WEBVTT 00:00.027 --> 00:03.767 [silence] 00:16.903 --> 00:21.141 [music] 00:46.843 --> 00:50.980 I first talked about AIDS in May of 1983 00:51.665 --> 00:55.085 in conjunction with Bob [?], a former resident here at the clinic. 00:55.620 --> 00:58.420 At that time, I think we both thought that this was a splash in a pan, 00:58.500 --> 01:04.060 and it was something that was going to go away as soon as medical science got 01:04.140 --> 01:08.940 a handle on etiology and began developing some therapy. 01:09.407 --> 01:10.780 Well, that hasn't been the case. 01:10.860 --> 01:12.960 This is the second update I've given on AIDS. 01:16.200 --> 01:19.740 The whole dilemma continues, and the beat goes on. 01:20.640 --> 01:23.680 Most of you are well aware of the medical emergency 01:23.760 --> 01:26.380 that AIDS has created in this country, and not only in this country, 01:26.460 --> 01:30.300 throughout the world, and it indeed is a pandemic. 01:31.440 --> 01:33.760 In fact, it is the first pandemic 01:33.840 --> 01:36.600 that has been a sexually transmitted disease. 01:37.860 --> 01:40.740 It doesn't come near the statistics, of course, 01:41.460 --> 01:44.020 from the plagues of the 14th century, 01:44.100 --> 01:48.660 and of course, the influenza epidemic in 1917, 1918. 01:49.620 --> 01:51.100 I think it's off to a good start, 01:51.180 --> 01:53.880 and I think it's got medical science very concerned. 01:54.480 --> 01:57.160 In fact, it has the entire government of many countries 01:57.240 --> 01:59.280 where AIDS has been reported very concerned. 02:00.350 --> 02:02.080 By way of an introduction, I just want 02:02.160 --> 02:05.340 to give you a little chronology as to what's happened thus far. 02:06.240 --> 02:09.900 The first cases of AIDS were really described in 1979. 02:15.960 --> 02:20.320 This was because there were some peculiar malady 02:20.400 --> 02:22.900 that was occurring in a specific population 02:22.980 --> 02:27.060 of patients in large urban areas on the West Coast in New York City. 02:29.100 --> 02:31.600 The intuitiveness of some of these public health investigators, 02:31.680 --> 02:34.780 namely Michael Gottlieb on the West Coast and Friedman-Kien 02:34.860 --> 02:40.000 on the East Coast, noted that there were some common denominators with respect to 02:40.080 --> 02:45.660 the syndrome complex that they were seeing in young and middle-aged homosexual males 02:47.100 --> 02:49.960 with an array of opportunistic infections 02:50.040 --> 02:55.180 and some strange malignant diseases such as Kaposi's sarcoma, 02:55.260 --> 02:58.320 which is not too terribly common, especially in that age group. 03:01.500 --> 03:05.640 They decided that this was something that was unique to this population. 03:06.540 --> 03:09.340 Again, CDC became bonafidely interested in it 03:09.420 --> 03:13.780 in early 1981 and began noting some of the common denominators 03:13.860 --> 03:18.280 and finally came up with a definition in June of 1981. 03:18.360 --> 03:20.820 They actually began registering cases at that time. 03:22.500 --> 03:23.620 By that time, there was about 03:23.700 --> 03:27.240 300 or 400 cases of AIDS, many of whom had died. 03:28.020 --> 03:32.860 Again, the peculiar high-risk groups such as homosexuals, 03:32.940 --> 03:35.700 bisexuals, and the IV drug users. 03:37.980 --> 03:40.120 When CDC finally got a handle on this, 03:40.200 --> 03:44.500 they began recognizing, and reports began coming in from other major urban areas 03:44.580 --> 03:48.540 throughout the country, Houston, Miami, and Chicago primarily. 03:49.238 --> 03:51.040 We had the East Coast and the West Coast, 03:51.120 --> 03:54.660 and again, the clinical syndrome was very common. 03:55.320 --> 03:58.660 The individuals that seemed to be at risk 03:58.740 --> 04:01.680 for the syndrome, again seemed to be common. 04:04.020 --> 04:06.220 CDC began collecting data. 04:06.300 --> 04:08.500 During this period of time, they began noting also 04:08.580 --> 04:11.580 that this had a terrible mortality rate associated with it. 04:12.300 --> 04:18.280 During 1982, Bob Gallo, Max Essex, and a few other notable virologists 04:18.360 --> 04:20.560 were working on the possible etiology of this. 04:20.640 --> 04:24.760 Initially, it was thought that this was all related to immune burnout. 04:24.840 --> 04:28.180 These patients had such a heavy antigen load 04:28.260 --> 04:30.160 that their immune system just simply burned 04:30.240 --> 04:33.880 out, and ie, they developed the immune deficiency syndrome 04:33.960 --> 04:38.260 and were so predisposed for the array of opportunistic infections, 04:38.340 --> 04:41.640 which were not treatable when one has their immune system decimated. 04:43.380 --> 04:47.080 Much of the work of Bob Gallo on other types of viral agents 04:47.160 --> 04:49.420 and in conjunction with other people, namely in 04:49.500 --> 04:52.120 Japan, and again, up at Harvard, the work of Max Essex, 04:52.200 --> 04:57.640 realized that there were some similarities between some viral agents 04:57.720 --> 05:00.040 that could produce an immune deficiency syndrome 05:00.120 --> 05:03.060 and the patients that were presenting with AIDS. 05:05.580 --> 05:08.740 Because there was an assay available for picking up 05:08.820 --> 05:11.560 reverse transcriptase, they were very suspicious. 05:11.640 --> 05:14.346 First of all, they were very suspicious of it being a retrovirus 05:14.426 --> 05:16.120 because of the analogous features 05:16.200 --> 05:19.200 to other syndromes that retroviruses caused. 05:20.760 --> 05:23.980 Indeed, they did pick up evidence of these patients 05:24.060 --> 05:26.620 having reverse transcriptase, and that meant, of course, 05:26.700 --> 05:28.800 that they were infected with the retrovirus. 05:29.400 --> 05:33.160 Retroviruses are pretty ubiquitous, but only the exogenous viruses. 05:33.240 --> 05:36.480 The exogenous retroviruses caused problems and caused disease. 05:37.740 --> 05:39.700 At that time, they finally recognized 05:39.780 --> 05:42.520 and realized that this was a filterable agent, number one 05:42.600 --> 05:44.997 because people were getting it through blood and blood products. 05:45.187 --> 05:48.060 Number two, it looked like it was a viral agent. 05:48.251 --> 05:50.980 Number three, it looked like there was enough evidence to pursue 05:51.060 --> 05:55.620 the area of investigating for a retrovirus as being the cause of the disease. 05:56.580 --> 06:00.640 In 1983, Dr. Bob Gallo and his group at NIH 06:00.720 --> 06:04.300 and also, Luc Montagnier over at the Pasteur Institute in France, 06:04.380 --> 06:07.180 in Paris, isolated the virus. 06:07.260 --> 06:08.860 Now, that's just the first step, 06:08.940 --> 06:12.280 isolating the virus, identifying the virus, but it was very, very difficult 06:12.360 --> 06:16.980 to determine whether this virus was different than HTLV-1 or HTLV-3. 06:17.820 --> 06:22.600 By the way, you're going to hear me talk about HTLV-3, HIV, and the AIDS virus. 06:22.680 --> 06:23.820 It's all synonymous. 06:26.100 --> 06:27.280 Please keep that in mind. 06:27.360 --> 06:29.020 They're synonyms. 06:29.100 --> 06:30.940 What we're talking about is the AIDS virus. 06:31.020 --> 06:35.800 I like to use the term HTLV-3 because of the HTLV-1, the HTLV-2, 06:35.880 --> 06:37.980 which we're going to be talking about more tomorrow. 06:40.140 --> 06:42.280 In 1983, the virus 06:42.360 --> 06:45.580 was finally isolated in France and as well in this country. 06:45.660 --> 06:48.940 Then we got to the nitty gritty work of trying to isolate the virus 06:49.020 --> 06:52.840 and culture the virus to the point where there was enough viral proteins 06:52.920 --> 06:57.280 to make some dependable test, that is, extracting some antigenic material 06:57.360 --> 07:02.400 so that we could look for antibodies in a serum of patients who were infected. 