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What we now know — and must do — about HIV disease and AIDS
JOURNAL
of the
AmeRiCaN ACaDemy OF
DerMaTOLOGY VOLUME 22
NUMBER 6 PART 2 JUNE 1990
What we now know-and must do-about HIV disease and AIDS Alvin E. Friedman-Kien, MD New York, New York
Zidovudine (Retrovir, formerly called azidothymidine [AZT]) may be useful early in the course of human immunodeficiency virus type 1 (HIV-l) infection to delay the onset of overt symptomatic disease, such as AIDS-related complex (ARC) or acquired immunodeficiency syndrome (AIDS). We now have something promising to offer the asymp.tomatic HIV-infected person and can justify and strongly encourage those in high-risk groups to be tested to determine whether, in fact, they are infected, for their own immediate benefit. It is inappropriate for physicians to respond to the epidemic of HIV-related disease with either a personal sense of helplessness or a professional attitude of hopelessness, although the pandemic dimensions of HIV infection and AIDS have grown so large as to be numbing, with neither a preventive vaccine nor a cure yet available. Indeed, there is a great deal to be done right now, especially by the clinical dennatologist. We can provide the earliest possible diagnosis of HIV infection, in asymptomatic persons, and implement therapeutic measures that will extend and improve the quality of life, by helping to delay, prevent, and effectively treat certain of the life-threatening opportunistic infections to which AIDS patients are vulnerable. Particularly in view ofthe dramatic advances that have been made in less than a decade, we have urgent and vital tasks to perform. However, these can be accomplished only by our continuing to be well informed about the rapidly developing scientific and From New York University Medical Center, Department of Dermatology. Reprint requests: Alvin E. Friedman-Kien, MD, New York University Medical Center, 550 First Ave., New York, NY 10016.
16/0/19157
therapeutic advances, at the same time remaining sensitive to the special emotional and social needs of our patients, so that we maintain competence to handle the responsibility to meet the challenges presented by HIV infection. As physicians we can serve as spokespersons for those infected with HIV and help assure that they receive the best health care and social services. We are privileged to be in a position of influence to serve as informed voices that can educate the public and campaign to arrest the spread of HIV infection. At the same time, we must continue to urge those decision makers who control the flow of government funds for research, prevention, and medical care to meet the mounting demands of the expanding AIDS epidemic. DIMENSIONS OF THE EPIDEMIC
Dermatologists have played a pivotal role in this epidemic since its initial recognition. They were among the first to identify the sudden, unexplained rise in Kaposi's sarcoma and opportunistic infections in homosexual men in New York and California. Those who forecast the magnitude of the impending AIDS disaster in 1981 experienced frustration and great difficulty finding acceptance, cooperation, and support, not only from the medical community and the public but also from government agencies responsible for funding medical research. Yet today AIDS is clearly the plague of the millennium. We are now almost a full decade into an epidemic that has rapidly spread throughout the world, moving across North America, Europe, Africa, Australia, the Caribbean, Central and South America, and Asia. It has been recognized as a "new" disease that is most likely to affect not only homosexual men but also intravenous drug users (IVDUs), hemophiliacs,
1163
1164
Journal of the American Academy of Dermatology
Friedman-Kien
other recipients of HIV-contaminated blood and blood products, as well as the sexual partners and offspring of HIV-infected persons. Although the incidence of HIV infection is now increasing most rapidly among men, women, and children in black and Hispanic inner-city communities in the United States, we need to recognize that, in time, AIDS is likely to touch every socioeconomic segment ofthe population. The realization that HIV disease has now been recognized to be a global pandemic of devastating magnitude in developing countries, especially the sub-Saharan Mrican nations where AIDS threatens to kill vast numbers of the population, calls for a major, organized, cooperative effort from the more affluent nations of the world to help with financial and medical support for these people unable to provide for themselves. As of December 1989, the Centers for Disease Control reported that the United States had more than 127,000 documented AIDS cases and over 50,000 deaths due to the disease. As many as 2 million persons in this country are probably infected with HIV, albeit without symptoms. It is suggested that there are more than 250,000 cases of AIDS worldwide, with possibly as many as 15 million persons who are now EIV-1 infected. It has been estimated that by the end of 1992 the United States will have had 450,000 cases of AIDS and nearly 300,000 deaths due to the disease. Indeed, projections indicate that in 1992 there will be over 80,000 new cases ofAIDS diagnosed in the United States-almost as many cases in that year alone as have