THE NEXT TEN YEARS A sense of crisis is hard to sustain. It thrives Iﾷ＠ on earthquakes and tornadoes, plane crashｾＭ es and terrorist bombings. But forces that kill people one at a time have a way of fading into the psychic landscape. So, if you've stopped thinking of AIDS as an emergency, consider a few numbers. In 1984, when scientists identified the virus that causes the illness, fewer than 4,500 Americans had been stricken. Today more than 3,000 cases of AIDS are reported every month in this country; SPECIAL REPORT t he total tops 130,000. An estimated 1 million Americans are infected with the virus-and by the end of the decade, most of those people will be sick. The AIDS epidemic is far from over. It's not even under control. "The worldwide situation is deteriorating," says Dr. Jonathan Mann, former director of the World Health Organization's Global Program on AIDS. "We are facing a decade in the 1990s that will be far more difficult than anything we saw in the 1980s." The WHO estimates that as of this year 700,000 people have developed AIDS worldwide and 6 million to 8 million have contracted the virus that causes it. By the end of the decade, an estimated 5 million to 6 million ost of the 1 million will be sick, and the total numinfected in the ber infected may approach 20 United States will be million. Worse still, the situasick by 2000; worldwide, tion isn't expected to stabilize six times that many. for several more decades. Already, the AIDS virus infects a third of the population in U.S. AIDS some parts of Africa. This naCases 25 percent among young men surveyed in Newark, N.J. But the poor aren't the only ones suffering. Dr. June Osborn, chairman of the National Commission on AIDS, foresees a time when most Americans may know someone with AIDS. "By the end of the 1990s," she says, "people will be shaking their fists and saying, 'Why didn't you tell us?' That's going to hurt, because we did." This week thousands of people from throughout the world will converge on San Francisco for the Sixth International Conference on AIDS (page 24). What once served as a quiet forum for sharing technical insights will look more like a political convention, as the affected segments of society- not just scientists but patients and caregivers, public &m officials and angry activistsWorl<l unfurl their flags. No longer AIDS Ca8es just a medical problem, AIDS has become a pock on the social order, a festering emblem of countless other ills. Federal spending for AIDS research and treatment has climbed to $1.6 billion in just nine years. ｬｩ｡ＺＳ Ｓｾｊ ｊ＠ Scientific progress has been O brisk. Yet for many of the af1982 84 86 88 90 92 94 96 98 2000 flicted , here and throughout SOURCES: (WORLD) WHO, IU.S.l CDC, NEWSWEEK ESTIMATES. CHART BY w. VOSBURGH the world, minimal health care is still a distant hope. Global Epidemic M tion's desperate neighborhoods most appear headed in the same direction. Regional surveys have turned up infection rates of 5 to 12 percent among pregnant women in the Bronx, 20 I N EWSWEEK : JUN E 2 5 , 1990 but facilitate the spread of the Though AIDS is spread solely Last year newborns got AIDS at a faster rate than gays or IV AIDS virus-have skyrocketed through the exchange of blood drug users. Many got it prenatally; in Romania, bad medical in recent years. At the same or other body fluids, local condiconditions also caused hundreds of infants to be infected. time, the crack epidemic has tions have a lot to do with who created a whole new class of gets sick and how. In Africa, the virus is transmitted almost exclusively through heterosexual con- high-risk heterosexuals: women who trade sex directly for the drug. tact. In Thailand-where the number of infected people has shot "We've seen the rate of syphilis in various parts of the country from 1,000 to roughly 50,000 in just three years-the epidemic quadruple because of sex associated with crack," says Don Des apparently started among intravenous drug users and spread into Jarlais of the Chemical Dependency Institute at New York's Beth the heterosexual community. In Eastern Europe, AIDS has been Israel Hospital. "The same thing could happen with AIDS." With or without crack, American teenagers are ripe targets for spreading mainly through unsafe medical practices. The U.S. epidemic has always been concentrated in major cities, AIDS: they're already experiencing 2.5 million cases of sexually among gay men and IV drug users. But that pattern is changing as transmitted disease every year, and nearly a million unintended the epidemic matures. Last year AIDS incidence rose nearly four pregnancies. "We know their sexual behavior results in signifitimes as fast in the nation's smallest cities as in its largest ones. cant risk for infection," says Dr. Gary Noble of the federal Centers And while the number of