
analyses of HIV-preventive interventions are relevant to many
other areas of public health.
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Progress in understanding "emerging" and re-emerging
infectious diseases
The emergence of HIV infection, SARS, Ebola virus infection, and
hantavirus infection within the past 15 years has demonstrated not
only that new diseases can appear in human populations but that they
will likely continue to "emerge" in the future. Diseases
once deemed "under control" also have re-emerged as
important health problems in this country and around the world.
Studies of the origin of HIV infection and the processes that
contributed to its worldwide spread have significant implications
for preventing or limiting similar epidemics in the future.
- HIV infection in humans appears to have originated from a
virus present in certain non-human primates. Inadvertent
transmission of the virus across species (so-called zoonotic
infection) allowed the virus to enter human populations. Study
of the origins and spread of HIV infection will provide a better
understanding of how this process occurs and how it can be
prevented.
- Experience gained from developing and testing vaccines
against the multiple clades of HIV will be useful in the design
of vaccine candidates against the numerous strains of the SARS
coronavirus.
- Studies of HIV-infected individuals with clinical syndromes
of previously unknown etiology have led to the discovery of a
number of important new infectious agents including: human
herpes virus 6 (HHV6), the cause of a number of clinical
illnesses including exanthem subitum in children; human herpes
virus 7 (HHV7), not yet associated with a specific clinical
illness; human herpes virus 8 (HHV8 or KSHV), the likely
causative agent of Kaposi's sarcoma; bacteria of the genus Rochalimaea,
also known as Bartonella, the causative agent of bacillary
angiomatosis and "cat scratch fever"; and a variety of
previously uncharacterized fungi. The discovery of these agents
and diagnostic methods to detect them also led to their
identification in persons not infected with HIV. HHV6, for
example, causes serious clinical complications in persons not
infected with HIV and has recently been implicated in the
development of multiple sclerosis.
- Using molecular diagnostic techniques developed in the study
of the AIDS epidemic, CDC researchers were able to rapidly
identify hantavirus as the causative virus infection of an
outbreak of cases of fatal pneumonia in the Southwestern United
States a few years ago. These techniques allowed the researchers
to determine the origin of the virus in local populations of
mice and to limit the further spread of infection among humans.
- The development of international collaborations for tracking
the natural history and epidemiology of infectious diseases and
for obtaining and identifying variants of infectious agents from
different geographic regions helped expedite AIDS research. This
experience, and the collaborations established, will be of
significant value should new epidemic diseases emerge in the
future.
- Computational methods and mathematical modeling developed to
study HIV transmission now are being applied to track the
parameters of transmission and dissemination of the bovine
spongiform encephalopathy agent and will certainly benefit the
study of other infectious agents as well.
- An improved understanding of the genes and mechanisms
responsible for drug resistance will permit the development of
new and more effective drugs and the control of potential
epidemics of multi-drug resistant strains of HIV, Mycobacterium
tuberculosis, and other microorganisms.
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