07:02.796 --> 07:05.110 This took a considerably longer period of time 07:05.190 --> 07:06.661 than it did to isolate the virus. 07:07.260 --> 07:11.020 Finally, in November of 1984, Mike Popovic, 07:11.100 --> 07:15.400 who was working with Bob Gallo in his laboratory, finally came up 07:15.480 --> 07:21.280 with a lymphocyte culture line, which the virus did not destroy. 07:21.360 --> 07:27.340 In other words, the difficulty with HTLV-3 is that when an infected lymphocytes, 07:27.420 --> 07:28.720 it destroys the lymphocytes. 07:28.800 --> 07:32.260 Its lympholitic, as opposed to HTLV-1 and HTLV-2, 07:32.340 --> 07:36.340 which causes the cells to proliferate and creates a proliferative disease, 07:36.420 --> 07:38.040 ie, leukemia. 07:39.120 --> 07:43.720 The problem was a major one but was finally overcome in Dr. 07:43.800 --> 07:44.969 Gallo's laboratory. 07:45.043 --> 07:46.120 At that time, 07:46.200 --> 07:51.580 we were able to grow the virus in culture with this unique cell line, 07:51.660 --> 07:55.120 the H9 cell line, and get enough viral material 07:55.200 --> 07:59.560 so that we could look at and concentrate the proteins of the virus. 07:59.640 --> 08:02.800 Then, of course, by additional techniques, 08:02.880 --> 08:07.720 use that protein as antigenic material and then run it against the serum 08:07.800 --> 08:10.420 of patients who had the virus or were exposed to the virus 08:10.500 --> 08:16.240 or were infected for detection of significant titers against the virus. 08:16.320 --> 08:18.100 This is how this all happened. 08:18.180 --> 08:21.760 As soon as we were able to grow the virus and immortalize 08:21.840 --> 08:26.860 the virus in these cell lines, it didn't take long for a screening test 08:26.940 --> 08:30.160 to be put on in market, an immunologic screening test, 08:30.240 --> 08:31.470 the ELISA test, 08:31.570 --> 08:35.800 which hit the market in March of 1985 and was quickly distributed 08:35.880 --> 08:37.920 throughout the country to most of the blood banks. 08:38.760 --> 08:44.260 I should add that there was one heck of a lot of work that was going on 08:44.340 --> 08:49.620 between 1982 when we first considered the retrovirus as being etiologic agent 08:50.220 --> 08:53.080 until we were able to commercially produce 08:53.160 --> 08:55.480 this screening test with the ELISA technique 08:55.560 --> 08:59.040 to pick up antibodies in a serum of patients infected with the virus. 09:00.180 --> 09:02.200 As Margaret Heckler said when we first announced 09:02.280 --> 09:05.680 that we had isolated the virus, never had we learned so much 09:05.760 --> 09:08.160 about a single disease in such a short period of time. 09:08.820 --> 09:09.940 Indeed, that is the case. 09:10.020 --> 09:13.780 I think we're going to see a great amount of spinoff 09:13.860 --> 09:17.560 from all the investigations that have gone on with respect 09:17.640 --> 09:21.120 to this disease that will hopefully impact on other areas of medicine. 09:22.080 --> 09:23.320 In fact, they already have. 09:23.400 --> 09:25.283 I think we're going to see it for years to come. 09:26.400 --> 09:30.640 With this test readily available in all of the blood banks 09:30.720 --> 09:32.620 throughout the country, we then had 09:32.700 --> 09:37.240 a screening method for picking up patients who were infected with the HTLV-3 virus. 09:37.320 --> 09:39.760 Now, please keep in mind, it's just picking up 09:39.840 --> 09:42.280 patients who have been exposed or infected with the virus. 09:42.360 --> 09:44.460 We're not talking about patients who had AIDS. 09:45.420 --> 09:50.080 Finally, here we are in 1987, the AIDS epidemic continues. 09:50.160 --> 09:53.160 It is indeed now a pandemic. 09:55.380 --> 09:58.260 There were more than 80 countries reporting AIDS. 09:59.280 --> 10:01.540 You'll see that the beat goes on. 10:01.620 --> 10:07.060 As one notes, as of January of 1987, I think you can get a good perspective 10:07.140 --> 10:10.560 as to what's going on with the AIDS epidemic in this country. 10:12.180 --> 10:15.220 As of January, there are more than 29,000 AIDS 10:15.300 --> 10:17.560 patients reported and registered at CDC. 10:17.640 --> 10:19.187 Again, this is in the United States. 10:19.560 --> 10:22.320 Here's another interesting and disturbing fact. 10:22.860 --> 10:27.280 There are more than 400 pediatric cases reported, 10:27.360 --> 10:29.380 and this is children less than 13 years of age. 10:29.460 --> 10:33.520 Now, the sad reality of this is that most of these patients, 10:33.600 --> 10:37.740 the vast majority of these kids are infected through infected mothers. 10:38.580 --> 10:41.380 Projections indicate that over the next four years, 10:41.460 --> 10:46.200 this will increase tenfold to more than 4,000 cases. 10:48.120 --> 10:50.680 There have now been more than 13-- actually, there are more 10:50.760 --> 10:55.660 than 14,000 deaths reported as of January 1 of 1987 of AIDS patients. 10:55.740 --> 10:59.560 Keep in mind that 80% of these patients who are diagnosed with AIDS will die 10:59.640 --> 11:03.520 within a 24-month period of time, and also, the median survival of a patient 11:03.600 --> 11:06.060 once he's diagnosed as having AIDS is 13 months. 11:06.840 --> 11:10.080 That's whether he's getting AZT or any kind of immunotherapy or whatever. 11:12.000 --> 11:16.840 The disturbing facts about all this is that the CDC estimates, 11:16.920 --> 11:20.100 and these are very conservative estimates, and they make that very clear, 11:20.820 --> 11:25.300 if the epidemic continues as it is now in this country, in 1988, 11:25.380 --> 11:29.160 we will have 91,000 registered cases of AIDS. 11:30.360 --> 11:34.020 In 1990, we will have almost 200,000 cases of AIDS. 11:34.920 --> 11:40.320 By January of 1991, we're going to have over 268,000 cases of AIDS. 11:41.280 --> 11:42.880 Now, you can see, 11:42.960 --> 11:46.200 it's almost an exponential increase in a number of cases. 11:47.160 --> 11:52.080 The number of cases of AIDS is doubling every 13 months in this country. 11:53.160 --> 11:55.360 Now, this is only the tip of the iceberg because, 11:55.440 --> 11:57.520 as I mentioned to you earlier in my open remarks, 11:57.600 --> 12:00.160 that AIDS is not unique to this country. 12:00.240 --> 12:01.600 It's a pandemic. 12:01.680 --> 12:04.240 There are more than 80 countries are now reporting AIDS. 12:04.320 --> 12:07.620 Unfortunately, we really don't have a good handle on their statistics. 12:08.400 --> 12:11.100 Many of these countries have gotten on a bandwagon rather late. 12:13.680 --> 12:19.480 The death rate to AIDS, one can see, again, we have a similar type of curve. 12:19.560 --> 12:24.034 By January of 1991, there will be 12:24.114 --> 12:27.340 more than 55,000 patients will have died 12:27.420 --> 12:29.160 because of AIDS. 12:30.180 --> 12:33.640 I think you have to understand that most of these patients 12:33.720 --> 12:38.200 over that 13-month period of time, from the diagnosis to the time of death, 12:38.280 --> 12:40.600 will require a great deal of medical care and attention, 12:40.680 --> 12:42.760 and it's a horrendous expense. 12:42.840 --> 12:45.820 I don't think you can think about AIDS without understanding 12:45.900 --> 12:49.480 and at least thinking about the implications it has for the 12:49.560 --> 12:52.000 cost of medicine in this country and any other country 12:52.080 --> 12:55.800 and also the socioeconomic impact it has on the country in general. 12:56.460 --> 13:00.300 That's why this is such a hot issue in legislation right now. 13:03.600 --> 13:06.120 As I mentioned, this is only the tip of the iceberg. 13:06.840 --> 13:08.260 Let me reiterate, too, 13:08.340 --> 13:11.680 that most of these countries have only recently begun 13:11.760 --> 13:14.260 reporting cases of AIDS to the World Health Organization. 