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I first talked about AIDS in May of 1983
in conjunction with Bob [?],a former resident here at the clinic.
At that time, I think we boththought that this was a splash in a pan,
and it was something that was goingto go away as soon as medical science got
a handle on etiologyand began developing some therapy.
Well, that hasn't been the case.
This is the second updateI've given on AIDS.
The whole dilemma continues,and the beat goes on.
Most of you are well awareof the medical emergency
that AIDS has created in this country,and not only in this country,
throughout the world,and it indeed is a pandemic.
In fact, it is the first pandemic
that has beena sexually transmitted disease.
It doesn't come near the statistics,of course,
from the plagues of the 14th century,
and of course,the influenza epidemic in 1917, 1918.
I think it's off to a good start,
and I think it's gotmedical science very concerned.
In fact, it has the entire governmentof many countries
where AIDS has been reportedvery concerned.
By way of an introduction, I just want
to give you a little chronologyas to what's happened thus far.
The first cases of AIDSwere really described in 1979.
This was because there weresome peculiar malady
that was occurringin a specific population
of patients in large urban areason the West Coast in New York City.
The intuitiveness ofsome of these public health investigators,
namely Michael Gottliebon the West Coast and Friedman-Kien
on the East Coast, noted that there weresome common denominators with respect to
the syndrome complex that they were seeingin young and middle-aged homosexual males
with an arrayof opportunistic infections
and some strange malignant diseasessuch as Kaposi's sarcoma,
which is not too terribly common,especially in that age group.
They decided that this was somethingthat was unique to this population.
Again, CDC became bonafidely interested in it
in early 1981 and begannoting some of the common denominators
and finally came upwith a definition in June of 1981.
They actually beganregistering cases at that time.
By that time,there was about
300 or 400 cases of AIDS,many of whom had died.
Again, the peculiar high-riskgroups such as homosexuals,
bisexuals, and the IV drug users.
When CDC finally got a handle on this,
they began recognizing, and reports begancoming in from other major urban areas
throughout the country,Houston, Miami, and Chicago primarily.
We had the East Coast and the West Coast,
and again, the clinical syndromewas very common.
The individuals that seemed to be at risk
for the syndrome,again seemed to be common.
CDC began collecting data.
During this period of time,they began noting also
that this had a terrible mortality rateassociated with it.
During 1982, Bob Gallo, Max Essex,and a few other notable virologists
were workingon the possible etiology of this.
Initially, it was thought thatthis was all related to immune burnout.
These patients hadsuch a heavy antigen load
that their immune system just simply burned
out, and ie, they developedthe immune deficiency syndrome
and were so predisposedfor the array of opportunistic infections,
which were not treatable when one hastheir immune system decimated.
Much of the work of Bob Galloon other types of viral agents
and in conjunctionwith other people, namely in
Japan, and again, up at Harvard,the work of Max Essex,
realized that there were some similaritiesbetween some viral agents
that could producean immune deficiency syndrome
and the patientsthat were presenting with AIDS.
Because there wasan assay available for picking up
reverse transcriptase,they were very suspicious.
First of all, they were very suspiciousof it being a retrovirus
because of the analogous features
to other syndromesthat retroviruses caused.
Indeed, they did pick upevidence of these patients
having reverse transcriptase,and that meant, of course,
that they were infectedwith the retrovirus.
Retroviruses are pretty ubiquitous,but only the exogenous viruses.
The exogenous retroviruses caused problemsand caused disease.
At that time, they finally recognized
and realized that this wasa filterable agent, number one
because people were getting itthrough blood and blood products.
Number two,it looked like it was a viral agent.
Number three, it lookedlike there was enough evidence to pursue
the area of investigating for a retrovirusas being the cause of the disease.
In 1983, Dr. Bob Galloand his group at NIH
and also, Luc Montagnierover at the Pasteur Institute in France,
in Paris, isolated the virus.
Now, that's just the first step,
isolating the virus, identifying the virus,but it was very, very difficult
to determine whether this virus wasdifferent than HTLV-1 or HTLV-3.
By the way, you're going to hear me talkabout HTLV-3, HIV, and the AIDS virus.
It's all synonymous.
Please keep that in mind.
They're synonyms.
What we're talking aboutis the AIDS virus.
I like to use the term HTLV-3because of the HTLV-1, the HTLV-2,
which we're goingto be talking about more tomorrow.
In 1983, the virus
was finally isolated in Franceand as well in this country.
Then we got to the nitty gritty workof trying to isolate the virus
and culture the virus to the pointwhere there was enough viral proteins
to make some dependable test, that is,extracting some antigenic material
so that we could look for antibodiesin a serum of patients who were infected.