new cases rose by 11 percent among gay for Disease Control. Indeed, at least 20 percent of today's AIDS males, it increased by 36 percent or more among heterosexuals and patients were probably infected as teens. As long as we fail at sex education and drug-abuse treatment, newborns. By the year 2000, says Dr. James Chin, an epidemiologist in charge of AIDS surveillance at the WHO, "heterosexual millions of Americans will remain at risk. And clearly we are transmission will predominate in most industrial countries." The failing. Medically, though, the past decade has brought remarkgrowth of the epidemic may be slower among heterosexuals than it able successes. No one had heard of AIDS when doctors started has been among gays or IV drug users, but it will be implacable describing the syndrome in 1981. Since then, scientists have not nonetheless. "AIDS is a sexually transmitted disease," says Dr. only identified the human immunodeficiency virus (HIV) but Robert Redfield of the Walter Reed Army Medical Center, "and learned a great deal about how it infects cells and ruins the immune system. The 1980s brought a diagnostic test, a safe blood the fact is that most of us in society are heterosexual." Monogamous couples are not at risk, but there's no evidence that supply and several useful treatments. Thanks to drugs like AZT Americans are about to become wholly monogamous. Syphilis and and pentamidine, patients who would once have died within gonorrhea--diseases that not only indicate unsafe sexual practices months of developing AIDS are now surviving a year or more. NEWSWEEK : JU N E 25 , 1990 21 SPECIAL REPORT In the short run, treating the myriad infections and cancers that actually kill AIDS patients is the surest way to extend their lives. Activists have long accused scientists, drug companies and federal agencies of neglecting these secondary complications, of preferring the higher drama of fighting the virus itself. The criticism has had an effect. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), says the proportion of federally funded AIDS studies relating to opportunistic infections has risen from 10 to 20 percent during the past year and may eventually grow to 30 or 40 percent. Yet treating symptoms won't solve the problem. AIDS patients who survive early bouts withpneumocystis carinii pneumonia and other once lethal infections are now falling prey to an array of other maladies. Among San Francisco AIDS patients, the number of lymphomas rose by 48 percent in 1987 alone. Until the AIDS virus can be locked out of the body, or paralyzed from within, the plague will spread and the afflicted will die. The epidemic has prompted a resurgence in the study of infectious disease. Antiviral drug research, long stagnant before AIDS struck, is now among the hottest fields in medicine. And the quest for a vaccine, though far from fruition, is proceeding briskly. Can this virus be stopped? What are the strategies? What are the obstacles? These turn out not to be simple questions, for the battle against AIDS is being fought inside the cell, amid genes and proteins and enzymes and antibodies. But the questions are worth grappling with. All ofhumanity ｨ｡ｳｾ＠ stake in the answers. • WHAT HIV DOES TO CELLS Just nine years ago, epidemic diseases were a thing of the past. Modern medicine, having subdued The Germ with vaccines and antibiotics, was busy saving us all from cancer and heart disease. Then came AIDS, and the realization that a devious bug could still cause a worldwide plague. At first no one knew what was causing the mysterious illness, but scientists in Paris and Washington soon linked it to an infectious agent known as a retrovirus. Today there are still unanswered questions about the human immunodeficiency virus, such as why it causes illness so much faster in some people than in others. But its basic mechanisms are now well understood. HIV has no life of its own. Unlike a bacterium, it doesn't absorb nutrients, generate waste or reproduce by dividing. It's just a protein capsule.containing two short strands of genetic material (RNA) and a few enzymes. It happens to use human cells to perpetuate itself. After infecting someone, HIV may spend 10 years or more quietly ensconced within various tissues and organs. But when activated, it turns certain immune cells into virus factories, which produce a flurry of new virus capsules and die. Other cells become infected in the process, and the immune system falls like a house of cards. The immune system is an elaborate, internal defense network that includes different types of blood cells. Among these immune cells, the ones that identify an intruder and authorize an attack on it are called T4 lymphocytes, or (imprecisely) "helper T cells." How the Virus Attacks, and How to Attack the Virus The AIDS virus turns cells