13:14.340 --> 13:17.020 They do have CDCs in some of the countries, 13:17.100 --> 13:19.360 but the World Health Organization has had to intervene 13:19.440 --> 13:22.840 because many of these countries are not reporting their cases of AIDS. 13:22.920 --> 13:26.920 Britain is doing a wonderful job in terms of education. 13:27.000 --> 13:28.780 The British people are very concerned about this. 13:28.860 --> 13:30.700 They've already made concerted efforts 13:30.780 --> 13:33.640 to curb the spread of AIDS throughout the British Isles. 13:33.720 --> 13:38.560 They have, as of 1982, only 548 cases reported. 13:38.640 --> 13:41.020 France, where the situation is a bit different, 13:41.100 --> 13:42.520 they're not doing much at all. 13:42.600 --> 13:44.800 The French government, over the past several years, 13:44.880 --> 13:50.920 is turning their head away from this whole terrible issue of AIDS, 13:51.000 --> 13:52.540 and it's believed that there are 13:52.620 --> 13:54.960 more than 2,000 cases in the city of Paris alone. 13:55.560 --> 13:56.980 This is from officials 13:57.060 --> 13:59.740 that are working with the French Red Cross, 13:59.820 --> 14:04.060 but the French government recognizes and realizes the tremendous drain 14:04.140 --> 14:07.960 on the economy if we begin in earnest looking 14:08.040 --> 14:11.140 for programs for education and treatment of AIDS patients. 14:11.220 --> 14:12.820 The same is true in West Germany. 14:12.900 --> 14:16.960 The West Germans have not chosen to really escalate this 14:17.040 --> 14:19.960 to a high-priority issue, and the government is 14:20.040 --> 14:23.580 not really carrying out any kind of meaningful education programs. 14:24.120 --> 14:28.060 Switzerland is an interesting story because Switzerland has 14:28.140 --> 14:32.100 the highest rate of AIDS per capita in the European countries. 14:32.640 --> 14:35.820 The four major cities in Switzerland have all reported AIDS, 14:36.720 --> 14:37.878 the four major cities. 14:39.240 --> 14:42.340 The incidents right now is quite disturbing. 14:42.420 --> 14:47.320 The Swiss government is carrying on some very good educational programs, 14:47.400 --> 14:50.920 and it seems that Switzerland, because of the four major cities, will be 14:51.000 --> 14:53.700 able to cope with the AIDS population in terms of treatment. 14:54.453 --> 14:56.746 That's what many of the underdeveloped countries 14:56.826 --> 14:58.338 are very concerned about. 14:58.457 --> 15:01.300 You notice on this list, you don't see the countries along the Mediterranean 15:01.380 --> 15:05.080 because their economy is a little less stable, and they're very, 15:05.160 --> 15:08.080 very concerned about the number of hospital beds 15:08.160 --> 15:11.580 and a number of hospital personnel to care for AIDS patients. 15:12.780 --> 15:17.820 We really have virtually no reports from Portugal, Spain, Italy, and Greece. 15:17.981 --> 15:20.922 There is no question that AIDS is prevalent 15:21.009 --> 15:22.840 in all these Mediterranean countries. 15:22.920 --> 15:24.400 Africa is quite a different story. 15:24.480 --> 15:27.400 It's just a big mess in Africa. 15:27.480 --> 15:29.320 It's the hidden plague, as they call it. 15:29.400 --> 15:32.380 Most of the British researchers and some of the people from CDC 15:32.460 --> 15:34.066 from our country who have been there 15:34.226 --> 15:36.700 recognize and realize that everything is in disarray. 15:36.780 --> 15:38.680 They are not reporting the cases. 15:38.760 --> 15:41.980 In fact, the first cases reported in Africa from some 15:42.060 --> 15:46.480 of the countries in South Central Africa, that is, Kenya, Uganda, Zambia 15:46.560 --> 15:52.420 were reported in 1983, and in Zambia, the first case was reported in early 1985. 15:52.500 --> 15:54.880 They like to think that they don't have an AIDS problem. 15:54.960 --> 15:56.140 They call it the slims there. 15:56.220 --> 15:59.140 The patients have a tremendous amount of weight loss. 15:59.220 --> 16:00.200 They look eclectic, 16:00.335 --> 16:03.420 and they die within a period of six months after the diagnosis is made. 16:04.500 --> 16:10.080 They've been really very, very hampered by statistics and medical care. 16:11.580 --> 16:14.620 Africa, we have no idea 16:14.700 --> 16:19.120 what the incidents of AIDS is in the major African urban areas, 16:19.200 --> 16:22.360 but I can tell you that there are some studies that are going on now, 16:22.440 --> 16:24.760 primarily by the British and some American investigators, 16:24.840 --> 16:29.800 that indicate that more than 50% of the prostitutes 16:29.880 --> 16:32.980 in the major cities in the countries in Central Africa, 16:33.060 --> 16:36.700 in South-Central Africa, are infected with this virus. 16:36.780 --> 16:39.400 Now, this is quite different the mode of transmission 16:39.480 --> 16:41.920 than what I'm going to talk about here in this country. 16:42.000 --> 16:45.580 These are prostitutes working in major cities, 16:45.660 --> 16:48.160 and there's no question that the disease is being transmitted 16:48.240 --> 16:53.020 in a sexual way as opposed to the urban areas in our country 16:53.100 --> 16:56.620 where the prostitutes are HTLV-3 positive, 16:56.700 --> 17:00.360 primarily because they are IV drug users and abusers. 17:01.440 --> 17:05.140 Africa remains a real hotspot for AIDS. 17:05.220 --> 17:07.780 Again, it's an area that we're going to have to watch very carefully 17:07.860 --> 17:11.620 because most people think that AIDS really started in Africa, 17:11.700 --> 17:13.740 came to United States by way of the Caribbean. 17:15.540 --> 17:17.620 There are some studies that indicate, 17:17.700 --> 17:22.360 or that estimate that 1% to 2% of the African population, 17:22.440 --> 17:27.400 that is the Sub-Sahara population, is infected with the virus. 17:27.480 --> 17:29.880 Now, that does not include South Africa. 17:31.500 --> 17:34.300 There are other studies that have come out of Kampala 17:34.380 --> 17:38.140 which indicate that 6% to 7% of the healthcare workers 17:38.220 --> 17:41.400 in the countries of Central Africa are infected with the virus. 17:42.240 --> 17:46.480 That's a staggering statistic because it really impacts greatly, 17:46.560 --> 17:49.920 not only on the medical care facilities but also on economy of the country. 17:52.080 --> 17:54.760 It's been estimated that 20% to 30% 17:54.840 --> 17:58.560 of the patients in Zambia are infected with this virus. 17:59.160 --> 18:02.140 Now, depending upon what percentage of patients 18:02.220 --> 18:06.400 are going to develop AIDS in the future after being infected with the virus, 18:06.480 --> 18:08.380 it's going to have a tremendous impact 18:08.460 --> 18:10.380 on the workforce in these countries as well. 18:11.220 --> 18:15.640 Currently, this is what the British healthcare workers are trying 18:15.720 --> 18:19.840 to get across to the governments in these countries in Central Africa. 18:19.920 --> 18:23.460 Brazil is, again, a real hotspot for AIDS. 18:24.300 --> 18:27.100 Brazil started reporting AIDS in 1984. 18:27.180 --> 18:29.080 They now have 1,100 cases. 18:29.160 --> 18:31.180 American Red Cross people in Brazil, 18:31.260 --> 18:33.100 in conjunction with the Brazilian Red Cross 18:33.180 --> 18:35.880 feel that there are more than 3,000 cases of AIDS. 18:36.540 --> 18:38.980 They are not reporting AIDS like they should be. 18:39.060 --> 18:41.460 Their education programs are very meager. 18:42.120 --> 18:44.320 I don't know how many of you are familiar with Brazil, 18:44.400 --> 18:47.740 but there are more than 10 major cities or urban areas in Brazil, 18:47.820 --> 18:50.080 and the sanitation conditions in Brazil 18:50.160 --> 18:52.900 are really quite bad in some of these major areas. 