HIV/AIDS Tight Spot

Feature Story

Although the actual number of diagnosed HIV/AIDS cases in the Philippines is still small compared to that of other countries like Thailand, our rate of increase is alarming and appears to be heading towards epidemic proportions. How can we stem this perilous tide?

By Rafael R. Castillo, MD

Just when we thought we may have won the battle against the dreaded HIV, recent figures on its incidence in the country make us realize otherwise. Statistics from the Department of Health (DOH) indicate that although the world trend for new HIV cases appears to be going down, thanks to intensive public health education and other preventive measures, we’ve recorded an alarming 3,147- percent increase in new cases in the country over a 10-year period from 2007 to 2017.

Last year, more than 11,000 new cases were diagnosed compared to 342 cases diagnosed for the whole year of 2007. So from an average of one new case diagnosed daily in 2007, 31 new cases are now being documented to be HIV+ daily as of June this year.

In contrast, the World Health Organization (WHO) reports that there is an appreciable decline in new HIV cases diagnosed worldwide—from 2.1 million in 2015 to 1.8 million in 2016.

It’s true that in terms of actual number of diagnosed HIV/AIDS cases in the Philippines our number is still small compared to that of other countries like Thailand, but what’s alarming is our rate of increase, which experts warn is heading towards epidemic proportions. The United Nations report that the Philippines is one of eight countries in the Asia-Pacific region accounting for more than 90 percent of new HIV infections. How can we stem this perilous tide?

Epicenter of HIV epidemic

Infectious disease experts like Dr. Edsel Salvaña, a molecular epidemiologist who’s one of the few scientists in Asia doing advanced biomolecular or genomic studies to determine the mutation of the HIV, have sounded the alarm that unless we make some concrete actions soon enough, we may have drug-resistant HIV/AIDS cases in our midst. Dr. Salvaña even describes the Philippines as an epicenter of a growing HIV epidemic in the region.

Dr. Edsel Salvaña, a molecular epidemiologist

Dr. Salvaña is the director of the Institute of Molecular Biology and Biotechnology at the National Institutes of Health at the University of the Philippines. He spearheaded the formulation of HIV treatment guidelines, raising public awareness on prevention, and campaigning against the stigma on individuals discovered to be HIV+. He was one of the speakers in the IM (Internal Medicine) Summit organized recently by LRI-Therapharma.

Despite the seeming gloomy outlook for HIV/AIDS based on the current trend in the country, Dr. Salvaña remains confident that we can still convert being HIV+ (positive) into a chronic medical condition just like hypertension and diabetes. If diagnosed early enough before one’s immune system totally crashes, HIV+ individuals may expect an almost similar long-term outcome as hypertensive and diabetic patients, provided they take their oral maintenance medications religiously and have their regular check-ups.

However, if we’re not vigilant, we just might be a few mutations away from a resurgence of the AIDS virus which can cause pandemic spread of the disease, warned Dr. Salvaña.

Even doctors and other healthcare professionals may be at risk to get the HIV because of their exposure to patients who may unknowingly be afflicted with HIV or AIDS.

Sometime at the emergency room or operating room when there’s a patient with a gushing wound or injury, some doctors and nurses may fail to do all the prescribed precautionary measures in their big rush to attend to the patient. To be sure, experts like Dr. Salvaña recommend that all individuals at risk should get themselves tested for HIV.

Living normally with HIV

The good news is that with available treatment, many diagnosed HIV+ cases can expect to live an almost normal life with some precautions, of course. Dr. Salvaña explained that HIV+ individuals who are under treatment can have their virus load suppressed to such a level that they can safely have sexual intimacy with their spouses with an almost zero risk of transmitting the virus. For practical purposes it’s actually zero since it would take more than 120 years of regualr sex to transmit the virus.

Dr. Salvaña at the TED Global Conference describes the aggressive HIV subtype AE that’s currently plaguing the Philippines — and warns us about what might become a global epidemic.