into factories that produce more viruses. New drugs show hope of bringing the process under control. Soluble CD4 : May keep the virus from penetrating a target cell. AZT: Blocks the production of viral DNA. Protease Inhibitors: Keep new viral material from assuming mature form. Interferon: May keep newly assembled virus particles from leaving host cell. Antisense: Blocks the production of new viral material. SOTOODEH-NEWSWEEK (1) he viral production cycle involves six basic steps. The virus attaches to receptors on a host cell, injecting pieces of T genetic material and enzymes. viral enzyme (2) A (RNA) transcribes the RNA into the same form as the host cell's genetic material (DNA). (3) The viral DNA is integrated into the chromosomes in the nucleus of the host cell. This integrated DNA is called provirus. · 22 NEWSWEEK: JUNE 25 , 1990 (4) After a long, idle period, the provirus directs enzymes in the host cell to produce new strands of viral RNA. The new viral RNA serves as a blueprint Other enzymes use it to produce proteins that will become new virus capsules. (5) An enzyme called protease cuts the long, unmilled proteins into shorter pieces, which clip together to form new capsules. (6) The completed capsules bud from the surface of the cell. tern on the viral RN A. AZT Every T4 cell has appendages looks just like one of these nucalled CD4 receptors, through cleosides. In fact, reverse tranwhich it exchanges informascriptase prefers it to the real tion with other immune cells. thing. But AZT turns out to And it is through these CD4 rehave a slightly different strucceptors that HIV attacks. The ture. When it's clipped on to a outer shell of the HIV capsule growingchainofDNA, the next (known as the envelope) is link doesn't fit and the whole equipped with an appendage production is foiled . called gp120. This distinctive Conceived as a cancer treatprotein molecule happens to ment back in the 1960s, AZT fit the CD4 receptor as a plug found no use until 1986. It now fits a socket. When the two molearns the Burroughs Wellcome ecules dock, the contents of Co. well over $100 million a the viral capsule-the RNA year. The big comeback started and the enzymes-fl.ow freely when scientists noted a decline into the cell's interior. in infection and death among Once inside, HIV becomes a AIDS patients taking a daipermanent feature of the cell. ly dose of 1,200 milliFirst, an enzyme called reverse grams. Despite a number of side transcriptase uses information effects- ranging from headencoded in the RNA to manuaches, vomiting and malaise to facture a double strand of bone-marrow suppression and DNA-a piece of software that anemia- AZTsped through the can direct the cell to manufacdrug-approval process in record ture more virus. This DNA, time. In March 1987, the Food known as the provirus, then inand Drug Administration aptegrates itself into the host proved it as a treatment for pacell's chromosomes. It repretients with symptoms of AIDS sents just a tiny segment of the orwithT4countsbelow200 (the cell's genetic code. Once actinormal range is 600 to 1,200). vated, however, it's the only Since then, AZT has been found segment that counts. to work just as well at half The trouble begins when the Linda Kean, 36, a heroin user and prostitute, suspects she the original dose, and federal provirus starts directing engot the virus from a contaminated needle. She hasn't felt guidelines have been changed zymes in the host cell to proany symptoms yet-and she doesn't tell customers or other to recommend the drug for duce new strands of viral hookers in Oakland that she's infected. That, she says, any infected person whose RNA. These rogue pieces of would be "professional suicide." T4 count dips below 500RNA serve as a blueprint, even if no sickness has set in. from which other enzymes That may sound like a minor adjustment, but it pushes the start churning out the raw material for new virus capsules. These raw materials (long protein molecules) get chopped into number of potential AZT users in this country from 40,000 to more shorter pieces by an enzyme called protease. Those pieces then than 600,000. A panel convened by the National Institutes of clip together to form new HIV particles, which burst from the Health made the early-treatment recommendation this spring, surface of the host cell and fl.oat off to infect others. The host cell after two studies showed that AZT could delay the initial appearance of AIDS. But many experts consider the move premature and is killed in the process. One reason HIV poses such a challenge is that the infection it- potentially dangerous. They note that several ongoing studies self is not even theoretically curable: modern biologists, for all have so far failed to show the same beneficial effect. Moreover, their ingenuity, are far from knowing