18:52.980 --> 18:55.480 San Paulo is the largest city 18:55.560 --> 18:57.600 in the world right now with 16 million people. 18:58.500 --> 19:02.560 There's a lot of people in Sao Paulo who have been infected with the virus 19:02.640 --> 19:03.760 and in fact, who have AIDS. 19:03.840 --> 19:05.020 One of the problems in Brazil 19:05.100 --> 19:07.840 that's pointed out is that their lack of hospital beds 19:07.920 --> 19:10.560 and lack of healthcare workers to care for these people. 19:11.640 --> 19:14.620 Again, the government is not too terribly interested in making 19:14.700 --> 19:16.540 concerted efforts along these lines. 19:16.620 --> 19:21.400 Brazil has just had a radical change in government in 1984, 19:21.480 --> 19:24.520 for those of you that haven't seen the latest National Geographic. 19:24.600 --> 19:27.940 Puerto Rico has reported 115 cases. 19:28.020 --> 19:30.720 Puerto Rico started reporting cases in 1982. 19:31.380 --> 19:34.440 115 patients reported primarily from San Juan. 19:36.060 --> 19:39.400 The interesting story about Japan is that Japan started reporting 19:39.480 --> 19:44.260 cases to the World Health Organization in conjunction with CDC back in 1981, 19:44.340 --> 19:48.460 a few months after the United States began reporting their case at the CDC. 19:48.540 --> 19:53.880 Japan has had only 25 cases reported, and this is as of January 1, 1987. 19:54.480 --> 19:59.340 They have done a horrendous job in terms of education with their people. 19:59.940 --> 20:03.340 Many of the bathhouses have been closed. 20:03.420 --> 20:06.180 The prostitutes are being screened. 20:07.620 --> 20:12.040 Although getting HTLV-3 serologies is not mandatory, 20:12.120 --> 20:15.280 they do draw one in every patient that is admitted to the hospital 20:15.360 --> 20:16.674 for whatever. 20:17.160 --> 20:20.020 The Japanese have got a much better handle on the situation. 20:20.100 --> 20:23.260 I think we're going to learn a lot from the Japanese in terms 20:23.340 --> 20:26.800 of looking at the overall incidence of infection with the virus. 20:26.880 --> 20:31.120 The Japanese, of course, had the advantage of having worked with the HTLV-1 virus, 20:31.200 --> 20:33.240 which is endemic in the southwest islands of Japan. 20:33.852 --> 20:35.440 They knew a lot about the virus, 20:35.520 --> 20:37.800 and they knew something about the modes of transmission. 20:38.400 --> 20:40.560 I think, more importantly, they're very astute people. 20:41.460 --> 20:46.300 Their government is quite aware of the impact this could have 20:46.380 --> 20:49.140 on a socioeconomic situation in the country. 20:51.600 --> 20:56.040 This is clearly an urban disease for the present. 20:58.320 --> 20:59.313 Is that clear? 21:01.500 --> 21:05.500 Most of the cases still are being reported from the major cities 21:05.580 --> 21:08.100 throughout the country, and it's true throughout the world. 21:09.840 --> 21:10.860 If we look at the slide, 21:13.560 --> 21:19.360 New York, San Francisco, and Los Angeles account for 43% 21:19.440 --> 21:23.820 of the AIDS cases that have been reported as of December in this country. 21:25.200 --> 21:28.420 These are really the hotbeds of AIDS. 21:28.500 --> 21:30.820 Of course, we all know that there's a very large gay population 21:30.900 --> 21:35.020 in San Francisco and Los Angeles, as well as New York, but there's a very, 21:35.100 --> 21:37.840 very large population of IV drug users and abusers 21:37.920 --> 21:39.127 in New York City. 21:39.480 --> 21:44.260 I think that New York City has had almost 4,000 cases 21:44.340 --> 21:45.570 just last year alone. 21:46.080 --> 21:51.300 Again, that's almost 45% of the number of cases that were reported in 1986. 21:52.800 --> 21:56.440 Again, as you get down the list, one can see virtually all the major cities 21:56.520 --> 21:59.160 throughout the country except Fort Lauderdale. 21:59.760 --> 22:06.220 I should mention, too, that there's been a very disconcerting number of cases in 22:06.300 --> 22:09.000 the Fort Lauderdale and Palm Beach area of Florida. 22:11.120 --> 22:15.940 The high-risk groups have stayed the same, except if you look here, 22:16.020 --> 22:19.600 I took out the Haitians primarily because it's no longer the Haitians. 22:19.680 --> 22:22.920 It's many, many immigrants from the Caribbean Islands. 22:24.000 --> 22:26.140 The Haitians got the bum rap in the early '80s. 22:26.220 --> 22:30.460 There was a very high incidence of people who immigrated here to the country 22:30.540 --> 22:32.380 from Haiti. 22:32.460 --> 22:35.800 I think we're well aware of people coming here from the Dominican Republic 22:35.880 --> 22:38.620 and other underdeveloped countries from the Caribbean 22:38.700 --> 22:41.220 who have a high incidence of infection. 22:42.120 --> 22:44.140 The homosexuals and bisexual males 22:44.220 --> 22:46.620 still make out the bulk of the patients with AIDS. 22:47.280 --> 22:51.820 They make up approximately 70% to 75% of the patients with AIDS. 22:51.900 --> 22:55.380 IV drug users are still holding firm at about 20% to 25%. 22:56.127 --> 22:57.580 This is an interesting statistic. 22:57.660 --> 23:00.660 90% of the IV drug users are heterosexuals. 23:01.260 --> 23:03.160 There's another little interesting caveat here, 23:03.240 --> 23:05.440 is that 30% of these heterosexual 23:05.520 --> 23:07.320 IV drug users are female. 23:09.180 --> 23:12.420 In conjunction with that, 90% of that 30% of the females 23:13.200 --> 23:14.460 are in childbearing age. 23:16.133 --> 23:18.100 That's where the pediatric cases are coming from. 23:18.180 --> 23:21.460 They're coming from the IV drug users that are female, 23:21.540 --> 23:23.200 the female prostitutes primarily, 23:23.280 --> 23:25.200 and they're passing it on through the children. 23:26.640 --> 23:29.880 It can be passed on through mother's milk or through delivery. 23:30.900 --> 23:33.580 The heterosexual females is a real problem. 23:33.660 --> 23:38.020 Of course, this is another mode of transmission. 23:38.100 --> 23:41.980 Of course, the heteros having this thing become more prominent 23:42.060 --> 23:45.640 in the heterosexual population means that none of us are going 23:45.720 --> 23:50.140 to be spared from the possibility of becoming infected with the AIDS virus. 23:50.220 --> 23:53.920 There are about 2,400 cases of heterosexual females 23:54.000 --> 23:56.340 that have been reported as of January of 1987. 23:57.180 --> 23:59.260 CDC estimates and again, conservatively, 23:59.340 --> 24:04.620 that there will be about 28,000 cases by January of 1991. 24:06.240 --> 24:09.060 They're concerned about that because of the incidents 24:09.840 --> 24:14.040 of infectivity found amongst the prostitutes. 24:15.420 --> 24:17.200 There's about one-third the number of houses 24:17.280 --> 24:21.780 of prostitution open in Houston as there was three years ago. 24:22.980 --> 24:25.800 The ladies are learning very, very quickly. 24:26.580 --> 24:27.940 I'm afraid that it's too late, 24:28.020 --> 24:32.320 and the situation is really running rampant now 24:32.400 --> 24:34.600 through the heterosexual population through the country. 24:34.680 --> 24:39.460 Hemophiliacs still make up 1% of the number of cases in AIDS. 24:39.540 --> 24:40.600 As of January, 24:40.680 --> 24:45.580 there were 284 cases of AIDS in hemophiliacs. 24:45.660 --> 24:50.020 This includes Hemophilia A, hemophilia B, and von Willebrand disease. 24:50.100 --> 24:53.980 Of course, these poor people contract dates 24:54.060 --> 24:55.660 by virtue of the fact that they received 24:55.740 --> 24:57.480 blood and blood products so very frequently. 