occurred to date! Epidemiologic surveillance and statistical projections are hampered by inaccurate and inadequate reporting of AIDS throughout the world and by the fact that sufficient time has not transpired to enable us to observe the long-term natural history of HIV1 infection. There appears to be a long incubation period, up to 10 years or longer, from the time of HIV infection to the development of symptomatic disease. Early intervention with antiviral therapy, as well as the development of additional therapeutic alternatives, will continue to improve the care of the HIV-infected person and, thereby, favorably alter the course of the illness and prolong survival to the extent that we may never know the total spectrum and prognosis of untreated HIV disease. As with most other viral infections, perhaps not everyone infected with HIV will develop overt disease; however, numerous ongoing, prospective
epidemiologic studies suggest that the percentage of infected persons who develop AIDS increases with each year. All evidence suggests that the epidemic will continue to spread for many years to come. The prospect for a vaccine against HIV infection is still remote. Public health education remains the key to preventing the spread of HIV-l infection, we must find new ways to inform the inner-city populations in our own country and the peoples of underdeveloped nations throughout the world who are difficult to reach by traditional methods of education. DRAMATIC PROGRESS
Just when many of us had begun to believe that the wealth of medical acumen, healing skills, and tools ofpreventive medicine had reached such a high level that many of the major diseases confronting humanity had either been or were about to be conquered, this enigmatic new disease erupted. It is remarkable that the AIDS epidemic appeared at a time in history when the state ofscientific knowledge was such that the causative retrovirus HIV could be identified. Had AIDS occurred 10 years earlier, biomedical science would not have been prepared to isolate the etiologic agent or understand the pathophysiology of the disease. It was only in the early 1970s that the unique group of RNA retroviruses, to which HIV-1 belongs, were first described. Simultaneously, advances in immunology had clarified the molecular biology of the CD4, T helper lymphocyte that plays a key role in cell-mediated immune function and is also the major cell of predilection for . HIV. The depletion of the T helper cell results in the profound, and, to date, irreversible immunologic dysregulation in patients with AIDS. We are faced with the challenge of combating an insidious virus that destroys the host's system of immune surveillance that normally provides protection against the onslaught ofthe various opportunistic infections and neoplastic disorders characteristic of AIDS. Most researchers and physicians were totally unprepared for the overwhelming and dramatic impact that HIV infection and AIDS have had on our health care system and society. Although the death toll from AIDS has continued to mount, a great deal has been accomplished as increasing numbers of scientists in the public and private sectors have focused intensive efforts to unravel the mysteries of HIV infection. Recall that the epidemic was first recognized in 1981; by 1983 the putative virus, HIV,
Volume 22 Number 6, Part 2 June 1990
What we now know-and must do-about HIV disease 1165
was identified. Two years later, a blood test was developed to detect antibodies to HIV, enabling more accurate tracking of the epidemic and helping to identify and eliminate HIV-seropositive donated blood from the world's blood supply. By 1986, the first antiviral agent, zidovudine, was shown to be effective in helping to inhibit the replication of HIV and was made available for treatment. In the history of medicine there is no precedent for these remarkable achievements in such a relatively short time. Despite the ongoing efforts to produce a vaccine to prevent the spread of HIV infection, the prospects for developing a universally effective vaccine against the multiple strains ofHIVwill probably not become a reality in this century, partly because of the antigenic variability of HIV and the virus' ability to spread from cell to cell by syncytia formation without coming into contact with serum antibodies. The application of an experimental vaccine raises critical ethical issues concerning how to test the efficacy of potential vaccines against a virus that causes such a lethal disease. Who would volunteer? Who would serve as controls? In a disease with what appears to be a long latency period, perhaps 10 years or more, how much time would it take to determine whether a vaccine would indeed provide adequate protection against HIV infection, and for how long? Even now we should consider the responses to these questions in anticipation of the day when a safe and effective vaccine will be available for testing. Further ethical concerns surround the evaluation of all experimental drug testing in HIV-infected individuals. The time-honored, double-blind, placebocontrolled study design traditionally used to evaluate potential drugs is no longer acceptable in patients with HIV infection in view of the fatal prognosis associated with AIDS. Because of the inexorable nature of the disease and the valid demands of our patients, it is likely that future treatment trials with promising drugs for HIV infection, as well as for the various opportunistic infections and neoplastic disorders associated with AIDS, will be evaluated only in an "open," unblinded fashion, or will be tested in comparison with such agents as zidovudine or other medications that have previously been shown to have beneficial effects. Fortunately, even as we increase our awareness of the therapeutic benefits of zidovudine, there are many other antiviral substances in development and under consideration for experi-