how to purge unwanted they say, the NIH studies didn't compare the advantages of early DNA sequences from human chromosomes. Still, scientists are and late treatment. They compared early treatment with no treathopeful that by keeping the virus from replicating so wildly, they ment. "We don't know that it ultimately does you any good to will gradually make it less deadly. Scores of researchers are delay crossing the 200 mark by a few months," says Dr. John working on drugs to interfere with HIV's production cycle at one Hamilton, chief of infectious diseases at the Durham, N.C., VA stage or another. Twenty-one such drugs are now under develop- Medical Center ·and cochair of an AZT trial designed to answer ment in this country alone. The hope is that they'll work, in some that question. " If you're building up resistance to AZT by takfelicitous blend, to make AIDS a chronic, manageable condition, ing it early, when you're still feeling fine, you may be losing a crutch you could use later." much like diabetes or high blood pressure. Even the proponents of early treatment agree that AZT leaves much to be desired. First, it's quite toxic: even with lower doses, nearly a third of those taking the drug develop grave bone-marrow problems within a year. Second, it's not cheap. Burroughs WellSo far, only one of these drugs has been approved as a treatment come has twice reduced the price but still charges $1.20 for every for AIDS. Zidovudine, or AZT, attacks the virus after it has 100-mg capsule-more than $200 for a month's supply. Third, wormed its way into the cell but before it has integrated itself into while it does help ward off opportunistic infections in AIDS pathe host cell's chromosomes. Specifically, it impedes the "reverse tients, it doesn't prevent the outbreak of lymphomas or tumors transcription" of viral RNA into DNA. The only way HIV's reverse such as Kaposi's sarcoma. Most important, it seems to become less transcriptase enzyme can manufacture DNA is by gathering up effective as the virus mutates out of its range of action. Researchers are hopeful that AZT's close relatives DDI and chemical units called nucleosides and matching them to the pat- • ONE DRUG THAT HELPS NEWSWEEK : JUNE 2 5 , 1990 23 Jay Feinstein, 44, moved to San Francisco in 1980. At that time, he says, "The gay culture stressed freedom." His AJDS was diagnosed in 1984; he quit his job as a hospital administrator two years later. "Almost everyone I've met since the epidemic began is dead." grated itself into the cell's DNA. But there are several other possibilities. One is to keep the virus from entering the cell in the first place. To do that, one would have to keep HIV from plugging its distinctive appendage-the gp120 envelope protein-into the CD4 receptors on target cells. Several laboratories have designed synthetic, free-fioatingCD4 receptors with just that thought in mind. In principle, flooding the blood with this "soluble CD4" should inactivate the virus by covering all its plugs before they find real sockets. That's exactly what happens in a test tube. There is no evidence yet on whether soluble CD4 will help infected people, but toxicity tests have shown no serious side effects. In an interesting variation on this same approach, the Upjohn Co. and others are now working on molecules that combine CD4 and a po ten tsyn thetic toxin. When the CD4 binds to the viral envelope proteins protruding from infected T4 cells, it's supposed to release the poison and kill them. Unfortunately, there is at least one large drawback to the whole CD4 approach. The molecule is very expensive to make, and it breaks down so fast that it has to be taken-by injection-every few hours. Suppose the virus eludes both CD4 and AZT, penetrating the cell and infiltrating the local DNA. There are still possibilities for checking its growth. Opportunity No. 3 arises shortly after the provirus (the integrated viral DNA) starts running off RN A copies ofitself. The enzymes that manufacture the raw materials for new virus particles from this RNA use its chemical sequence as a blueprint. If the enzymes can't read the blueprint, they can't do their work. And it's possible-using genetically engineered "antisense" molecules- to make the blueprint illegible. Byzippingitself ontoacrucialsegmentoftheviralRNA,anantisensemoleculeblots out vital information, and protein production grinds to a halt. Antisense represents a whole new approach to drug design, and HIV is not its only potential target. Traditionally, notes biochemist Jack Cohen of Georgetown University Laboratories, researchers have treated people with various organic compounds in the hope that one would prove therapeutic. With antisense, he says, "you figure out exactly what genetic process you need to alter and design a molecule accordingly." In test-tube