24:58.500 --> 25:01.540 Of course, remember back in 1982 when Bob Gallo was investigating 25:01.620 --> 25:04.060 an etiologic agent, he recognized and realized 25:04.140 --> 25:07.150 that this was a filterable virus 25:07.230 --> 25:11.320 because of the incidence of infectivity 25:11.400 --> 25:14.640 being caused in patients who are receiving blood and blood products. 25:15.008 --> 25:16.540 That these were just a token number 25:16.620 --> 25:18.400 of blood and blood products in some of these patients, 25:18.480 --> 25:20.996 and that population we're still concerned about. 25:23.160 --> 25:27.460 I think these are very disturbing statistics. 25:27.540 --> 25:34.360 I really feel compelled to show this because this is disconcerting. 25:34.440 --> 25:36.220 Again, it points out 25:36.300 --> 25:38.920 the problems that are occurring in the major urban areas. 25:39.000 --> 25:42.480 This is New York City, which is the epitome of the AIDS problem. 25:44.400 --> 25:47.020 Of the IV drug abusers that have been studied in New York City, 25:47.100 --> 25:50.680 60% are HTLV-3 or HIV positive. 25:50.760 --> 25:53.640 60% have been infected by the virus. 25:55.320 --> 25:58.780 Of a large group of homosexual and bisexual males, 25:58.860 --> 26:01.200 40% are infected. 26:01.860 --> 26:05.620 It's a horrendous population of homosexuals and bisexuals 26:05.700 --> 26:06.922 in New York City. 26:07.380 --> 26:10.300 Now, what's really disturbing is the 26:10.380 --> 26:14.200 number of military enlistees who are HTLV-3 positive. 26:14.280 --> 26:16.480 One out of every 50 people 26:16.560 --> 26:19.060 between the ages of 18-- This is males, by the way. 26:19.140 --> 26:20.302 I should qualify that. 26:20.640 --> 26:25.660 Between the ages of 15 and 25 who enlist into the service are positive. 26:25.740 --> 26:27.240 1 out of 50. 26:28.140 --> 26:33.360 Now, what's the national average, about 1 in 700, same age group, same-sex. 26:34.200 --> 26:39.660 In women, it's much, much less frequent, but that is very disturbing. 26:40.500 --> 26:45.480 1 out of 50 from Manhattan is HTLV-3 positive. 26:46.380 --> 26:49.240 Now, if one looks at the five Boroughs of New York, 26:49.320 --> 26:52.840 the incidence is significantly less. 26:52.920 --> 26:56.160 It's about 1 out of every 200 or 1 out of every 300. 26:57.000 --> 26:59.380 The national average is about 1 out of every 800, 26:59.460 --> 27:00.720 1 out of every 750. 27:02.340 --> 27:04.840 When the military finds that they're HTLV-3 positive, 27:04.920 --> 27:06.463 they drop them like a hot potato. 27:06.840 --> 27:09.820 They have no other responsibility to these people. 27:09.900 --> 27:13.840 In fact, they're not even responsible 27:13.920 --> 27:16.500 to report this to CDC, although they have. 27:18.840 --> 27:20.880 That is being contested at this time. 27:22.440 --> 27:25.360 I think that that gets us into the whole matter of the ethics 27:25.440 --> 27:30.160 and the morality and the individual rights in people in this country, 27:30.240 --> 27:33.520 the confidentiality laws, which are being banned around 27:33.600 --> 27:36.300 from pillar to post with respect to the whole AIDS issue. 27:36.567 --> 27:38.140 I don't want to get into that now, 27:38.220 --> 27:40.980 but we can probably talk about that when I get through here. 27:44.280 --> 27:45.580 Now, of course, 27:45.660 --> 27:49.180 what everybody's wondering about and worried about is how many people 27:49.260 --> 27:51.413 who are infected with the virus are going to get AIDS. 27:51.780 --> 27:53.817 I don't think anybody has a good handle on that. 27:54.180 --> 27:57.100 CDC estimates that there are 27:57.180 --> 28:01.560 1 to 2.5 million people in this country who are infected with the AIDS virus. 28:02.493 --> 28:05.080 I told you earlier that there are some countries in Central Africa 28:05.160 --> 28:06.780 that have an incidence of 15% to 20% 28:07.920 --> 28:10.800 of the sexually active individuals are infected with the virus. 28:11.340 --> 28:15.780 The overall population may be as high as one in 2% in the Central Africa. 28:16.680 --> 28:18.760 In this country, we think it's around 2 million. 28:18.840 --> 28:21.400 That's a ballpark figure. 28:21.480 --> 28:22.840 I'm not sure how they arrive 28:22.920 --> 28:24.700 at these things, but it comes 28:24.780 --> 28:29.460 from the reputable organizations who have been studying the AIDS situation. 28:30.720 --> 28:32.320 Again, in some of the countries 28:32.400 --> 28:33.900 in Central Africa, and this is Zambia, 28:35.400 --> 28:40.180 20% to 30% of the sexually active people are positive, and incidentally, 28:40.260 --> 28:43.120 the Red Cross has shown that about 15% to 20% 28:43.200 --> 28:47.680 of the sexually active people in Brazil are HTLV-3 positive. 28:47.760 --> 28:50.500 I think Brazil's another country we're going to have to watch 28:50.580 --> 28:53.160 for marked escalation of the AIDS problems. 28:55.020 --> 28:58.920 CDC and the National Academy of Science who have been looking at this, 29:00.300 --> 29:06.100 and again, these are just estimates, feel that about 20% to 30% of patients 29:06.180 --> 29:09.000 who are infected with the virus will go on and develop AIDS. 29:09.660 --> 29:13.320 Now, this figure varies all over from 10% to 50%, 29:14.460 --> 29:17.820 and if you're a redneck Southern Baptist, it's going to be a hundred percent. 29:20.940 --> 29:22.720 It varies greatly. 29:22.800 --> 29:24.760 I think that these are the conservative estimates 29:24.840 --> 29:27.340 of CDC and the National Academy of Science. 29:27.420 --> 29:28.840 Within the next five years, 29:28.920 --> 29:32.160 20% to 30% of individuals will develop AIDS. 29:32.700 --> 29:36.040 Now, we're talking about everybody that has a positive HTLV-3 test. 29:36.120 --> 29:39.180 We're talking about, for the most part, asymptomatic patients, 29:40.080 --> 29:41.760 people who have no symptoms at all, 29:42.540 --> 29:46.300 many people who are positive and are picked up serendipitously 29:46.380 --> 29:50.460 through screening methods, ie, going to give blood. 29:51.240 --> 29:54.220 This is how I picked up the last new patient 29:54.300 --> 29:55.860 we had here in the clinic. 29:56.640 --> 29:59.520 She went to give blood and was found to be HTLV-3 positive. 30:02.400 --> 30:03.820 This is a real dilemma. 30:03.900 --> 30:06.280 I think the last word is not in on this situation, 30:06.360 --> 30:08.320 of course, and I think we're all going to 30:08.400 --> 30:10.840 be very interested to see how things go. 30:10.920 --> 30:12.400 I think we're going to get a handle on this 30:12.480 --> 30:14.040 by looking at the military recruits. 30:15.000 --> 30:18.940 One other interesting point, no one knows what the incubation period 30:19.020 --> 30:23.680 of the AIDS virus is, but we do know that it can be longer than 10 years. 30:23.760 --> 30:25.600 There are some interesting studies that have come 30:25.680 --> 30:30.220 out of San Francisco and out of Atlanta looking at serum specimens 30:30.300 --> 30:32.860 from patients who were studied for other problems and other diseases. 30:32.940 --> 30:36.280 The one in San Francisco was the hepatitis B virus study. 30:36.360 --> 30:37.620 That was done in 1972. 30:38.160 --> 30:41.040 They went back and pulled these frozen specimens. 30:41.354 --> 30:42.700 They found, indeed, 30:42.780 --> 30:45.880 that there was a small but significant percentage of those patients 30:45.960 --> 30:49.960 that had evidence of having been infected with the virus. 30:50.040 --> 30:51.900 They had antibodies to the virus. 30:52.560 --> 30:54.460 We know that the AIDS virus has been around 30:54.540 --> 30:56.220 for at least 10 years, 15 years, 30:56.760 --> 31:00.720 but what the incubation period of that virus is, we have no idea. 31:02.580 --> 31:05.986 Again, these are the estimates of small cohorts of patients 31:06.066 --> 31:09.780 that have been followed by CDC since 1981. 