mental treatment evaluations. With recent evidence that certain strains of HIV have apparently developed in vitro reduced sensitivity to zidovudine and with the probability that this virus is likely also to become less sensitive to other antiviral agents, the need for a larger "menu" of therapeutic agents will be essential for continuous suppression of HIV-l. The goal remains the same: to prevent the unrelenting deterioration of the infected host's immune system that occurs with progression of the disease. Yet, despite these stumbling blocks, biomedical research has already provided physicians with more acute diagnostic skills and insights with a broader therapeutic armamentarium to cope with the cascade of opportunistic infections and neoplasms to which HIV-l-infected individual are prone and, thereby, has provided help to prolong survival and maintain a better quality of life. TODAY'S RESPONSIBILITIES As dermatologists, we must be constantly vigilant in the identification of the early, and sometimes subtle, symptoms of HIV-I-related diseases. Often the HIV-l-infected patient's first contact with a health care provider is the dermatologist. In particular, persons who are unaware that they are HIVI-infected may turn to dermatologists with seemingly minor, but often persistent, mucocutaneous problems that often do not respond readily to standard treatments. Symptoms that may be the first harbingers of the HIV-1 disease include oral thrush; recurrent condylomata acuminata and other warts; disseminated molluscum contagiosum, and severe and often persistent herpes simplex or herpes zoster virus infections; eruptions such as seborrheic dermatitis; severe unexplained pruritus; hives; widespread folliculitis; fungal infections of the skin and nails; and newly described conditions, oral "hairy" leukoplakia and epithelioid (bacillary) angiomatosis, which have recently been seen only in HIVI-infected individuals. The occurrence of one or more of these conditions should alert the physician to consider the possibility that a patient may have an underlying infection with HIV-1. With time, we have become acutely aware of the expanding spectrum of life-threatening opportunistic infections caused by a variety of unusual parasitic, bacterial, and fungal organisms that are commonly seen in patients with AIDS, as well as the particular neoplastic disorders to which they are also
1166
Friedman~Kien
susceptible. The clinician must become familiar with the earliest signs and symptoms of these AIDSrelated diseases and must initiate appropriate available treatment. For certain life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia, which afflicts about 60% of AIDS patients, prophylactic treatment is now available and should be prescribed, especially to those HIVI-infected patients with evidence of diminishing cell-mediated immunity. As physicians, we must serve as role models for society by caring for those with AIDS with compassion and understanding. We must take every opportunity to convey accurate information about the nature of HIV disease and the means of transmission to help prevent the spread ofinfection. We must help to dispel the stigma that has been attached to AIDS and thereby eliminate the unjust prejudice against those afflicted with this disease. Each of us must personally ful:fill a responsibility to act as advocates for the afflicted and plead for their welfare in our own community. Such affirmative action will help quell unwarranted public hysteria about HIV-1 contagion and will instill a sense of communal compassion and kindness to help meet the needs and subdue the fears and isolation of those who are now infected with HIV-1. Albert Camus wrote in his prophetic novel, The Plague: "The populace thought they could protect themselves by closing the gates of the city. But, in time, they realized that they were just as much at 'risk' and as 'responsible' as those they had tried to quarantine." It is our job to help educate society to accept the fact that AIDS is everyone's problem and that all must assume responsibility for those among us who are ill and less fortunate. Itis also part of the physician's job to counsel and console AIDS patients' spouses, lovers, families, and friends, as well as the other care providers who will help to look after these patients throughout the duration of their illness. We must also be prepared to intercede on behalf ofthese patients and provide advice to their employers and insurers. These patients may look to us for guidance in identifying community resources essential to their lives. Perhaps most important, we must be prepared and must make ourselves available to listen to their concerns. Yes, we can do a great deal to help our patients live with HIV-l infection and AIDS.