experiments, antisense molecules have slowed production of the AIDS virus by 90 percent. The catch is that they're still difficult-and exceedingly expensive-to make. "We've been working on [an antisense drug] for a year," says Dr.Jeffrey Laurence of the Laboratory for AIDS Virus Research at Cornell University Medical College. "I'm promised that by the end of the summer we'll have enough to treat one mouse." While awaiting affordable antisense, researchers are targeting still later stages in the viral life cycle. A fourth possible strategy is to keep HIV's protease enzyme from milling the construction materials into pieces that can form new virus particles. A num- DDC, both now in clinical trials, will help address some of these problems. DDI and, especially, DDC are toxic in their own right: both cause a painful nerve irritation called peripheral neuropathy, and DDI can damage the pancreas. But they could provide alternatives for people who can't tolerate AZT or who develop resistance to it . Both drugs are also being tested in low-dose combinations with AZT. The hope is that patients will get cumulative benefits but, because of the lower doses, experience less toxicity and resistance. "The way to go," says he Sixth International Aids Conference convening June 20 in San Francisco will, as Dr. Samuel Broder, head of the usual, devote itself mostly to medical issues. But National Cancer Institute, "is this year medicine may be upstaged by activinot to discard drugs that show ties of a decidedly unscientific nature. For one promise, even with side effects, thing, this also happens to be the week of the but to find ways to use them annual Lesbian and Gay Freedom Day Parade, more creatively." which stirs gay pride and will likely attract more than 200,000 spectators. And demonstrators, including the militant ACT UP (AIDS Coalition to Unleash Power), are expected to disrupt proceedings throughout the five-day conference; the most dramatic protest could come during a speech by Health Secretary LouAZTanditskinallattackHIV is Sullivan on June 24. This will also be the first at the second stage of its life cycle-after it has entered the host cell but before it has inte- What Will Happen at the AIDS Conference? AIDS conference to be boycotted: more than 100 organizations, including the International T Red Cross, are staying away to protest a contro- • BREAKING THE CYCLE 24 NEWSWEE K : JUNE 25, 1990 versial U.S. immigration law barring foreigners with HIV infection from American shoreseven though Washington has created special 10-day visas for conference participants. Meanwhile, the scientific quality of the meetings is expected to be higher than in past years, with only half of 4,900 submitted research abstracts accepted for presentation. (Last year eight were rejected.) Yet despite a number of papers devoted to promising new vaccines, no bombshells are expected. A rundown of the main inside and outside events: her of companies have developed drugs that work at this stage, and human trials are expected to start within the next year. These "protease inhibitors" have performed well in test-tube experiments, and animal tests have turned up no serious side effects. That's not surprising. For unlike AZT and its kin, which disrupt a number of cellular processes, the protease inhibitors affect only a single enzyme. As a result, researchers expect them to be far less toxic. In other labs, scientists are working with a fifth group of antiviral agents, known as interferons. These are antiviral chemicals produced naturally by cells. Drugs that step up production of interferons can help control the growth of tumorsand at high doses, the same drugs seem to impede the budding ofnew virus particles from infected cells. In a study published this month, NIH researchers conclude that alpha interferon can have a "significant antiviral effect" in patients whose immune systems are still largely intact. In a small trial involving asymptomatic patients, the investigators found that 41 percent of those getting the drug hecame "culture negative," meaning the virus dropped temporarily out of sight in their blood samples. Only 13 percent of the untreated subjects became culture negative (a common but temporary occurrence). Moreover, T4 counts held steady in the treated patients but declined slightly in the others. There is a catch, of course: the treatment was so toxic that a third of those receiving it dropped out of the trial. Joe Muriuki. 