31:11.417 --> 31:12.420 In Africa, 31:13.200 --> 31:17.340 there's a very high incidence of the AIDS virus in children. 31:18.120 --> 31:20.800 Many people think that the incubation period of 31:20.880 --> 31:23.260 the virus in children is very long, and in fact, 31:23.340 --> 31:26.760 it may not lead to AIDS at all or the ARC syndrome. 31:29.160 --> 31:32.440 This may be something very common in the environment, 31:32.520 --> 31:37.240 whatever way it may be transmitted in the countries, in Central Africa 31:37.320 --> 31:42.040 that children get infected with, just like the EB virus 31:42.120 --> 31:45.820 and just some of the other viruses that children get infected 31:45.900 --> 31:48.280 with early in life, and their immune systems handles it 31:48.360 --> 31:50.820 somewhat differently and probably more efficiently. 31:51.840 --> 31:56.140 They live in symbiosis with the virus, or they may just retain 31:56.220 --> 31:59.080 viral antigen material, which stimulates the immune system 31:59.160 --> 32:02.340 enough to keep the antibody tighter, high enough, so it's detectable. 32:06.840 --> 32:10.240 I think, getting down to the real nitty-gritty 32:10.320 --> 32:13.740 and some of the socioeconomic problems that we're having with AIDS, 32:15.660 --> 32:17.500 people in this country are very concerned 32:17.580 --> 32:23.220 about the government not doing its bit for the AIDS dilemma. 32:24.120 --> 32:28.240 They've declared it a medical emergency, but they're not giving 32:28.320 --> 32:32.320 the appropriate amount of attention in terms of dollars for research, 32:32.400 --> 32:38.100 dollars for education, and programs for caring for these patients. 32:39.660 --> 32:42.340 I think that this has a great number of people upset. 32:42.420 --> 32:45.880 We are supposed to be the most progressive country in the world, 32:45.960 --> 32:48.454 and we should be setting examples for other countries. 32:48.780 --> 32:52.780 With this being a pandemic, I think we have to be very careful 32:52.860 --> 32:56.460 and look at these other countries where AIDS is flourishing. 32:57.300 --> 33:01.780 The first 15,400 cases, and this was as of November 33:01.860 --> 33:06.489 I think of 1985, cost the government 33:06.569 --> 33:09.880 $4.1 billion in direct and indirect costs. 33:09.960 --> 33:12.700 Now, this was the care of these patients. 33:12.780 --> 33:17.200 This had nothing to do with the loss of work, 33:17.280 --> 33:20.040 that is, these patients die prematurely. 33:20.880 --> 33:26.740 There's a horrendous loss of manpower and professional work hours, 33:26.820 --> 33:30.640 and that is not taken into account with these figures. 33:30.720 --> 33:32.213 I just want to point that out. 33:32.580 --> 33:37.240 The proposed government expenditure for AIDS education and the AIDS programs 33:37.320 --> 33:39.720 throughout the country, and there are a number of them, 33:41.100 --> 33:45.720 in 1987 is $411 million. 33:46.560 --> 33:51.420 In 1988, it's projected at $534 million. 33:52.440 --> 33:54.340 The National Academy of Science and CDC 33:54.420 --> 33:57.660 think that these are woefully inadequate, very inadequate. 33:58.123 --> 34:00.520 The study that was done by the National Academy of Science 34:00.600 --> 34:02.783 in conjunction with the Institute of Medicine 34:02.940 --> 34:05.800 indicates that, by 1990, 34:05.880 --> 34:10.200 the government is going to be spending more than $2 billion for the AIDS problem. 34:11.520 --> 34:15.700 By 1991, and you saw the curves, the increased incidents, 34:15.780 --> 34:21.520 remember by January of 1991, we're going to have almost 270,000 cases of AIDS. 34:21.600 --> 34:24.040 That's the projections and our conservative projections. 34:24.120 --> 34:26.400 It's going to cost the government $8 billion. 34:27.300 --> 34:29.340 Truly, this is a medical emergency. 34:29.400 --> 34:30.880 It's certainly going to influence 34:30.960 --> 34:33.149 the cost of medical care here in this country. 34:35.400 --> 34:38.080 One other sad statistic about these AIDS patients 34:38.160 --> 34:41.200 is that not a lot of them have third-party carrier insurance 34:41.280 --> 34:42.720 or cover. 34:43.560 --> 34:47.880 There are 40% of them which do not have medical health insurance. 34:49.403 --> 34:51.640 That means that you and I are going to help defray 34:51.720 --> 34:56.887 the costs of these AIDS programs and caring for AIDS patients. 34:56.968 --> 34:58.660 The other thing that they're concerned about 34:58.740 --> 35:03.240 is healthcare personnel and helping to care for these patients. 35:06.120 --> 35:08.560 I think if one looks at this more carefully, 35:08.640 --> 35:11.320 I think you can see why it's such a horrendous expense. 35:11.400 --> 35:16.480 I looked at the costs of an average-age patient 35:16.560 --> 35:18.400 being hospitalized from the time of diagnosis 35:18.480 --> 35:21.600 was made to the time of death in various parts of the country. 35:22.680 --> 35:27.340 This is inpatient billing only. 35:27.420 --> 35:30.179 Keep that in mind. This is patients who are in the hospital. 35:30.900 --> 35:32.380 In San Francisco General Hospital, 35:32.460 --> 35:35.320 where there's a great number of AIDS programs that are being funded, 35:35.400 --> 35:38.020 national grants, and there's a big house staff, 35:38.100 --> 35:41.340 and many of these things are not charged to the AIDS patient. 35:42.720 --> 35:45.820 In fact, Paul Volberding, who's the head honcho 35:45.900 --> 35:48.700 at San Francisco General Hospital who's written a great deal about AIDS, 35:48.780 --> 35:53.140 has a tremendous amount of manpower at his availability 35:53.220 --> 35:55.740 to go ahead and implement some of these programs. 35:56.280 --> 35:59.620 He's been heavily granted by NCI or the NIH 35:59.700 --> 36:01.840 to carry out some of these programs. 36:01.920 --> 36:07.900 He's been really one of the first persons who's gathered meaningful statistics 36:07.980 --> 36:11.440 concerning these AIDS patients and the care of these AIDS patients 36:11.520 --> 36:12.600 on an inpatient basis. 36:13.860 --> 36:16.900 The bill for the average patient in San Francisco General Hospital 36:16.980 --> 36:18.540 was $27,500. 36:19.140 --> 36:21.280 This was surprisingly low. 36:21.360 --> 36:24.100 Jerry Groopman, who was out at the New England Deaconess Hospital, 36:24.180 --> 36:28.000 again, who was a very prominent figure 36:28.080 --> 36:32.680 in the AIDS research area estimated or calculated 36:32.760 --> 36:38.033 by looking at his age patients that it costs an average of $46,500 36:38.114 --> 36:40.165 for these patients during their hospitalization. 36:40.246 --> 36:42.569 Now keep in mind that the average-age patient 36:42.831 --> 36:45.580 is hospitalized about 3.2 times 36:45.660 --> 36:48.520 from the time the diagnosis is made until the time of death. 36:48.600 --> 36:51.780 That the average survival is about 1 year, 13 months. 36:52.680 --> 36:56.040 The average number of days they spend in a hospital is about 60 or 58. 36:57.540 --> 37:01.420 The California Department of Health Services, 37:01.500 --> 37:05.920 which gather their statistics primarily from Southern California Hospitals, 37:06.000 --> 37:12.187 estimated that it costs $67,300 37:12.267 --> 37:15.280 for AIDS patients in the hospitals in Southern California. 37:15.360 --> 37:17.320 These is the AIDS patients' bills. 37:17.400 --> 37:19.080 Again, inpatient medicine. 37:19.920 --> 37:21.360 Here at St. Joseph's Hospital, 37:21.960 --> 37:25.420 I took an AIDS patient who was diagnosed as AIDS here. 37:25.500 --> 37:29.680 He had all his hospitalizations here, which was three, by the way, 37:29.760 --> 37:33.520 and he died this past November. 