This took a considerably longerperiod of time
than it did to isolate the virus.
Finally, in November of 1984, Mike Popovic,
who was working with Bob Galloin his laboratory, finally came up
with a lymphocyte culture line,which the virus did not destroy.
In other words, the difficulty with HTLV-3is that when an infected lymphocytes,
it destroys the lymphocytes.
Its lympholitic,as opposed to HTLV-1 and HTLV-2,
which causes the cells to proliferateand creates a proliferative disease,
ie, leukemia.
The problem was a major onebut was finally overcome in Dr.
Gallo's laboratory.
At that time,
we were able to grow the virus in culturewith this unique cell line,
the H9 cell line,and get enough viral material
so that we could look atand concentrate the proteins of the virus.
Then, of course, by additional techniques,
use that protein as antigenic materialand then run it against the serum
of patients who had the virusor were exposed to the virus
or were infected for detectionof significant titers against the virus.
This is how this all happened.
As soon as we were able togrow the virus and immortalize
the virus in these cell lines,it didn't take long for a screening test
to be put on in market,an immunologic screening test,
the ELISA test,
which hit the market in March of 1985and was quickly distributed
throughout the countryto most of the blood banks.
I should add that there was one heckof a lot of work that was going on
between 1982 when we first consideredthe retrovirus as being etiologic agent
until we were able to commercially produce
this screening testwith the ELISA technique
to pick up antibodies in a serumof patients infected with the virus.
As Margaret Heckler saidwhen we first announced
that we had isolated the virus,never had we learned so much
about a single diseasein such a short period of time.
Indeed, that is the case.
I think we're goingto see a great amount of spinoff
from all the investigationsthat have gone on with respect
to this disease that will hopefully impacton other areas of medicine.
In fact, they already have.
I think we're going to see itfor years to come.
With this test readily availablein all of the blood banks
throughout the country, we then had
a screening method for picking up patientswho were infected with the HTLV-3 virus.
Now, please keep in mind,it's just picking up
patients who have been exposedor infected with the virus.
We're not talkingabout patients who had AIDS.
Finally, here we are in 1987,the AIDS epidemic continues.
It is indeed now a pandemic.
There weremore than 80 countries reporting AIDS.
You'll see that the beat goes on.
As one notes, as of January of 1987,I think you can get a good perspective
as to what's going onwith the AIDS epidemic in this country.
As of January, there aremore than 29,000 AIDS
patients reportedand registered at CDC.
Again, this is in the United States.
Here's another interestingand disturbing fact.
There are more than 400pediatric cases reported,
and this is childrenless than 13 years of age.
Now, the sad reality of thisis that most of these patients,
the vast majority of these kidsare infected through infected mothers.
Projections indicatethat over the next four years,
this will increase tenfoldto more than 4,000 cases.
There have now been more than 13--actually, there are more
than 14,000 deaths reportedas of January 1 of 1987 of AIDS patients.
Keep in mind that 80% of these patientswho are diagnosed with AIDS will die
within a 24-month period of time,and also, the median survival of a patient
once he's diagnosed as having AIDSis 13 months.
That's whether he's getting AZTor any kind of immunotherapy or whatever.
The disturbing facts about all thisis that the CDC estimates,
and these are very conservative estimates,and they make that very clear,
if the epidemic continuesas it is now in this country, in 1988,
we will have91,000 registered cases of AIDS.
In 1990, we will havealmost 200,000 cases of AIDS.
By January of 1991, we're goingto have over 268,000 cases of AIDS.
Now, you can see,
it's almost an exponential increasein a number of cases.
The number of cases of AIDS is doublingevery 13 months in this country.
Now, this is only the tipof the iceberg because,
as I mentioned to youearlier in my open remarks,
that AIDS is not unique to this country.
It's a pandemic.
There are more than 80 countriesare now reporting AIDS.
Unfortunately, we really don't havea good handle on their statistics.
Many of these countrieshave gotten on a bandwagon rather late.
The death rate to AIDS, one can see, again,we have a similar type of curve.
By January of 1991, there will be
more than 55,000 patients will have died
because of AIDS.
I think you have to understandthat most of these patients
over that 13-month period of time,from the diagnosis to the time of death,
will require a great dealof medical care and attention,
and it's a horrendous expense.
I don't think you can think about AIDSwithout understanding
and at least thinkingabout the implications it has for the
cost of medicine in this countryand any other country
and also the socioeconomic impact it hason the country in general.
That's why this issuch a hot issue in legislation right now.
As I mentioned,this is only the tip of the iceberg.
