Ensnared by AIDS. David K. Beine

construction. Much has changed in the realm of HIV and AIDS since the first edition of this book appeared in 2003. Beyond the change of vocabulary (from HIV/AIDS to HIV and AIDS), new treatments are now available and there is even talk of a potential “cure” on the horizon. At the time of the first edition of this book, due to the emergence of antiretroviral therapy (ART) treatments and the subsequent first-time declines in associated death rates in the late 1990s—at least in the West—many (including myself) were just beginning to challenge the popular “dire predictions” narrative of the preceding decade.22 Because of the unequal access to these drugs, however, and with no foreseeable cure in sight, many (again including myself) expected the AIDS epidemic to continue relatively unabated outside the west, and certainly in Nepal, into the foreseeable future. What we couldn’t see at that time was the possibility of treatment as prevention and the emergence of possible “functional cures” that lay just around the corner. Given the recent developments of ART treatment as prevention and perhaps “functional cures,” many scholars believe we may be at a significant “turning point” in the HIV and AIDS epidemic. These recent developments will be discussed further in this chapter.

2.1 AIDS as biomedical fact

      AIDS is the acronym used for the medically defined acquired immuno-deficiency syndrome. In lay terms, the acronym can be explained in this way:

      Acquired: the virus is non-hereditarily transmitted23

      Immunodeficiency: the virus weakens the immune system, resulting in greater susceptibility to various opportunistic infections24

      Syndrome: a collection of common symptoms or signs (usually opportunistic infections) appears, which are fairly typical in infected persons.

      AIDS is caused by a group of related viruses referred to as HIV (human immunodeficiency viruses).25 HIV, like most other viruses, requires reproduction within the cells of the body. Once inside the body, the virus attaches itself to the surface of T-cells (T-lymphocytes), commonly referred to as white blood cells. The virus then enters the host cell by attaching itself to a protein known as a CD4 receptor in the plasma membrane of the cell. When HIV comes in contact with the CD4 receptor, the cell opens up, letting the virus enter the host cell.

      A defining characteristic of retroviruses (which include HIV) is that they are able to transcribe RNA into DNA (through the use of a special enzyme called reverse transcriptase), allowing the virus to integrate into the host DNA of the cell nucleus.26 Thus, HIV becomes resident in the cell nucleus by inserting itself into the infected person’s own DNA and grows in the body as cells divide and multiply. Cell reproduction takes place in the normal way (divide and multiply), but the newly emerging T-cells, which usually are involved in fighting infection, are compromised. T-cells are involved in attacking infected cells in our bodies. The HIV-infected T-cells, however, lack this ability, reducing the effectiveness of the body’s immune system. As the number of these HIV-infected T-cells increases in the body, the immune system becomes more and more depressed, allowing foreign bodies to enter the body and survive. In this weakened state, the body finally succumbs to the “invaders” and the result is death.

      According to AmfAR (2012), over 60 million people have contracted HIV since the beginning of the epidemic, and nearly 30 million of these have since died. It is estimated that there are currently 34 million people living with HIV or AIDS around the world (USAID 2012). In 2011, 2.5 million people became newly infected with HIV (UNAIDS 2012) and 1.7 million died from AIDS (AmfAR 2012). Each day nearly 7,000 persons contract HIV worldwide (AmfAR 2012) at a time when it is known how to prevent the infection by the virus that causes AIDS. By 1997 AIDS had been reported in over two hundred countries (Frumkin and Leonard 1997:117) and today it would appear that there is not a single nation remaining untouched by the epidemic.27

      While these numbers are certainly daunting, recent advances in prevention and treatment are decreasing the infection rate around the globe. According to the latest figures from UNAID (2012), twenty-five countries have seen a 50 percent (or greater) drop in new infections since 2001. The Caribbean region (which ranks second behind sub-Saharan Africa as the most affected region of the world) has seen a 42 percent reduction in infections, and over the past two years, half of all reductions in new HIV infections have been among newborn children, demonstrating that elimination of new infections in children is possible. It would appear that, likely owing to the new ART as a prevention strategy now being employed around the world, globally the epidemic has actually leveled off and is now beginning a decline. According to UNAIDS (2010), the number of new HIV infections peaked globally in 1996 and the number of AIDS-related deaths peaked in 2004.

