Twenty year-old HIV- AIDS by C. D. Fermin, R. F. Garry, T. Habtemariam & B. Tameru
After more than two decades (Essex et al. 1988; Fineberg 1988; Gallo et al. 1988; Haseltine et al. 1988; Heyward et al. 1988; Mann et al. 1988; Matthews et al. 1988; Redfield et al. 1988; Weber et al. 1988; Wright 1988; Yarchoan et al. 1988) of studies on HIV-AIDS, many significant discoveries, the design of new clinical approaches to buy time for AIDS patients, and a significant amount of basic research data we are unable to holt the demise that the virus causes to the immune system. For additional information please see (levy 1994) .
It is well established that AIDS does not discriminate on the basis of race, gender, personal preferences, or lifestyle. The disease devastates many communities and continues to be an insidious problem, hard to control. It is almost impossible to make people with risky behaviors understand that HIV infection is similar to playing Russian roulette. Although a great majority of affluent individuals suffer from the disease, the greatest majority of victims are those with no access to proper healthcare, education, and/or financial means to afford viable treatment.
In 1995, (Battjes et al. 1995) reported that "sexual risk behaviors continue at high levels in all cities, suggesting relatively little sexual risk reduction" during the course of most studies on AIDS. More than 10 years later risky sex remains as an important variable for contracting the HIV infection and developing AIDS
.
(Beyrer 2007) reported that the "emerging epidemic among injecting drug users across Eurasia are largely the result of needle sharing, but the drivers of the disease spread include increase in opiate availability, limited HIV infection prevention and programs for drug users and undermining policy environments." Tuskegee University College of Veterinary Medicine Nursing and Allied Health is located in the hearth of the African-American county belt of US, where a disproportionate number of AIDS patients reside. It is timely discuss health issues affecting the black belt counties of the USA. For the above and other reasons which will be referred to below, this conference at Tuskegee University and sponsored by the College of Veterinary Medicine Nursing & Allied Health (CVMNAH) centers on the health disparity issues related to HIV/AIDS epidemic worldwide, and African-American community where Tuskegee University is located.
Homosexual and heterosexual transmission of the virus continues to be a problem. A sexual route of infection is further worsen by the use of illicit drugs, primarily because injectable forms of opiates provide a more concentrated form of drugs than for instance smoking (Jarlais et al. 1994) . The AIDS epidemic caused by HIV along the earth globe can be traced along some drugs distribution routes. One very well established is that of the golden triangle of Southeast Asia that includes Thailand, Myanmar, Laos, and other regions. The epidemic of the virus moves through Northeast India into Thailand, Malaysia, Vietnam and then east across China to Hong Kong. The virus tends to also move along those routes for distribution of cocaine within Brazil and other American countries (these include South, Central, and North America). Yet Africa (see http://www.bioafrica.net/subtype/subC/index.html ) remains the hardest hit (Caldwell et al. 1996) . With the current globalization of travel, the epidemic continues to increase at a fast rate and programs established to try to halt the spread the disease continues today with variable progress. However, it is clear that AIDS prevention activities to include community involvement offer some of the best hopes for at least controlling the disease partially
While Africa has been most affected by the AIDS epidemic (Evans et al. 2004) , the epidemic is also spreading to Asia and Russia. All drugs used to treat AIDS have tremendous side effects including neurological problems, hematopoietic tissues, cerebral and abdominal problems and lypodystrophy. One of the greatest concerns for the attending physician is the occurrence of opportunistic infections in patients with AIDS. (Berenguer et al. 2004) noted that the highly active antiretroviral therapy (HAART) use so effectively to buy patient time, remains the best strategy for the prevention of this opportunistic infection in HIV positive patients. However prophylaxis is necessary in countries with limited resources where those most affected are unable to afford the cost of these vary expensive treatments (Caldwell & Caldwell 1996) . In addition, the HAART therapy has also increased the importance of virus resistance, which can also become a problem in patients receiving a regimen of these drugs without proper monitoring (Fellay et al. 2006) . Then there is the issue of patient management on those infected with not only HIV but also Hepatitis C virus which can complicate the treatment program as well as management of the patient (Iribarren et al. 2004; Schouten 2007; Simon et al. 2006) .