Let me reiterate, too,
that most of these countrieshave only recently begun
reporting cases of AIDSto the World Health Organization.
They do have CDCsin some of the countries,
but the World Health Organizationhas had to intervene
because many of these countriesare not reporting their cases of AIDS.
Britain is doing a wonderful jobin terms of education.
The British people arevery concerned about this.
They've already made concerted efforts
to curb the spread of AIDSthroughout the British Isles.
They have, as of 1982,only 548 cases reported.
France, where the situationis a bit different,
they're not doing much at all.
The French government,over the past several years,
is turning their head awayfrom this whole terrible issue of AIDS,
and it's believed that there are
more than 2,000 casesin the city of Paris alone.
This is from officials
that are working withthe French Red Cross,
but the French government recognizesand realizes the tremendous drain
on the economyif we begin in earnest looking
for programs for educationand treatment of AIDS patients.
The same is true in West Germany.
The West Germans have not chosento really escalate this
to a high-priority issue,and the government is
not really carrying outany kind of meaningful education programs.
Switzerland is an interesting storybecause Switzerland has
the highest rate of AIDS per capitain the European countries.
The four major cities in Switzerlandhave all reported AIDS,
the four major cities.
The incidentsright now is quite disturbing.
The Swiss government is carryingon some very good educational programs,
and it seems that Switzerland,because of the four major cities, will be
able to cope with the AIDS populationin terms of treatment.
That's what manyof the underdeveloped countries
are very concerned about.
You notice on this list, you don't seethe countries along the Mediterranean
because their economy isa little less stable, and they're very,
very concernedabout the number of hospital beds
and a number of hospital personnelto care for AIDS patients.
We really have virtually no reportsfrom Portugal, Spain, Italy, and Greece.
There is no questionthat AIDS is prevalent
in all these Mediterranean countries.
Africa is quite a different story.
It's just a big mess in Africa.
It's the hidden plague, as they call it.
Most of the British researchersand some of the people from CDC
from our country who have been there
recognize and realizethat everything is in disarray.
They are not reporting the cases.
In fact, the firstcases reported in Africa from some
of the countries in South Central Africa,that is, Kenya, Uganda, Zambia
were reported in 1983, and in Zambia,the first case was reported in early 1985.
They like to thinkthat they don't have an AIDS problem.
They call it the slims there.
The patients havea tremendous amount of weight loss.
They look eclectic,
and they die within a period of six monthsafter the diagnosis is made.
They've been really very, very hamperedby statistics and medical care.
Africa, we have no idea
what the incidents of AIDSis in the major African urban areas,
but I can tell you that there aresome studies that are going on now,
primarily by the Britishand some American investigators,
that indicatethat more than 50% of the prostitutes
in the major citiesin the countries in Central Africa,
in South-Central Africa,are infected with this virus.
Now, this is quite differentthe mode of transmission
than what I'm goingto talk about here in this country.
These are prostitutesworking in major cities,
and there's no questionthat the disease is being transmitted
in a sexual way as opposedto the urban areas in our country
where the prostitutes are HTLV-3 positive,
primarily because they areIV drug users and abusers.
Africa remains a real hotspot for AIDS.
Again, it's an area that we're goingto have to watch very carefully
because most people thinkthat AIDS really started in Africa,
came to United Statesby way of the Caribbean.
There are some studies that indicate,
or that estimatethat 1% to 2% of the African population,
that is the Sub-Sahara population,is infected with the virus.
Now, that does not include South Africa.
There are other studiesthat have come out of Kampala
which indicatethat 6% to 7% of the healthcare workers
in the countries of Central Africaare infected with the virus.
That's a staggering statisticbecause it really impacts greatly,
not only on the medical care facilitiesbut also on economy of the country.
It's been estimatedthat 20% to 30%
of the patients in Zambiaare infected with this virus.
Now, depending uponwhat percentage of patients
are going to develop AIDS in the futureafter being infected with the virus,
it's going to have a tremendous impact
on the workforcein these countries as well.
Currently, this is what the Britishhealthcare workers are trying
to get across to the governmentsin these countries in Central Africa.
Brazil is, again, a real hotspot for AIDS.
Brazil started reporting AIDS in 1984.
They now have 1,100 cases.
American Red Cross people in Brazil,
in conjunctionwith the Brazilian Red Cross
feel that there aremore than 3,000 cases of AIDS.
They are not reporting AIDSlike they should be.
Their education programs are very meager.
I don't know how many of youare familiar with Brazil,
but there are more than 10 major citiesor urban areas in Brazil,
and the sanitation conditions in Brazil
are really quite badin some of these major areas.