31, found out he had the virus two years ago; he says he got it from "one of my girlfriends." He now works at a ramshackle clinic in downtown Nairobi, where he coun· sels other AIDS patients to cope with "the feeling of shame and hopelessness." people to a virus in some harmless form to provoke a natural immune response without causing serious illness. Unfortunately, the AIDS virus is well designed to foil that approach. One problem is that no one knows what natural immunity would consist of. Infected people produce a flurry of antibodies directed at different parts of the virus, but those people don't end up safe from future infection. They end up dead, as the virus destroys the system producing the antibodies. It's possible that one or more of those antibodies would prevent infection in healthy people, but there's Antiviral drugs aren't the only hope for eliminating AIDS. Ifwe no guarantee. A second problem is that HIV is not a single, wellcould vaccinate everyone, the epidemic might really be stopped. identified target. Like a cold virus, it varies widely and changes Vaccines have triumphed famously over other viral diseases, from fast. There are dozens of strains of HIV, and a vaccine that worked measles to smallpox to polio. The approach consists of exposing against one might prove worthless against another. Despite these and other obstacles, the quest for a vaccine is gaining momentum. "A year •Several dozen conference papers will ad- of gay men relapse into risky sex practices. ago I wouldn't have been able to dress new therapies showing mixed results in • Researchers monitoring the rate of heterosay whether we would ever clinical trials. They include the controversial sexual transmission of the AIDS virus in the have a vaccine," says Fauci, of antiviral drug, Compound Q, and lentinan, a United States will discuss a study showing that the NIAID. "I think most scienmushroom extract that may boost the immune less than 2 percent of all men are infected by female partners, while 20 percent of women are tists are now reasonably optisystem by raising the CD4 cell count. • A Canadian researcher will report on ad- infected by their male partners. mistic that some time, hopefully in the 1990s, we will." The • There will be four times more abstracts verse effects of nonoxynol 9- a contraceptive jelly once believed to afford protection against from the Soviet Union and Eastern Europe change of heart stems from a than in the past-including a report about the handful ofrecent experiments. HIV infection. Two research teams have suc• TherewillbemanypapersonAIDSin wom- transmission of HIV from an infected baby to ceeded at protecting monkeys en and children, with one San Francisco study its mother through breast-feeding. All the above is apt to be played out against from SIV (the simian AIDS virevealing that children of infected mothers rus), and two other groups have who are born free of the HIV virus nevertheless some of the liveliest street theater yet seen at an AIDS conference. The estimated 10,000 parprotected chimpanzees from suffer from developmental problems. HIV itself. Still other scientists • Researchers will discuss new findings on ticipants-plus 2,000 journalists, including at have shown that infected womsexual attitudes in the AIDS era. One study least one network anchorman-will make it en who produce large amounts will show that after four years, 19 percent the biggest AIDS gathering ever. of a particular antibody are less likely to bear infected chi!- • AVACCINE IN THE '90S? NEWSWEEK : JUNE 25 , 1990 25 SPECIAL REPORT dren- a finding that could lead directly to a prenatal vaccine. hies, not one was producing an antibody directed at the HIV In the monkey trials, conducted at primate-research centers in envelope protein's so-called principal neutralizing domain (PND), Massachusetts and Louisiana, scientists injected animals with a short molecular segment that is common to many different whole, inactivated SIV to produce an immune response and then strains of the virus. By contrast, the PND antibody was present in challenged them with unadulterated virus to see what would three of the four mothers who bore heal thy babies. "We suspect the happen. The New England researchers managed to protect two fourth mother had the antibody," Rubinstein says, "because it out of six monkeys from infection, the Louisiana group eight showed up in the baby." The PND antibody doesn't seem to help people once they're out of nine. The chimpanzee experiments involved a different approach. infected; the mothers who produce it suffer the same fate as those Researchers at two biotechnology companies- Pasteur-Vaccins who don't. But ifthat antibody is the reason some babies are born in Paris and Genentech in South San Francisco-inoculated uninfected, then protecting others might be fairly simple: you their animals with "subunits" of the human AIDS virus before would simply inoculate mothers with the tiny piece of the virus injecting them with the whole agent. (HIV infects chimps but that engenders it. Dr. Yair Devash of Ortho Diagnostics has aldoesn't cause illness.) In the Pasteur experiments, two chimps ready fabricated the viral