Journal of the American Academy of Dermatology
As the information in this supplement makes
clear, many newly developed prophylactic and treatment regimens are available for delaying and treating opportunistic infections and neoplastic diseases that not only prolong but also significantly improve the lives of persons with HIV disease thereby helping to make them considerably more comfortable. This supplement is based on presentations from the symposia devoted to HIV-1 infection and AIDS given at the annual meetings of the American Academy of Dermatology in 1987,1988, and 1989. We have tried to present a comprehensive overview of the current state of knowledge about the epidemic of HIV-1 infection and AIDS by addressing the various epidemiologic, medical, social, and economic issues surrounding HIV-l infection based on the experience and findings of some of the foremost experts involved with AIDS since the beginning of the epidemic. All physicians must become familiar with, and keep abreast of, the most current information of HIV-1 infection and AIDS since each one of us will surely be involved with this disease during our medical careers. This knowledge can enable physicians to take up their historically vital roles in making an early diagnosis, treating the sick, and educating our patients and the public about a disease that has and will continue to have an enormous impact on our lives. Finally, we must recognize that, even with the Significant increases in public and private monies for AIDS research, education, and patient care that are now forthcoming~ funding is still inadequate. When we are confronted the criticism that the medical community and society have not done enough to meet the urgent challenge of the AIDS crisis, remember that we are not among those who are dying prematurely. The anger often expressed represents the desperate plea for help that should inspire us to become more sympathetic and actively involved as we serve to meet the continuous emotional, social, and health needs of those infected with HIV1. Knowledge is the key for the physician's fu1:fillment of his obligations not only to provide the best treatment but also to give hope, understanding, and, above all, to give comfort to the patients, their lovers, families, and friends who look to us for help and kindness.
of the
AmeRiCaN ACaDemy OF
DerMaTOLOGY VOLUME 22
NUMBER 6 PART 2 JUNE 1990
What we now know-and must do-about HIV disease and AIDS Alvin E. Friedman-Kien, MD New York, New York
Zidovudine (Retrovir, formerly called azidothymidine [AZT]) may be useful early in the course of human immunodeficiency virus type 1 (HIV-l) infection to delay the onset of overt symptomatic disease, such as AIDS-related complex (ARC) or acquired immunodeficiency syndrome (AIDS). We now have something promising to offer the asymp.tomatic HIV-infected person and can justify and strongly encourage those in high-risk groups to be tested to determine whether, in fact, they are infected, for their own immediate benefit. It is inappropriate for physicians to respond to the epidemic of HIV-related disease with either a personal sense of helplessness or a professional attitude of hopelessness, although the pandemic dimensions of HIV infection and AIDS have grown so large as to be numbing, with neither a preventive vaccine nor a cure yet available. Indeed, there is a great deal to be done right now, especially by the clinical dennatologist. We can provide the earliest possible diagnosis of HIV infection, in asymptomatic persons, and implement therapeutic measures that will extend and improve the quality of life, by helping to delay, prevent, and effectively treat certain of the life-threatening opportunistic infections to which AIDS patients are vulnerable. Particularly in view ofthe dramatic advances that have been made in less than a decade, we have urgent and vital tasks to perform. However, these can be accomplished only by our continuing to be well informed about the rapidly developing scientific and From New York University Medical Center, Department of Dermatology. Reprint requests: Alvin E. Friedman-Kien, MD, New York University Medical Center, 550 First Ave., New York, NY 10016.