San Paulo is the largest city
in the world right nowwith 16 million people.
There's a lot of people in Sao Paulowho have been infected with the virus
and in fact, who have AIDS.
One of the problems in Brazil
that's pointed out is thattheir lack of hospital beds
and lack of healthcare workersto care for these people.
Again, the government is nottoo terribly interested in making
concerted efforts along these lines.
Brazil has just hada radical change in government in 1984,
for those of you that haven't seenthe latest National Geographic.
Puerto Rico has reported 115 cases.
Puerto Rico startedreporting cases in 1982.
115 patients reportedprimarily from San Juan.
The interesting story about Japanis that Japan started reporting
cases to the World Health Organizationin conjunction with CDC back in 1981,
a few months after the United States beganreporting their case at the CDC.
Japan has had only 25 cases reported,and this is as of January 1, 1987.
They have done a horrendous jobin terms of education with their people.
Many of the bathhouses have been closed.
The prostitutes are being screened.
Although getting HTLV-3serologies is not mandatory,
they do draw one in every patientthat is admitted to the hospital
for whatever.
The Japanese have gota much better handle on the situation.
I think we're goingto learn a lot from the Japanese in terms
of looking at the overall incidenceof infection with the virus.
The Japanese, of course, had the advantageof having worked with the HTLV-1 virus,
which is endemicin the southwest islands of Japan.
They knew a lot about the virus,
and they knew somethingabout the modes of transmission.
I think, more importantly,they're very astute people.
Their government isquite aware of the impact this could have
on a socioeconomic situationin the country.
This is clearlyan urban disease for the present.
Is that clear?
Most of the cases still are being reportedfrom the major cities
throughout the country,and it's true throughout the world.
If we look at the slide,
New York, San Francisco,and Los Angeles account for 43%
of the AIDS cases that have been reportedas of December in this country.
These are really the hotbeds of AIDS.
Of course, we all know thatthere's a very large gay population
in San Francisco and Los Angeles,as well as New York, but there's a very,
very large populationof IV drug users and abusers
in New York City.
I think that New York Cityhas had almost 4,000 cases
just last year alone.
Again, that's almost 45% of the numberof cases that were reported in 1986.
Again, as you get down the list,one can see virtually all the major cities
throughout the countryexcept Fort Lauderdale.
I should mention, too, that there's beena very disconcerting number of cases in
the Fort Lauderdaleand Palm Beach area of Florida.
The high-risk groups have stayed the same,except if you look here,
I took out the Haitians primarilybecause it's no longer the Haitians.
It's many, many immigrantsfrom the Caribbean Islands.
The Haitians got the bum rap inthe early '80s.
There was a very high incidence of peoplewho immigrated here to the country
from Haiti.
I think we're well aware of peoplecoming here from the Dominican Republic
and other underdeveloped countriesfrom the Caribbean
who have a high incidence of infection.
The homosexuals and bisexual males
still make out the bulkof the patients with AIDS.
They make up approximately 70% to 75%of the patients with AIDS.
IV drug users are still holding firmat about 20% to 25%.
This is an interesting statistic.
90% of the IV drug usersare heterosexuals.
There's another littleinteresting caveat here,
is that 30%of these heterosexual
IV drug usersare female.
In conjunction with that, 90% ofthat 30% of the females
are in childbearing age.
That's where the pediatric casesare coming from.
They're coming from the IV drug usersthat are female,
the female prostitutes primarily,
and they're passing it onthrough the children.
It can be passed onthrough mother's milk or through delivery.
The heterosexual females is a real problem.
Of course,this is another mode of transmission.
Of course, the heteros havingthis thing become more prominent
in the heterosexual population meansthat none of us are going
to be spared from the possibilityof becoming infected with the AIDS virus.
There are about 2,400 casesof heterosexual females
that have been reportedas of January of 1987.
CDC estimates and again, conservatively,
that there will be about 28,000 casesby January of 1991.
They're concerned about thatbecause of the incidents
of infectivityfound amongst the prostitutes.
There's about one-thirdthe number of houses
of prostitution open in Houstonas there was three years ago.
The ladies are learning very, very quickly.
I'm afraid that it's too late,
and the situationis really running rampant now
through the heterosexual populationthrough the country.
Hemophiliacs still make up1% of the number of cases in AIDS.
As of January,
there were 284 cases of AIDSin hemophiliacs.
This includes Hemophilia A, hemophilia B,and von Willebrand disease.
Of course,these poor people contract dates
by virtue of the fact that they received
blood and blood productsso very frequently.