Even surgeons who have effectively suppressed virus levels can still operate because the risk of transmitting the virus is practically zero. There should be no moral qualms about not disclosing it to their patients, but they should be responsible enough to have themselves checked regularly to make sure their virus levels remain suppressed.

So there’s really that optimistic and realistic prospect that HIV may be transformed to an ordinary chronic illness very similar to hypertension and diabetes. But that’s how far the good news about HIV/AIDS goes.

Alarming HIV capability to mutate

“On the surface, it seems as if we are just a late bloomer. However, the reasons for our current epidemic are much more complicated and may foreshadow a global resurgence of HIV,” Dr. Salvaña emphasized.

Regarding the global decline in HIV cases, Dr. Salvaña said: “This trend may be shortlived when the next wave of more aggressive and resistant viruses arrive. HIV has apotential to transform itself into a new and different virus every time it infects a cell. Despite the remarkable progress we’ve made in reversing the epidemic, the truth is that we are just a few viral mutations away from disaster.”

The manner at which HIV mutates can really make scientists like Dr. Salvaña shake their heads in disbelief. To illustrate it, he made a genetic comparison of the DNA variation among humans of different races and the actual inter-racial DNA difference is only 0.1 percent. Comparing humans and apes, it’s around seven percent.

“In huge contrast, the genetic difference between HIV subtypes from different patients may be as much as 35 percent,” he explained. And in the same patient infected with HIV, the genetic difference between the infecting original virus and the subsequent “daughter viruses” has been demonstrated in genomic studies done by Dr. Salvaña and his fellow scientists to be as much as five percent. It’s almost incredible. “This is the equivalent of a gorilla giving birth to a chimpanzee, then to an orangutan, then to a baboon, then to any random great ape within its lifetime,” explained Dr. Salvaña, who heads a team using nextgeneration sequencing and other cutting-edge genetic tools to study HIV viral diversity and superinfection.

Aggressive HIV subtypes

To this date, nearly 100 subtypes of HIV have been discovered, and new subtypes keep on adding to the list regularly. However, in the developed world, almost all HIV cases belong to the subtype B. “Mostly everything we know and do to treat HIV is based on studies on subtype B, even though it only accounts for 12 percent of the total number of cases of HIV in the world,” Edsel said. The newer subtypes are more likely to become drugresistant or they may progress to AIDS faster. And at the rate that the virus is mutating, we may not be able to catch up in finding new treatments for the more potent mutations of the virus.

This may be one reason for the alarming rate of increase of HIV cases in the Philippines. Dr. Salvaña’s group found out by their genomic studies that the explosion of HIV cases in the country is due to a shift from the Western subtype B to the more aggressive Southeast Asian subtype AE.

Sometime ago, it was reported by health authorities that many new cases come from the ranks of call center employees. Dr. Salvaña said that they are seeing younger and sicker patients with high rates of drug resistance. This different subtype is also now reported in developed countries, like Australia, Canada and the United States. This may indicate a new wave or resurgence of cases in these countries.

If our health officials and citizenry become complacent and think we’ve already figured out how to curb HIV/AIDS, we may be in for a big surprise in the near future. Everyone has to remain vigilant, said Dr. Salvaña, recognizing that HIV is a rapidly evolving and growing family of viruses—each of which is highly unique—which can set off the next deadly epidemic. He stressed the importance of urgent researches on the behavior and proper treatment of non-B subtypes. Governments and funding sources must recognize this and allocate the necessary resources.

With more than 35 million people already dead from HIV/AIDS, and scores of thousands diagnosed to be HIV+ , the future still looks uncertain. It can swing both ways—either we become AIDS-free or massively AIDS-afflicted with no known effective treatments for the mutated forms of HIV/AIDS.

“Despite the remarkable progress we’ve made in reversing the epidemic, the truth is that we are just a few viral mutations away from disaster”

Nov 2018 Health and Lifestyle

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