fragment, and Rubinstein has incorporesisted infection after receiving cocktails of several HIV frag- rated it into a vaccine that could be given to pregnant patients. ments. The Genentech vaccine, based on a fragment of HIV's He's now testing it for toxicity in animals and expects to start a gp120 envelope protein, also protected both of the chimps that human trial later this year. If the vaccine were to succeed at protecting babies, he notes, it might protect other uninfected received it. However impressive, none of these feats means that school people as well. Preventing infection is not the only goal of vaccine research. kids will soon be lining up for inoculations against AIDS. To be of real use, a preventive AIDS vaccine would need to have a lasting Scientists are also testing vaccinelike agents designed to boost the effect against a wide range of virus strains. The animals in these defenses of people who are already infected. These researchers experiments were tested at the peak of their immune responses, study the body's production of antibodies to different parts of HIV, and they received the same strains of virus they had encountered then try to amplify the most useful responses. Several preliminary in their vaccines. "If we had a simple vaccine that worked in studies show promise. Dr. Robert Redfield of the Walter Reed chimps," says Marc Girard, the virologist who directed the Army Medical Center has observed that when some patients are French experiments, "it would be five years before it could be exposed to a synthetic fragment of gp160 (a large envelope protein used in man, with toxicity tests and all that. And we're very far that includes gp120), they produce antibodies directed specifically at that fragment and their T4 from that takeoff point." Even cells die less quickly. Allan a vaccine that proved effective Goldstein of George Washingin chimps might perform miston University has sparked poerably in people. And finding tentially useful immune activiout would be a challenge in ost AIDS patients are still gay men and IV drug users. ty by exposing people to a piece itself, since human subjects But the rate of increase among heterosexuals and of the virus core. And Jonas can't be purposely exposed. newborns proves that the virus knows no boundaries. Salk, inventor of the polio vaccine, has reported beneficial effects in about half of the patients he has treated with Gay or bisexual men whole virus stripped of its envelope. Again, because HIV can hide One virtue of trying to block IV drug 7,970 in places that are beyond the users mother-to-child transmission reach of the immune system, is that success is easier to none of these therapeutic vacgauge. Since 30 to 40 percent 1,562 cines could root out the infecof the children born to infecttion completely. But as Salk ed women are themselves Number of AIDS observed recently, winning and HIV positive, a vaccine that Cases 1989 losing are not the only alternachanged that ratio would cleartives in the battle against AIDS. ly be making a difference. No A negotiated settlement may one has yet tested such an still be possible. agent, but Dr. Arye Rubinstein, director of the Center for AIDS Research at New York's 11% Albert Einstein College of Percent Increase Medicine, is rapidly laying the 1988-1 989 groundwork. 20% IV drug users Intrigued by the fact that AIDS, unfortunately, is not many infected mothers don't just a medical challenge. Scibear infected children, RubinHeterosexuals ence will eventually produce stein and his colleagues set out better treatments, maybe even to identify specific antibodies a vaccine. The question is that might set those women whether these costly advances Newborns a part. Last month, in a study of will reach the populations 15 AIDS pregnancies, the remost in need. It's clear that searchers described such an CHART BY WHJTNEY VOSBURGfl SOURCE: CDC the burden of sick people will antibody. Of the 11 women in rise steeply during the 1990s, the study who bore infected ba- The Changing Profile of AIDS M • SAVING THE BABIES I • THIS WILL HAPPEN AGAIN 26 N EWSWEEK: J UN E 25 , 1990 but not at all clear that the world's health systems are prepared to respond. "My fear," says Dr. Ruth Osborn, of the National Commission on AIDS, "is that [scientific progress] will be overwhelmed by a health-care disaster." All over the world, the epidemic is raging most fiercely within groups that are most removed from education and health care. One major exception is the U.S. gay population. Since the epidemic began, homosexual men have fought discrimination, demanded treatment and research, and reaped the rewards of safe sex and blood testing. In large groups that have been followed over the past decade, the proportion becoming infected each year (not developing AIDS but contracting the virus) has