37:33.600 --> 37:34.900 He lived about 15 months, 37:34.980 --> 37:39.540 so right on the money here with the average, almost. 37:40.140 --> 37:42.940 He was hospitalized a little longer than 58 days, though, 37:43.020 --> 37:44.880 if you calculated his three hospitalizations. 37:45.840 --> 37:48.160 With the help of Debbie Sossamon who helped gather 37:48.240 --> 37:51.120 all these statistics for me and looking at the hospital bills-- 37:52.740 --> 37:56.680 Debbie works at the Infectious Disease Control office. 37:56.760 --> 38:00.934 We calculated that our patient's bill was a little over $47,000. 38:01.015 --> 38:03.457 It was about $47,400. 38:04.020 --> 38:07.320 Again, let me reiterate that this is only inpatient billings. 38:08.160 --> 38:09.820 We really don't have a good handle on 38:09.900 --> 38:11.800 outpatient costs to these patients. 38:11.880 --> 38:14.860 We have no idea about the education programs 38:14.940 --> 38:19.440 and the other ancillary healthcare workers who visit these patients. 38:20.520 --> 38:22.780 The only thing we can look at is the hard figures 38:22.860 --> 38:25.262 that come out of the hospital with the hospital bills. 38:25.366 --> 38:29.440 Now, much of the outpatient care is, in fact, provided by the government, 38:29.520 --> 38:30.820 at least some of it is. 38:30.900 --> 38:33.880 The medications that they're on, 38:33.960 --> 38:35.680 a token medications that they've been put on, 38:35.760 --> 38:39.180 these small drug programs have not been charged for. 38:39.960 --> 38:42.220 Again, we really don't have a good handle 38:42.300 --> 38:47.520 on the non-inpatient AIDS cost, that is, the outpatient care. 38:48.120 --> 38:49.780 I should add, too, in San Francisco, 38:49.860 --> 38:52.260 they don't keep these patients in a hospital very long. 38:53.220 --> 38:56.020 I don't know whether it's because they do they need to do quickly, 38:56.100 --> 39:00.280 they expedite their care, but the average number of hospital days 39:00.360 --> 39:03.160 in San Francisco patients was considerably lower than it was 39:03.240 --> 39:06.160 in New England Deaconess Institute and in the California Department 39:06.240 --> 39:08.040 of Health Service study. 39:09.600 --> 39:11.980 You can see what it costs at St. 39:12.060 --> 39:14.740 Joseph's Hospital for an AIDS patient. It's a typical AIDS patient, 39:14.820 --> 39:18.720 at least by way of these national statistics here. 39:19.800 --> 39:25.180 Getting a little closer to home, in Wisconsin, there are 135 cases of AIDS 39:25.260 --> 39:29.022 registered at the state CDC in talking to Jim [?]. 39:29.578 --> 39:32.880 Now, these are interesting statistics, so pay attention. 39:34.080 --> 39:38.680 The non-residents, that is, the patients who contracted their AIDS 39:38.760 --> 39:42.240 outside of the state of Wisconsin, was 45. 50%. 39:46.320 --> 39:48.400 The residents, the number of patients 39:48.480 --> 39:51.340 who contracted their disease in Wisconsin was 90. 39:51.420 --> 39:55.420 It's twice as many residents as non-residents that we have registered now. 39:55.500 --> 39:57.700 Of course, this is the total. 39:57.780 --> 40:00.574 Now if we look at the number of cases, in 1986, 40:00.654 --> 40:03.838 there were 60 new cases in Wisconsin. 40:04.800 --> 40:07.680 Look at the difference in resident, non-resident cases. 40:08.220 --> 40:12.460 There were 48 resident cases, and there were only 12 non-resident cases. 40:12.540 --> 40:17.320 Now, what this means is that many patients contract their disease 40:17.400 --> 40:19.600 elsewhere, in other states, and other big urban areas 40:19.680 --> 40:20.920 that I showed you on the earlier slides, 40:21.000 --> 40:23.320 and they come back to Wisconsin because Wisconsin is their home. 40:23.400 --> 40:26.340 They come back here to spend their last time with their family. 40:27.480 --> 40:29.260 Most of these patients die here in Wisconsin, 40:29.340 --> 40:31.800 and they're counted as non-resident cases. 40:33.480 --> 40:37.540 That's what we were seeing in the early years when we were collecting the cases. 40:37.620 --> 40:41.620 These people were coming back from Miami and San Francisco or San Diego. 40:41.700 --> 40:44.674 Indeed, that's been our experience here with the six cases that we have had. 40:44.880 --> 40:47.280 Most of these patients contracted their disease elsewhere. 40:48.600 --> 40:51.520 You can see the trend is changing. Trend is changing. 40:51.600 --> 40:52.860 By far and away, 40:53.460 --> 40:57.900 there are many more resident cases than there were non-resident cases in 1986. 40:58.680 --> 41:00.760 Of course, you can see the significant increase 41:00.840 --> 41:03.460 in a number of cases in 1986. 41:03.540 --> 41:05.740 We had a total of 135 cases, 41:05.820 --> 41:09.100 60 of which were picked up and registered in 1986 alone. 41:09.180 --> 41:13.680 Now, where are these being picked up? Of course, as you might imagine, 41:13.922 --> 41:15.640 in the large urban areas of Wisconsin, 41:15.721 --> 41:19.331 57 cases in Milwaukee County 41:19.411 --> 41:23.221 and 21 cases in Dane County. 41:25.673 --> 41:32.560 You can see that we're not really immune to the AIDS problem here in Wisconsin, 41:32.640 --> 41:36.900 even though we think of ourselves as being a rural community or rural state. 41:37.620 --> 41:39.520 Let me expand on that a little bit. 41:39.600 --> 41:43.000 I think CDC is well aware that this has been, 41:43.080 --> 41:48.820 to this point, a very urban disease, but they estimate that there will be 41:48.900 --> 41:51.460 an equal number of cases in the next five years coming 41:51.540 --> 41:54.360 from rural areas in smaller urban areas. 41:56.160 --> 41:58.960 Again, this is primarily due to the different modes of transmission 41:59.040 --> 42:02.940 that we're seeing, ie, the heterosexual population. 42:06.900 --> 42:09.400 Here at Marshfield, our experience thus far, 42:09.480 --> 42:12.700 we saw our first AIDS patient in-- 42:12.780 --> 42:15.880 well, I diagnosed him as having ARC in January of 1984. 42:15.960 --> 42:18.120 He died in June of 1984. 42:18.534 --> 42:19.780 Since that time, 42:19.860 --> 42:25.540 we've registered six cases with CDC, and we're now following eight cases of ARC. 42:25.620 --> 42:26.980 This is the AIDS-related complex. 42:27.060 --> 42:30.160 That is, these are patients who have immune deficiency 42:30.240 --> 42:35.020 who do not have the criteria to make the diagnosis of AIDS. 42:35.100 --> 42:38.260 CDC has been very rigid about these criteria 42:38.340 --> 42:40.060 of making the diagnosis of AIDS. 42:40.140 --> 42:42.460 There's a very interesting editorial 42:42.540 --> 42:44.560 on some of that material that I handed out to you 42:44.640 --> 42:50.140 that's in the Annals of Internal Medicine this past month pointing out 42:50.220 --> 42:54.580 this whole nebulous area of how you make the diagnosis of AIDS. 42:54.660 --> 42:59.380 You've got to have either a complicating, an opportunistic infection, 42:59.460 --> 43:02.980 or a malignancy associated with the immune deficiency state 43:03.060 --> 43:06.820 in order to be classified or categorized and registered as AIDS. 43:06.900 --> 43:09.820 We all know that AIDS is a spectrum. 43:09.900 --> 43:12.340 Patients may be entirely asymptomatic 43:12.420 --> 43:14.620 initially and then develop the AIDS-related complex, 43:14.700 --> 43:18.220 which they may be just asymptomatic and have anemia. 43:18.300 --> 43:21.360 They may have a reversal of their T-site subset ratio. 43:22.740 --> 43:25.380 It's a continuum process. 43:26.580 --> 43:30.040 It's probably not accurate to just register those patients who 43:30.120 --> 43:34.200 develop opportunistic infections and malignancies as having AIDS. 43:35.400 --> 43:37.800 Five out of our six patients have died. 43:38.520 --> 43:41.740 Of course, I guess that didn't surprise anybody. 