16/0/19157
therapeutic advances, at the same time remaining sensitive to the special emotional and social needs of our patients, so that we maintain competence to handle the responsibility to meet the challenges presented by HIV infection. As physicians we can serve as spokespersons for those infected with HIV and help assure that they receive the best health care and social services. We are privileged to be in a position of influence to serve as informed voices that can educate the public and campaign to arrest the spread of HIV infection. At the same time, we must continue to urge those decision makers who control the flow of government funds for research, prevention, and medical care to meet the mounting demands of the expanding AIDS epidemic. DIMENSIONS OF THE EPIDEMIC
Dermatologists have played a pivotal role in this epidemic since its initial recognition. They were among the first to identify the sudden, unexplained rise in Kaposi's sarcoma and opportunistic infections in homosexual men in New York and California. Those who forecast the magnitude of the impending AIDS disaster in 1981 experienced frustration and great difficulty finding acceptance, cooperation, and support, not only from the medical community and the public but also from government agencies responsible for funding medical research. Yet today AIDS is clearly the plague of the millennium. We are now almost a full decade into an epidemic that has rapidly spread throughout the world, moving across North America, Europe, Africa, Australia, the Caribbean, Central and South America, and Asia. It has been recognized as a "new" disease that is most likely to affect not only homosexual men but also intravenous drug users (IVDUs), hemophiliacs,
1163
1164
Journal of the American Academy of Dermatology
Friedman-Kien
other recipients of HIV-contaminated blood and blood products, as well as the sexual partners and offspring of HIV-infected persons. Although the incidence of HIV infection is now increasing most rapidly among men, women, and children in black and Hispanic inner-city communities in the United States, we need to recognize that, in time, AIDS is likely to touch every socioeconomic segment ofthe population. The realization that HIV disease has now been recognized to be a global pandemic of devastating magnitude in developing countries, especially the sub-Saharan Mrican nations where AIDS threatens to kill vast numbers of the population, calls for a major, organized, cooperative effort from the more affluent nations of the world to help with financial and medical support for these people unable to provide for themselves. As of December 1989, the Centers for Disease Control reported that the United States had more than 127,000 documented AIDS cases and over 50,000 deaths due to the disease. As many as 2 million persons in this country are probably infected with HIV, albeit without symptoms. It is suggested that there are more than 250,000 cases of AIDS worldwide, with possibly as many as 15 million persons who are now EIV-1 infected. It has been estimated that by the end of 1992 the United States will have had 450,000 cases of AIDS and nearly 300,000 deaths due to the disease. Indeed, projections indicate that in 1992 there will be over 80,000 new cases ofAIDS diagnosed in the United States-almost as many cases in that year alone as have occurred to date! Epidemiologic surveillance and statistical projections are hampered by inaccurate and inadequate reporting of AIDS throughout the world and by the fact that sufficient time has not transpired to enable us to observe the long-term natural history of HIV1 infection. There appears to be a long incubation period, up to 10 years or longer, from the time of HIV infection to the development of symptomatic disease. Early intervention with antiviral therapy, as well as the development of additional therapeutic alternatives, will continue to improve the care of the HIV-infected person and, thereby, favorably alter the course of the illness and prolong survival to the extent that we may never know the total spectrum and prognosis of untreated HIV disease. As with most other viral infections, perhaps not everyone infected with HIV will develop overt disease; however, numerous ongoing, prospective
epidemiologic studies suggest that the percentage of infected persons who develop AIDS increases with each year. All evidence suggests that the epidemic will continue to spread for many years to come. The prospect for a vaccine against HIV infection is still remote. Public health education remains the key to preventing the spread of HIV-l infection, we must find new ways to inform the inner-city populations in our own country and the peoples of underdeveloped nations throughout the world who are difficult to reach by traditional methods of education. DRAMATIC PROGRESS