fallen from 7.5 percent in the early 1980s to 1 or 2 percent today. Studies also suggest that infected gay men are living longer thanks to AZT and new treatments for secondary infections. The experience of inner-city minorities could hardly be more different. Infection rates have not declined substantially among intravenous drug users. And as the epidemic spreads to their sex partners and children, new treatments are making little difference. "These people are intensely poor, alienated, powerless," says Dr. Harold Freeman of Columbia University and Harlem Hospital. Last fall Freeman coauthored a · study showing that black men in Harlem were less likely to reach 65 than men in Bangladesh. The data were collected before AIDS even struck. "This is a disaster on top of a disaster," he says. "The people who are suffering need to cry out. But the people involved in this problem have no voice." Minority women who are infected by their part ners may avoid seeking treatment for fear they will lose their children to foster homes iftheir illness is discovered. Maria, a 31-year-old Hispanic woman in Chicago, is the widow of the man who infected her after contracting the virus through his own drug use. Now, with three children to care for (one of them HIV positive), she is suffering full-blown AIDS. Yet she and her family keep her illness a secret. They fear that if others knew, the children would be excluded from school and they from their jobs and their church congregation. Maria's family curandera, a traditional healer who treats patients with herbs, incantations and prayer, believes persistent illness is a sign that the sufferer has strayed too far from Latino culture and is being punished by God. Inner cities aren't the only places health care is lagging. Consider rural Georgia, where AIDS rates have soared in recent years. None of the 14 hospitals in the Southeast Health Unit, a 16-county area roughly the size of Massachusetts, can afford to buy the $80,000 machine needed to test patients' T4 counts. "The problem is real 'critical now," says Dr. Ted Holloway, director of the Southeast Health Unit. "There is a limited amount of AZT that we can give to indigent patients, but we have to have a T-cell count." The problem is compounded by a lack of physicians willing to treat the disease. "No one wants to be the AIDS doctor," says Halloway. "If you set up a service, people are going to come from miles away." Because people who are infected with HIV can't buy private insurance, Medicaid has become a major source of care. Roughly 40 percent of AIDS patients end up on Medicaid, and the federal portion of AIDS-related Medicaid spending has soared from $10 million in 1983 to an anticipated $670 million this year. Yet many infected people who need the assistance don't qualify: besides being poor, one has to be over 65 or a member of a family with dependent children or totally dis-· abled. For many people, that means no medical care until total disability sets in. When AIDS patients finally do qualify for Medicaid, they're often hospitalized for illnesses that might have been prevented through earlier intervention. To eliminate the Catch22, Congress is now considering legislation that would let states approve outpatient services for infected people as soon as treatment is needed to prevent a decline in health. And the House and Senate have recently passed bills that, if signed into law, would provide an additional $600 million to $700 million for AIDS care each year. To Ruth Osborn, head of the National Commission on AIDS, such efforts are mere "fingers in the dike." This spring the federally appointed commission issued a report to the president, decrying a lack of leadership from the federal government and repeating its demand for a national AIDS plan with clear roles for federal agencies, state governments and the private sector. To date the report has elicited a proforma letter of appreciation. No single government initiative is going to solve the AIDS crisis. The crisis is global, and it is magnifying social problems that were already enormous. But complacency would be a mistake. Jonathan Mann, the former WHO official, argues that the world has actually been lucky with the AIDS epidemic so far. Had the virus had a longer latency, the disease might just now be coming to light, in a much greater number of people. The next such virus-and there will most assuredly be others-may be more devious than this one. What HIV teaches us about retroviruses, and about the necessity of education and basic health care for all, could turn out to be valuable. "It takes a lot of hubris to imagine that this couldn't happen again," says Mann. "It could be happening right now." GEOFFREY COWLEY with MARY HAGER in Washington, Ru TH MAR s HALL in Paris and bureau reports NEWSWEEK: JUNE 25 , 199 0 27