Of course, remember back in 1982when Bob Gallo was investigating
an etiologic agent,he recognized and realized
that this was a filterable virus
because of the incidence of infectivity
being caused in patientswho are receiving blood and blood products.
That these were just a token number
of blood and blood productsin some of these patients,
and that populationwe're still concerned about.
I think these are very disturbing statistics.
I really feel compelled to show thisbecause this is disconcerting.
Again, it points out
the problems that are occurringin the major urban areas.
This is New York City,which is the epitome of the AIDS problem.
Of the IV drug abusersthat have been studied in New York City,
60% are HTLV-3 or HIV positive.
60% have been infected by the virus.
Of a large groupof homosexual and bisexual males,
40% are infected.
It's a horrendous populationof homosexuals and bisexuals
in New York City.
Now, what's really disturbing is the
number of military enlisteeswho are HTLV-3 positive.
One out of every 50 people
between the ages of 18--This is males, by the way.
I should qualify that.
Between the ages of 15 and 25 who enlistinto the service are positive.
1 out of 50.
Now, what's the national average,about 1 in 700, same age group, same-sex.
In women, it's much, much less frequent,but that is very disturbing.
1 out of 50 from Manhattanis HTLV-3 positive.
Now, if one looks atthe five Boroughs of New York,
the incidence is significantly less.
It's about 1 out of every 200 or 1out of every 300.
The national average isabout 1 out of every 800,
1 out of every 750.
When the military findsthat they're HTLV-3 positive,
they drop them like a hot potato.
They have no other responsibilityto these people.
In fact, they're not even responsible
to report this to CDC,although they have.
That is being contested at this time.
I think that that gets usinto the whole matter of the ethics
and the morality and the individual rightsin people in this country,
the confidentiality laws,which are being banned around
from pillar to postwith respect to the whole AIDS issue.
I don't want to get into that now,
but we can probably talk about thatwhen I get through here.
Now, of course,
what everybody's wondering aboutand worried about is how many people
who are infected with the virusare going to get AIDS.
I don't think anybodyhas a good handle on that.
CDC estimates that there are
1 to 2.5 million people in this countrywho are infected with the AIDS virus.
I told you earlier that there aresome countries in Central Africa
that have an incidence of 15% to 20%
of the sexually active individualsare infected with the virus.
The overall population may beas high as one in 2% in the Central Africa.
In this country,we think it's around 2 million.
That's a ballpark figure.
I'm not sure how they arrive
at these things,but it comes
from the reputable organizationswho have been studying the AIDS situation.
Again, in someof the countries
in Central Africa,and this is Zambia,
20% to 30% of the sexually active peopleare positive, and incidentally,
the Red Cross has shownthat about 15% to 20%
of the sexually active people in Brazilare HTLV-3 positive.
I think Brazil's another countrywe're going to have to watch
for marked escalation of the AIDS problems.
CDC and the National Academy of Sciencewho have been looking at this,
and again, these are just estimates,feel that about 20% to 30% of patients
who are infected with the viruswill go on and develop AIDS.
Now, this figure varies all overfrom 10% to 50%,
and if you're a redneck Southern Baptist,it's going to be a hundred percent.
It varies greatly.
I think that these arethe conservative estimates
of CDC and the National Academy of Science.
Within the next five years,
20% to 30% of individualswill develop AIDS.
Now, we're talking about everybodythat has a positive HTLV-3 test.
We're talking about, for the most part,asymptomatic patients,
people who have no symptoms at all,
many people who are positiveand are picked up serendipitously
through screening methods,ie, going to give blood.
This is how I picked upthe last new patient
we had here in the clinic.
She went to give bloodand was found to be HTLV-3 positive.
This is a real dilemma.
I think the last wordis not in on this situation,
of course, and I thinkwe're all going to
be very interestedto see how things go.
I think we're going to geta handle on this
by looking at the military recruits.
One other interesting point,no one knows what the incubation period
of the AIDS virus is, but we do knowthat it can be longer than 10 years.
There are some interesting studiesthat have come
out of San Francisco and out of Atlantalooking at serum specimens
from patients who were studiedfor other problems and other diseases.
The one in San Franciscowas the hepatitis B virus study.
That was done in 1972.
They went backand pulled these frozen specimens.
They found, indeed,
that there was a small but significantpercentage of those patients
that had evidenceof having been infected with the virus.
They had antibodies to the virus.
We know that the AIDS virushas been around
for at least 10 years, 15 years,
but what the incubation periodof that virus is, we have no idea.
Again, these are the estimatesof small cohorts of patients
that have been followed by CDC since 1981.
In Africa,
there's a very high incidenceof the AIDS virus in children.