Just when many of us had begun to believe that the wealth of medical acumen, healing skills, and tools ofpreventive medicine had reached such a high level that many of the major diseases confronting humanity had either been or were about to be conquered, this enigmatic new disease erupted. It is remarkable that the AIDS epidemic appeared at a time in history when the state ofscientific knowledge was such that the causative retrovirus HIV could be identified. Had AIDS occurred 10 years earlier, biomedical science would not have been prepared to isolate the etiologic agent or understand the pathophysiology of the disease. It was only in the early 1970s that the unique group of RNA retroviruses, to which HIV-1 belongs, were first described. Simultaneously, advances in immunology had clarified the molecular biology of the CD4, T helper lymphocyte that plays a key role in cell-mediated immune function and is also the major cell of predilection for . HIV. The depletion of the T helper cell results in the profound, and, to date, irreversible immunologic dysregulation in patients with AIDS. We are faced with the challenge of combating an insidious virus that destroys the host's system of immune surveillance that normally provides protection against the onslaught ofthe various opportunistic infections and neoplastic disorders characteristic of AIDS. Most researchers and physicians were totally unprepared for the overwhelming and dramatic impact that HIV infection and AIDS have had on our health care system and society. Although the death toll from AIDS has continued to mount, a great deal has been accomplished as increasing numbers of scientists in the public and private sectors have focused intensive efforts to unravel the mysteries of HIV infection. Recall that the epidemic was first recognized in 1981; by 1983 the putative virus, HIV,
Volume 22 Number 6, Part 2 June 1990
What we now know-and must do-about HIV disease 1165
was identified. Two years later, a blood test was developed to detect antibodies to HIV, enabling more accurate tracking of the epidemic and helping to identify and eliminate HIV-seropositive donated blood from the world's blood supply. By 1986, the first antiviral agent, zidovudine, was shown to be effective in helping to inhibit the replication of HIV and was made available for treatment. In the history of medicine there is no precedent for these remarkable achievements in such a relatively short time. Despite the ongoing efforts to produce a vaccine to prevent the spread of HIV infection, the prospects for developing a universally effective vaccine against the multiple strains ofHIVwill probably not become a reality in this century, partly because of the antigenic variability of HIV and the virus' ability to spread from cell to cell by syncytia formation without coming into contact with serum antibodies. The application of an experimental vaccine raises critical ethical issues concerning how to test the efficacy of potential vaccines against a virus that causes such a lethal disease. Who would volunteer? Who would serve as controls? In a disease with what appears to be a long latency period, perhaps 10 years or more, how much time would it take to determine whether a vaccine would indeed provide adequate protection against HIV infection, and for how long? Even now we should consider the responses to these questions in anticipation of the day when a safe and effective vaccine will be available for testing. Further ethical concerns surround the evaluation of all experimental drug testing in HIV-infected individuals. The time-honored, double-blind, placebocontrolled study design traditionally used to evaluate potential drugs is no longer acceptable in patients with HIV infection in view of the fatal prognosis associated with AIDS. Because of the inexorable nature of the disease and the valid demands of our patients, it is likely that future treatment trials with promising drugs for HIV infection, as well as for the various opportunistic infections and neoplastic disorders associated with AIDS, will be evaluated only in an "open," unblinded fashion, or will be tested in comparison with such agents as zidovudine or other medications that have previously been shown to have beneficial effects. Fortunately, even as we increase our awareness of the therapeutic benefits of zidovudine, there are many other antiviral substances in development and under consideration for experi-
mental treatment evaluations. With recent evidence that certain strains of HIV have apparently developed in vitro reduced sensitivity to zidovudine and with the probability that this virus is likely also to become less sensitive to other antiviral agents, the need for a larger "menu" of therapeutic agents will be essential for continuous suppression of HIV-l. The goal remains the same: to prevent the unrelenting deterioration of the infected host's immune system that occurs with progression of the disease. Yet, despite these stumbling blocks, biomedical research has already provided physicians with more acute diagnostic skills and insights with a broader therapeutic armamentarium to cope with the cascade of opportunistic infections and neoplasms to which HIV-l-infected individual are prone and, thereby, has provided help to prolong survival and maintain a better quality of life. TODAY'S RESPONSIBILITIES As dermatologists, we must be constantly vigilant in the identification of the early, and sometimes subtle, symptoms of HIV-I-related diseases. Often the HIV-l-infected patient's first contact with a health care provider is the dermatologist. In particular, persons who are unaware that they are HIVI-infected may turn to dermatologists with seemingly minor, but often persistent, mucocutaneous problems that often do not respond readily to standard treatments. Symptoms that may be the first harbingers of the HIV-1 disease include oral thrush; recurrent condylomata acuminata and other warts; disseminated molluscum contagiosum, and severe and often persistent herpes simplex or herpes zoster virus infections; eruptions such as seborrheic dermatitis; severe unexplained pruritus; hives; widespread folliculitis; fungal infections of the skin and nails; and newly described conditions, oral "hairy" leukoplakia and epithelioid (bacillary) angiomatosis, which have recently been seen only in HIVI-infected individuals. The occurrence of one or more of these conditions should alert the physician to consider the possibility that a patient may have an underlying infection with HIV-1. With time, we have become acutely aware of the expanding spectrum of life-threatening opportunistic infections caused by a variety of unusual parasitic, bacterial, and fungal organisms that are commonly seen in patients with AIDS, as well as the particular neoplastic disorders to which they are also
