The HIV problem will inexorably increase over the next decade, with an increasing proportionate impact upon women and children over the next decade. HIV will become endemic, essentially worldwide. Some regions in the developed world may be relatively spared if current trends continue. This may reduce the willingness to expend necessary resources, particularly if trends toward increasing isolationism continue. There are already signs of a world becoming 'bored' with AIDS and the chronicity of a difficult problem. This engenders an atmosphere ripe for increasing discrimination, with the development of loopholes in protective legislation. Already in the United States, some lawsuits concerning health care access among employees have been decided in the employer's favor, permitting them to restrict access to health insurance, despite other regulations which might have protected such workers. Similarly, some HIV-infected health care workers have been dismissed or lost their privileges in the 1990s, despite passage of the Americans with Disabilities Act as well as preceding legislation. It remains to be seen how society will cope with these complicated issues. The view of AIDS in 2004 presented above is pessimistic. There are some important rays of hope. Recent innovative vaccine work and new theoretical models may put us on to the road to success, both with preventive and therapeutic vaccines. In particular, the first success in eliciting protection against vaginal HIV exposure, albeit partial, was reported in mid 1993. In a simian immunodeficiency virus (SIV) in vivo experimental model, cellular immunity to SIV was induced in macaques without their developing any signs of SIV infection. These macaques after rechallenge with low-dose SIV remained free of detectable SIV, so there may be an element of protection associated with specific cellular immune responses to immunodeficiency viruses. However, very high-dose SIV rechallenge experiments in similar macaques still led to acquisition of active SIV infection, suggesting that any such protection was only partial. It is also possible that cellular immune protection may be of varying efficacy against different types of exposure, particularly parenteral versus mucosal (such as sexual) exposures. There is also reason for specific optimism concerning interventions that might directly reduce the risk of perinatal transmission. Data from studies of twins suggest that a substantial proportion of perinatal transmission does not occur until after labor has commenced. Thus, caesarian sections may potentially reduce the risk of transmission to the fetus in some cases. On the other hand, some small uncontrolled studies have not demonstrated a reduction in HIV infection rates among children delivered by caesarian delivery, and examination of some aborted fetuses indicate HIV transmission can occur by the first trimester. However, this may reflect selection phenomena for more complicated pregnancies (necessitating surgical intervention) or even simply prolonged labors during which the HIV transmission might have occurred. Controlled clinical studies are warranted. Furthermore, these data raise the hope that maternal therapy in the third trimester and perhaps even as late as labor might become effective as prevention strategies in terms of perinatal transmission. In addition to antiretroviral therapy, trials of purified anti-HIV antibodies derived from the plasma of HIV-infected persons (HIVIG) have been planned. These have been delayed, in part, by vendor liability concerns. Although HIVIG cannot eliminate intracellular HIV infection, such antibodies may reduce the level of free virus in the peripheral blood. Vaccination strategies that boost cellular immunity, either in the mother before delivery or in the neonate, may also be useful in prevention. Many women at highest risk of HIV receive little or no prenatal care. Thus, a therapy that could be given at the time of labor or later would be a particularly useful new public health tool for our armamentarium. Ultimate success, however, lies in much earlier steps towards prevention-reduction of the growing epidemic of HIV among women of childbearing age worldwide. And this in turn requires at the very least a major commitment of funds, an available supply of low-cost (or free) condoms, development of intravaginal microbicides, an intensive education campaign, and control of STDs. It is a monumental but not an insurmountable task.
All Science Journal Classification (ASJC) codes
- Pediatrics, Perinatology, and Child Health
- Obstetrics and Gynecology