Many people think that theincubation period of
the virus in childrenis very long, and in fact,
it may not lead to AIDS at allor the ARC syndrome.
This may be somethingvery common in the environment,
whatever way it may be transmittedin the countries, in Central Africa
that children get infected with,just like the EB virus
and just some of the other virusesthat children get infected
with early in life,and their immune systems handles it
somewhat differently and probablymore efficiently.
They live in symbiosis with the virus,or they may just retain
viral antigen material,which stimulates the immune system
enough to keep the antibody tighter,high enough, so it's detectable.
I think,getting down to the real nitty-gritty
and some of the socioeconomic problemsthat we're having with AIDS,
people in this country are very concerned
about the government not doingits bit for the AIDS dilemma.
They've declared it a medical emergency,but they're not giving
the appropriate amount of attentionin terms of dollars for research,
dollars for education,and programs for caring for these patients.
I think that this hasa great number of people upset.
We are supposed to bethe most progressive country in the world,
and we should be settingexamples for other countries.
With this being a pandemic,I think we have to be very careful
and look at these other countrieswhere AIDS is flourishing.
The first 15,400 cases,and this was as of November
I think of 1985, cost the government
$4.1 billion in direct and indirect costs.
Now, this was the care of these patients.
This had nothing to dowith the loss of work,
that is, these patients die prematurely.
There's a horrendous lossof manpower and professional work hours,
and that is not taken into accountwith these figures.
I just want to point that out.
The proposed government expenditurefor AIDS education and the AIDS programs
throughout the country,and there are a number of them,
in 1987 is $411 million.
In 1988, it's projected at $534 million.
The National Academy of Science and CDC
think that these arewoefully inadequate, very inadequate.
The study that was doneby the National Academy of Science
in conjunctionwith the Institute of Medicine
indicates that, by 1990,
the government is going to be spendingmore than $2 billion for the AIDS problem.
By 1991, and you saw the curves,the increased incidents,
remember by January of 1991, we're goingto have almost 270,000 cases of AIDS.
That's the projectionsand our conservative projections.
It's going to costthe government $8 billion.
Truly, this is a medical emergency.
It's certainly going to influence
the cost of medical carehere in this country.
One other sad statisticabout these AIDS patients
is that not a lot of themhave third-party carrier insurance
or cover.
There are 40% of themwhich do not have medical health insurance.
That means that you and Iare going to help defray
the costs of these AIDS programsand caring for AIDS patients.
The other thingthat they're concerned about
is healthcare personneland helping to care for these patients.
I think if one looksat this more carefully,
I think you can seewhy it's such a horrendous expense.
I looked at the costsof an average-age patient
being hospitalizedfrom the time of diagnosis
was made to the time of deathin various parts of the country.
This is inpatient billing only.
Keep that in mind.This is patients who are in the hospital.
In San Francisco General Hospital,
where there's a great numberof AIDS programs that are being funded,
national grants,and there's a big house staff,
and many of these thingsare not charged to the AIDS patient.
In fact, Paul Volberding,who's the head honcho
at San Francisco General Hospitalwho's written a great deal about AIDS,
has a tremendousamount of manpower at his availability
to go ahead and implementsome of these programs.
He's been heavily grantedby NCI or the NIH
to carry out some of these programs.
He's been really one of the first personswho's gathered meaningful statistics
concerning these AIDS patientsand the care of these AIDS patients
on an inpatient basis.
The bill for the average patientin San Francisco General Hospital
was $27,500.
This was surprisingly low.
Jerry Groopman, who was outat the New England Deaconess Hospital,
again, who was a very prominent figure
in the AIDS research areaestimated or calculated
by looking at his age patientsthat it costs an average of $46,500
for these patientsduring their hospitalization.
Now keep in mindthat the average-age patient
is hospitalized about 3.2 times
from the time the diagnosis is madeuntil the time of death.
That the average survivalis about 1 year, 13 months.
The average number of daysthey spend in a hospital is about 60 or 58.
The CaliforniaDepartment of Health Services,
which gather their statisticsprimarily from Southern California Hospitals,
estimated that it costs $67,300
for AIDS patients in the hospitalsin Southern California.
These is the AIDS patients' bills.
Again, inpatient medicine.
Here at St. Joseph's Hospital,
I took an AIDS patientwho was diagnosed as AIDS here.
He had all his hospitalizations here,which was three, by the way,
and he died this past November.
He lived about 15 months,
so right on the money herewith the average, almost.
He was hospitalizeda little longer than 58 days, though,
if you calculatedhis three hospitalizations.
With the help of Debbie Sossamonwho helped gather
all these statistics for meand looking at the hospital bills--
Debbie worksat the Infectious Disease Control office.