Probably one of the worst obstacles to reduce the spread of HIV is not the lack of resources or knowledge about consequences of the disease, but rather a lack of political resolve ( see Cohen articles in Science below, 2006 ) to utilize alternative methods that may prove more beneficial than the conventional approach currently utilized by basic, clinical and social scientists. For instance, the debate over syringe exchange has been complicated by historical tendency to single out certain ethnic groups. The best hope for resolving some of the issues associated with HIV transmission probably rest on political resolve to implement new approaches that might not be politically correct, sociably acceptable, or currently being used. The manner in which the virus defeats the immune system requires much understanding by experts (O'Brien et al. 1997). For this and other reasons it is very difficult to communicate the exact devastating effect that the virus has on the immune system (Ezzell 2003) .
The progression toward AIDS is shown on the chart downloadable from the web site (http://www.healthdisparity.tuskegee.edu/8thSymposium/symp8th.htm ). This image modified from sources elsewhere demonstrates that the initial response of the immune system to the HIV infection may pass as a simple malaise similar to that of a flu-like symptom. Nonetheless, the devastation the virus has on the immune system continues despite lack of serious symptoms and the transmission of the virus is spread rapidly by both lack of knowledge of the mode of transmission, misunderstanding of the consequences of transmission, and perhaps even worse, disdain about the lack of cure of for this disease
The ability of the virus to change from the initial time of infection to the time of appearance of the AIDS disease is generally accepted after a drop of less than 200 CD4+ T-lymphocyte count (Nowak et al. 1995) . However, during the course of infection leading to AIDS the virus can undergo as many changes (mutations) as a human may undergo in a million years. For this and other reasons it is almost impossible to control the propagation of the virus and/or design vaccines that can show promise in the near future. The virus is so tricky that it can constantly evade the immune system attacks, at least to certain degree, that allow the virus sufficient time to change rapidly. Thus, even if the immune system gathers enough strength to neutralize newly mutated particles that appear to change rapidly, some escape to continue the vicious cycle until the system can no longer fight back. While the initial triggering for the virus to latch on to the cell that contains the CD4 receptor are well understood, the virus continues to evade reliable therapeutic approaches to halt the infection, and "completely" eliminate the virus from the infected host. We now know that certain chemokines, and cytokines are required for the successful attachment of the virus, and to facilitate delivery of the virus genome into the cytoplasm that allows the particle to deliver its cargo to the infected cell.
Regardless of progress both of the clinical and the basic research levels it is clear that HIV replicates very rapidly and remains at high levels in the infected host. While its presence in the infected host does not lead to serious illness sometimes for up to a decade after the initial infection, it is now clear that the demise of the infected host is inevitable, even after expensive HAART therapy (Bartlett et al. 1998) . Even with hope offered by HAART, there is the issue resistance by the virus, which tends to adapt quickly and mutates to more resistance viral forms unless the therapy is well designed, managed, and administered. While many patients can be asymptomatic, as miracle of the HAART cure, many failing therapy manage to only buy patient valuable time while the virus continues to erode the immune response and lead to ultimate death of its host.
Until a proven therapy can eliminate the virus from the host and lead to re-establishment of a healthy immune system, the best hope for managing the spread of disease is education through community outreach and implementation of programs that may not be politically correct and/or acceptable by the clergy and/or the medical profession but nevertheless responsible enough to convey the severity that the message deserves: if you contact HIV, there is not cure for it. A recent report describing unconventional efforts put forward in Latin America may be prove useful in the US as well (Cohen 2006a; Cohen 2006b; Cohen 2006c; Cohen 2006d; Cohen 2006e; Cohen 2006f; Cohen 2006g; Cohen 2006h; Cohen 2006i; Cohen 2006j; Cohen 2006k; Cohen 2006l; Cohen 2006m; Cohen 2006n; Cohen 2006o; Cohen 2006p; Cohen 2006q; Cohen 2006r; Cohen 2006s; Cohen 2006t) . Hopefully the success that those unconventional methods have demonstrated will encourage health care providers, counselors, and centers to adapt methods that are probably not politically correct, and certainly go against the recommendations of most religious institutional practices
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