43:41.820 --> 43:46.080 Again, I reiterate 80% of the patients will die within 24 months. 43:46.920 --> 43:49.420 The average survival after the diagnosis is made 43:49.500 --> 43:50.760 as about 13 months. 43:51.853 --> 43:54.880 We're continuing to watch. I don't know how many cases we have 43:54.960 --> 43:57.900 of people who are asymptomatic and just simply HTLV-3 positive. 43:58.800 --> 44:02.920 The ARC patients are patients who do have some features 44:03.000 --> 44:08.740 of immune suppression, immune deficiency, and we're going to continue to follow them. 44:08.820 --> 44:11.380 We're following them mostly with the people in infectious disease. 44:11.460 --> 44:15.040 Bruce Hathaway, Doug Lee, Ray Hazel, 44:15.120 --> 44:19.560 and Tom Sell are all involved with the AIDS patient. 44:22.680 --> 44:25.920 How do these patients present? Well, it's the same old story. 44:26.520 --> 44:29.440 Most of these patients present with opportunistic infections 44:29.520 --> 44:33.100 or malignancies, and of course, that's how you make the diagnosis. 44:33.180 --> 44:35.920 The most prominent type of opportunistic infection 44:36.000 --> 44:39.780 is the bilateral pneumonitis caused by pneumocystis carinii. 44:40.620 --> 44:44.520 This is thought to be an organism, which, indeed, is an opportunistic type. 44:45.120 --> 44:46.920 It affects people who are immune suppressed. 44:47.820 --> 44:51.940 There's a significant number of patients who present with Kaposi's sarcoma. 44:52.020 --> 44:54.100 One of the curious things about Kaposi's sarcoma is, 44:54.180 --> 44:56.200 as I mentioned earlier, it's not a very common type 44:56.280 --> 44:57.300 of malignancy, number one. 44:57.900 --> 45:00.100 Number two, it seems to be much, much more common 45:00.180 --> 45:05.580 in the homosexual population with AIDS rather than the IV drug users. 45:09.060 --> 45:12.120 CDC is still perplexed as to why this is the case. 45:13.320 --> 45:16.020 Kaposi's sarcoma is so much more common in San Francisco 45:16.860 --> 45:19.200 than it is in New York with respect to the numbers. 45:20.340 --> 45:24.280 It's because of the proportionately higher number 45:24.360 --> 45:29.920 of patients who are gay and develop AIDS as compared to the heterosexual 45:30.000 --> 45:32.040 population who are IV drug users in New York City. 45:33.540 --> 45:37.240 It's not uncommon at all to have Kaposi's sarcoma and pneumocystis carinii. 45:37.320 --> 45:41.440 In fact, our last patient that just died last month presented 45:41.520 --> 45:44.620 with bilateral pneumocystis carinii, and he developed 45:44.700 --> 45:47.560 during his hospitalization here at St. Joe's Kaposi's sarcoma. 45:47.640 --> 45:49.140 Developed this right under our nose. 45:50.580 --> 45:55.300 Other opportunistic infections, absolutely, a wide array of opportunistic infections. 45:55.380 --> 45:58.540 Some organisms that microbiologists have never really even heard 45:58.620 --> 46:01.560 of before and certainly not infecting humans. 46:03.300 --> 46:05.820 This spectrum continues to grow, by the way. 46:07.380 --> 46:11.140 Apparently, this never ceases a surprise, the microbiologists 46:11.220 --> 46:14.380 as to the new organisms which are being picked up 46:14.460 --> 46:17.820 in these patients who have profound immune deficiency. 46:18.275 --> 46:19.540 Malignant lymphomas, 46:19.620 --> 46:24.460 and I should spend a moment on this, the incidence of malignant lymphomas 46:24.540 --> 46:27.060 in the AIDS patient is growing all the time. 46:27.960 --> 46:30.040 This is a large cell type of lymphoma. 46:30.120 --> 46:32.080 A very aggressive type of lymphoma. 46:32.160 --> 46:35.460 Frequently has central nervous system involvement primarily. 46:36.420 --> 46:40.000 These patients run a very short course. 46:40.080 --> 46:42.900 They are not very sensitive to chemotherapy. 46:43.860 --> 46:48.840 Again, it's a very aggressive type of large cell lymphoma that we're seeing. 46:50.940 --> 46:54.640 I should mention, too, that there is a relatively new syndrome 46:54.720 --> 47:00.100 of central nervous system syndrome that's been reported in AIDS patients. 47:00.180 --> 47:02.100 This is being reported with increasing frequency. 47:03.240 --> 47:06.580 The AIDS virus has been found in a central nervous system. 47:06.660 --> 47:07.960 I think, tomorrow, I'll show you 47:08.040 --> 47:10.380 what cells the AIDS virus has been picked up in. 47:10.980 --> 47:16.720 I think that the syndrome is one of a wide variety of presentations 47:16.800 --> 47:19.480 that these patients may present with dementia. 47:19.560 --> 47:23.760 They may present with extensive motor and sensory deficit. 47:24.720 --> 47:28.000 The histopathology is very, very analogous 47:28.080 --> 47:31.180 to a demyelinating process or multiple sclerosis. 47:31.260 --> 47:35.200 In fact, some of the NMR studies shown in these AIDS patients 47:35.280 --> 47:37.360 can actually pick up these large plaque areas 47:37.440 --> 47:39.867 where there's de-modernization occurring in the white matter. 47:40.800 --> 47:47.740 Again, we continue to learn about this virus and the AIDS dilemma. 47:47.820 --> 47:52.720 I think that we're going to have to get a handle on this thing very soon 47:52.800 --> 47:56.500 because of the number of cases throughout the 47:56.580 --> 47:58.360 entire population continues to grow. 47:58.440 --> 48:00.400 This is one of our patients that we have here. 48:00.480 --> 48:02.440 Many of you recognize this patient. 48:02.520 --> 48:04.120 He was a young man from Steven's Point 48:04.200 --> 48:07.600 who died last year from AIDS in his complications. 48:07.680 --> 48:10.240 He's got extensive Kaposi's sarcoma. 48:10.320 --> 48:12.640 Ray Hazel and I took care of this young man. 48:12.720 --> 48:14.860 He had two bone marrow transplants at NIH. 48:14.940 --> 48:20.920 He was followed at NIH and here for about a year with his disease. 48:21.000 --> 48:24.220 These are the Kaposi's lesions on his face. 48:24.300 --> 48:28.120 By the way, these are not just cutaneous malignant lesions. 48:28.200 --> 48:30.520 These occur all through the GI tract and may occur 48:30.600 --> 48:34.060 in a central nervous system as well. A curious thing about Kaposi's, though, 48:34.140 --> 48:37.920 it's not very commonly the cause of death in AIDS patients. 48:38.940 --> 48:43.120 Most frequently, these patients will get, in conjunction with their Kaposi's, 48:43.200 --> 48:46.560 opportunistic infections and will die of the opportunistic infections. 48:47.193 --> 48:50.740 The opportunistic infections are horrendous and are very difficult to treat. 48:50.820 --> 48:53.500 This is a chest x-ray of our first AIDS patient 48:53.580 --> 48:57.220 who was admitted to the hospital, I think, on Memorial Day of 1984. 48:57.300 --> 49:00.550 This is what his chest x-ray looked like. He died 10 days later. 49:01.080 --> 49:02.880 He had bilateral pneumocystis carinii. 49:04.020 --> 49:05.260 I think I'll stop there. 49:05.340 --> 49:09.180 If any of you want to stay around, I hope the Infectious Disease people will stay. 49:10.200 --> 49:15.280 Is Doug Corey here? Doug's been interested in this. 49:15.360 --> 49:18.100 Dean Crystal just got back from a meeting, so they've got all the latest scoop 49:18.180 --> 49:21.360 on these statistics in terms of infectivity, 49:22.200 --> 49:24.900 the number of the incidents of positive 49:27.900 --> 49:30.180 HTLV-3 specimens in blood donors. 49:30.840 --> 49:33.780 I think these are things that we're all very interested in. 49:36.810 --> 49:38.620 I'll go ahead and entertain some questions. 49:38.700 --> 49:41.020 Don't forget, tomorrow, we're going to talk primarily about the virus 49:41.100 --> 49:45.420 and about the immunology, the immune deficiency syndrome.