We calculated that our patient's billwas a little over $47,000.
It was about $47,400.
Again, let me reiteratethat this is only inpatient billings.
We really don't havea good handle on
outpatient coststo these patients.
We have no idea aboutthe education programs
and the other ancillary healthcare workerswho visit these patients.
The only thing we can look atis the hard figures
that come out of the hospitalwith the hospital bills.
Now, much of the outpatient care is,in fact, provided by the government,
at least some of it is.
The medications that they're on,
a token medicationsthat they've been put on,
these small drug programshave not been charged for.
Again, we really don't have a good handle
on the non-inpatient AIDS cost,that is, the outpatient care.
I should add, too, in San Francisco,
they don't keep these patientsin a hospital very long.
I don't know whether it's becausethey do they need to do quickly,
they expedite their care,but the average number of hospital days
in San Francisco patientswas considerably lower than it was
in New England Deaconess Instituteand in the California Department
of Health Service study.
You can see what it costs at St.
Joseph's Hospital for an AIDS patient.It's a typical AIDS patient,
at least by wayof these national statistics here.
Getting a little closer to home,in Wisconsin, there are 135 cases of AIDS
registered at the state CDCin talking to Jim [?].
Now, these are interesting statistics,so pay attention.
The non-residents, that is,the patients who contracted their AIDS
outside of the state of Wisconsin,was 45. 50%.
The residents, the number of patients
who contracted their diseasein Wisconsin was 90.
It's twice as many residents as non-residentsthat we have registered now.
Of course, this is the total.
Now if we lookat the number of cases, in 1986,
there were 60 new cases in Wisconsin.
Look at the differencein resident, non-resident cases.
There were 48 resident cases,and there were only 12 non-resident cases.
Now, what this means is thatmany patients contract their disease
elsewhere, in other states,and other big urban areas
that I showed you on the earlier slides,
and they come back to Wisconsinbecause Wisconsin is their home.
They come back hereto spend their last time with their family.
Most of these patientsdie here in Wisconsin,
and they're countedas non-resident cases.
That's what we were seeing in the early yearswhen we were collecting the cases.
These people were coming backfrom Miami and San Francisco or San Diego.
Indeed, that's been our experience herewith the six cases that we have had.
Most of these patientscontracted their disease elsewhere.
You can see the trend is changing.Trend is changing.
By far and away,
there are many more resident casesthan there were non-resident cases in 1986.
Of course, you can seethe significant increase
in a number of cases in 1986.
We had a total of 135 cases,
60 of which were picked upand registered in 1986 alone.
Now, where are these being picked up?Of course, as you might imagine,
in the large urban areas of Wisconsin,
57 cases in Milwaukee County
and 21 cases in Dane County.
You can see that we're not really immuneto the AIDS problem here in Wisconsin,
even though we think of ourselvesas being a rural community or rural state.
Let me expand on that a little bit.
I think CDC is well awarethat this has been,
to this point, a very urban disease,but they estimate that there will be
an equal number of casesin the next five years coming
from rural areas in smaller urban areas.
Again, this is primarilydue to the different modes of transmission
that we're seeing, ie,the heterosexual population.
Here at Marshfield,our experience thus far,
we saw our first AIDS patient in--
well, I diagnosed himas having ARC in January of 1984.
He died in June of 1984.
Since that time,
we've registered six cases with CDC,and we're now following eight cases of ARC.
This is the AIDS-related complex.
That is, these arepatients who have immune deficiency
who do not have the criteriato make the diagnosis of AIDS.
CDC has been very rigidabout these criteria
of making the diagnosis of AIDS.
There's a very interesting editorial
on some of that materialthat I handed out to you
that's in the Annals of Internal Medicinethis past month pointing out
this whole nebulous areaof how you make the diagnosis of AIDS.
You've got to have either a complicating,an opportunistic infection,
or a malignancy associatedwith the immune deficiency state
in order to be classifiedor categorized and registered as AIDS.
We all know that AIDS is a spectrum.
Patients may be entirely asymptomatic
initially and then developthe AIDS-related complex,
which they may be just asymptomaticand have anemia.
They may have a reversalof their T-site subset ratio.
It's a continuum process.
It's probably not accurateto just register those patients who
develop opportunistic infectionsand malignancies as having AIDS.
Five out of our six patients have died.
Of course,I guess that didn't surprise anybody.
Again, I reiterate 80% of the patientswill die within 24 months.
The average survivalafter the diagnosis is made
as about 13 months.
We're continuing to watch.I don't know how many cases we have
of people who are asymptomaticand just simply HTLV-3 positive.