      The latest data from UNAIDS (2012) also suggests, however, that new HIV infections have increased in East and North Africa by 35 percent or more for the same period (since 2001) and that Central Asia and Eastern Europe have also seen increases in HIV infection rates in recent years. This same data elaborates on the worrisome connection between HIV and tuberculosis (TB), concluding that TB remains the leading cause of death among People Living with HIV and AIDS (PLWHA). Furthermore, it concludes that although ART can reduce the risk of contracting TB by PLWHAs by up to 65 percent, fewer than half of those infected with both HIV and TB were receiving ART treatment as of 2011. And as is the case in Nepal (and likely elsewhere as well) there is certainly still a disparity between the availability of and access to ART treatments. So it would appear that the gap between rich and poor nations in regard to AIDS (noted in Beine 2003:56) remains true today, despite the progress noted above.

2.1.1 The history of AIDS

      Although the term AIDS was not coined until 1981, and HIV, the virus which causes AIDS, was not “discovered” until 1983 (Frumkin and Leonard 1997:1), recent evidence suggests that HIV was already present in the West as early as the 1950s (Frunkin and Leonard 1997:7), and new evidence suggests that HIV may have had its origin among humans in Africa possibly as early as the period between the 1880s and 1920s (Worobey 2008). There is much controversy and continued debate about the origin of HIV and its subsequent transfer from simians to humans.

      By the early 1980s the infection had become widespread enough to gain popular attention. Physicians were seeing multiple patients with strange symptoms. It wasn’t so much that the symptoms were unusual, but the diseases identified were being diagnosed in populations not normally associated with these diseases. By 1981, the Center for Disease Control (CDC) had over one hundred reports of young, healthy, gay men who had contracted diseases such as Kaposi’s sarcoma, a type of cancer that usually affects elderly men of Mediterranean descent, and Pneumocystis carinii pneumonia (PCP), an unusual lung infection in young, otherwise healthy men. When this phenomenon grew large enough, it caught the attention of the CDC, a government-funded agency whose job it is to study such anomalies. On the basis of their findings, scientists at the CDC hypothesized an immunodeficiency syndrome but still hadn’t discovered the causative virus, HIV.28 The link between HIV and AIDS would not be made definitively for another two years.29

      Because the first cases noted were mostly in gay men, the disease was first termed gay-related immunodeficiency (GRID) (Flynn and Lound 1995:11). Fed by media reports of the new “gay disease,” the first cultural model of AIDS—as it would later be called—began to emerge, namely that AIDS was a “gay” disease and a “death sentence.”

      During the next few years many immigrant Haitians were also found to be infected with GRID, as were hemophiliacs and even newborn infants (AmfAR 1999:370–374). Because the scope of the disease had now moved well beyond the initial community, GRID was renamed AIDS. The new findings began to modify the new cultural model of AIDS that was emerging among the general public. AIDS was still very much considered a “death sentence” but no longer understood as just a “gay” disease.

      It has long been suspected that HIV had its origin as a zoonotic disease. Because HIV is so similar to simian immunodeficiency virus (SIV), a virus that causes AIDS-like symptoms in some kinds of monkeys, the link between HIV and SIV was hypothesized (Frumkin and Leonard 1997:13). New research (Gao, Bailes and Robertson 1999) has confirmed this hypothesis, suggesting the common chimpanzee (Pan troglodytes troglodytes) as the origin of HIV-1. Tests carried out on strains of SIV suggest that HIV-1 arose first in this species (as a related SIV). The natural range of this species also corresponds with the areas where HIV-1 is endemic,