1166
Friedman~Kien
susceptible. The clinician must become familiar with the earliest signs and symptoms of these AIDSrelated diseases and must initiate appropriate available treatment. For certain life-threatening opportunistic infections, such as Pneumocystis carinii pneumonia, which afflicts about 60% of AIDS patients, prophylactic treatment is now available and should be prescribed, especially to those HIVI-infected patients with evidence of diminishing cell-mediated immunity. As physicians, we must serve as role models for society by caring for those with AIDS with compassion and understanding. We must take every opportunity to convey accurate information about the nature of HIV disease and the means of transmission to help prevent the spread ofinfection. We must help to dispel the stigma that has been attached to AIDS and thereby eliminate the unjust prejudice against those afflicted with this disease. Each of us must personally ful:fill a responsibility to act as advocates for the afflicted and plead for their welfare in our own community. Such affirmative action will help quell unwarranted public hysteria about HIV-1 contagion and will instill a sense of communal compassion and kindness to help meet the needs and subdue the fears and isolation of those who are now infected with HIV-1. Albert Camus wrote in his prophetic novel, The Plague: "The populace thought they could protect themselves by closing the gates of the city. But, in time, they realized that they were just as much at 'risk' and as 'responsible' as those they had tried to quarantine." It is our job to help educate society to accept the fact that AIDS is everyone's problem and that all must assume responsibility for those among us who are ill and less fortunate. Itis also part of the physician's job to counsel and console AIDS patients' spouses, lovers, families, and friends, as well as the other care providers who will help to look after these patients throughout the duration of their illness. We must also be prepared to intercede on behalf ofthese patients and provide advice to their employers and insurers. These patients may look to us for guidance in identifying community resources essential to their lives. Perhaps most important, we must be prepared and must make ourselves available to listen to their concerns. Yes, we can do a great deal to help our patients live with HIV-l infection and AIDS.
Journal of the American Academy of Dermatology
As the information in this supplement makes
clear, many newly developed prophylactic and treatment regimens are available for delaying and treating opportunistic infections and neoplastic diseases that not only prolong but also significantly improve the lives of persons with HIV disease thereby helping to make them considerably more comfortable. This supplement is based on presentations from the symposia devoted to HIV-1 infection and AIDS given at the annual meetings of the American Academy of Dermatology in 1987,1988, and 1989. We have tried to present a comprehensive overview of the current state of knowledge about the epidemic of HIV-1 infection and AIDS by addressing the various epidemiologic, medical, social, and economic issues surrounding HIV-l infection based on the experience and findings of some of the foremost experts involved with AIDS since the beginning of the epidemic. All physicians must become familiar with, and keep abreast of, the most current information of HIV-1 infection and AIDS since each one of us will surely be involved with this disease during our medical careers. This knowledge can enable physicians to take up their historically vital roles in making an early diagnosis, treating the sick, and educating our patients and the public about a disease that has and will continue to have an enormous impact on our lives. Finally, we must recognize that, even with the Significant increases in public and private monies for AIDS research, education, and patient care that are now forthcoming~ funding is still inadequate. When we are confronted the criticism that the medical community and society have not done enough to meet the urgent challenge of the AIDS crisis, remember that we are not among those who are dying prematurely. The anger often expressed represents the desperate plea for help that should inspire us to become more sympathetic and actively involved as we serve to meet the continuous emotional, social, and health needs of those infected with HIV1. Knowledge is the key for the physician's fu1:fillment of his obligations not only to provide the best treatment but also to give hope, understanding, and, above all, to give comfort to the patients, their lovers, families, and friends who look to us for help and kindness.