The ARC patients arepatients who do have some features
of immune suppression, immune deficiency,and we're going to continue to follow them.
We're following them mostly withthe people in infectious disease.
Bruce Hathaway, Doug Lee, Ray Hazel,
and Tom Sell are allinvolved with the AIDS patient.
How do these patients present?Well, it's the same old story.
Most of these patientspresent with opportunistic infections
or malignancies, and of course,that's how you make the diagnosis.
The most prominent typeof opportunistic infection
is the bilateral pneumonitiscaused by pneumocystis carinii.
This is thought to be an organism,which, indeed, is an opportunistic type.
It affects people who are immune suppressed.
There's a significant number of patientswho present with Kaposi's sarcoma.
One of the curious thingsabout Kaposi's sarcoma is,
as I mentioned earlier,it's not a very common type
of malignancy,number one.
Number two,it seems to be much, much more common
in the homosexual population with AIDSrather than the IV drug users.
CDC is still perplexedas to why this is the case.
Kaposi's sarcoma isso much more common in San Francisco
than it is in New Yorkwith respect to the numbers.
It's because ofthe proportionately higher number
of patients who are gay and develop AIDSas compared to the heterosexual
population who are IV drug usersin New York City.
It's not uncommon at all to haveKaposi's sarcoma and pneumocystis carinii.
In fact, our last patientthat just died last month presented
with bilateral pneumocystis carinii,and he developed
during his hospitalization hereat St. Joe's Kaposi's sarcoma.
Developed this right under our nose.
Other opportunistic infections, absolutely,a wide array of opportunistic infections.
Some organisms that microbiologistshave never really even heard
of before and certainlynot infecting humans.
This spectrum continues to grow,by the way.
Apparently, this never ceases a surprise,the microbiologists
as to the new organismswhich are being picked up
in these patientswho have profound immune deficiency.
Malignant lymphomas,
and I should spend a moment on this,the incidence of malignant lymphomas
in the AIDS patientis growing all the time.
This is a large cell type of lymphoma.
A very aggressive type of lymphoma.
Frequently has central nervous systeminvolvement primarily.
These patients run a very short course.
They are not very sensitiveto chemotherapy.
Again, it's a very aggressive typeof large cell lymphoma that we're seeing.
I should mention, too,that there is a relatively new syndrome
of central nervous system syndromethat's been reported in AIDS patients.
This is being reportedwith increasing frequency.
The AIDS virus has been foundin a central nervous system.
I think, tomorrow, I'll show you
what cells the AIDS virushas been picked up in.
I think that the syndrome isone of a wide variety of presentations
that these patients may presentwith dementia.
They may presentwith extensive motor and sensory deficit.
The histopathology is very, very analogous
to a demyelinating processor multiple sclerosis.
In fact, some of the NMR studiesshown in these AIDS patients
can actually pick upthese large plaque areas
where there's de-modernizationoccurring in the white matter.
Again, we continue to learnabout this virus and the AIDS dilemma.
I think that we're going to haveto get a handle on this thing very soon
because of the numberof cases throughout the
entire populationcontinues to grow.
This is one of our patientsthat we have here.
Many of you recognize this patient.
He was a young man from Steven's Point
who died last year from AIDSin his complications.
He's got extensive Kaposi's sarcoma.
Ray Hazel and Itook care of this young man.
He had two bone marrow transplants at NIH.
He was followed at NIH and herefor about a year with his disease.
These are the Kaposi's lesions on his face.
By the way, these are not justcutaneous malignant lesions.
These occur all through the GI tractand may occur
in a central nervous system as well.A curious thing about Kaposi's, though,
it's not very commonlythe cause of death in AIDS patients.
Most frequently, these patients will get,in conjunction with their Kaposi's,
opportunistic infections and will dieof the opportunistic infections.
The opportunistic infections arehorrendous and are very difficult to treat.
This is a chest x-rayof our first AIDS patient
who was admitted to the hospital,I think, on Memorial Day of 1984.
This is what his chest x-ray looked like.He died 10 days later.
He had bilateral pneumocystis carinii.
I think I'll stop there.
If any of you want to stay around, I hopethe Infectious Disease people will stay.
Is Doug Corey here?Doug's been interested in this.
Dean Crystal just got back from a meeting,so they've got all the latest scoop
on these statisticsin terms of infectivity,
the number of the incidentsof positive
HTLV-3 specimensin blood donors.
I think these are thingsthat we're all very interested in.
I'll go ahead and entertain some questions.
Don't forget, tomorrow, we're goingto talk primarily about the virus
and about the immunology,the immune deficiency syndrome.