With World AIDS Day being marked next Friday, Dr Charles Savona-Ventura looks at the spread of the disease in the world - and in Malta
Twenty-five have passed since the first cases of AIDS were recognised. The doctors from the Centres of Disease Control of the United States little suspected that they were heralding a new pandemic when on June 5, 1981 they reported five cases of the previously rare Pneumocystis carinii pneumonia in young homosexual men in Los Angelis.
On July 4 of that year, the CDC further reported that during the previous 30 months, 26 cases of the rare Kaposi Sarcoma had been reported among homosexual males, and that eight have died, all within 24-months of diagnosis.
By 1982, the CDC established the name Acquired Immune Deficiency Syndrome (AIDS) for this infection, identifying the populations at risk as being male homosexuals, intravenous drug abusers, haemophilic sufferers, and those of Haitian origin. That year the first case of AIDS was reported from Africa. In 1983, the CDC warned blood banks of a possible problem with the blood supply accounting for the cases found in haemophilic sufferers.
In 1983, Luc Montagnier of the Pasteur Institute isolated a retrovirus from patients from AIDS, which in 1984 was shown by Robert Gallo of the National Cancer Institute to be responsible for causing the disease. This retrovirus was later named the Human Immunodeficiency Virus (HIV). By 1983, the CDC added female sexual partners of men with AIDS as being at risk of developing the infection, while a heterosexual AIDS epidemic was revealed in Central Africa.
By 1985, at least one AIDS case had been reported from each region of the world. The first test to enable the detection of antibodies to HIV enabling early diagnosis was licensed by the US Food and Drug Administration (FDA) in 1985; while the first antiretroviral drug AZT was approved by the FDA in 1987. The first World Aids Day was held in 1988.
Despite the advances and increasing appreciation of the disease entity, the US government in 1990 was implementing an immigration policy whereby people with HIV infection were denied entry to the country. In 1993, President Bill Clinton signed an HIV immigration exclusion policy into law.
During the first two decades, the epidemiology and clinical presentation of the disease were established, and potent antiviral therapies were developed - for those who could afford them! The medical progress in the last five years has been less dramatic. However the number of victims continues to rise, while the infected population profile is gradually changing to a more universal one.
In the 25 years since the first report, more than 65 million persons have been infected with HIV, and more than 25 million have died from AIDS. Even more worrisome is the observation that more than 40 per cent of new infections among adults are in young people aged 15 to 24.
Ninety-five per cent of these infections and deaths have occurred in developing countries particularly in Sub-Saharan Africa where almost 64 per cent of the estimated 38.6 million persons living with HIV live. AIDS is now the leading global cause of premature death among people aged 15 to 59. In the hardest-hit countries, the infection erodes the foundations of society, governance, and national security. Safety nets and services are being stretched to breaking point causing social and economic repercussions that will span generations.
The Maltese story
The HIV-AIDS pandemic has not spared the Maltese population. The first case of AIDS in Malta was reported in 1984, with a second case being reported the subsequent year. Both cases died from the disease. By the end of 1986, five cases had been reported with four deaths; the estimated number of HIV positive individual amounted to 25 persons.
The appearance of the disease in the Maltese community stimulated an early response from the health authorities, and the Health Education Unit published its first educational leaflet entitled Fatti dwar l-AIDS in 1986. This publication aimed at informing the public about this new untreatable infection with the scope of promoting prevention and avoiding an excessive response from the public and health personnel.
As far as could be established, HIV was introduced to Malta in the early 1980s in Abbott Anti-Haemophilic Factor injections and by a few sero-positive homosexual men previously domiciled overseas. In March 1986, AIDS was made a compulsory notifiable disease and in December 1986, a National Committee for the Prevention and Control of AIDS was established. The WHO/CDC 1987 definition was formally adopted in Malta in January 1988, and a circular to this effect, including a copy of the definition was circulated to all doctors.
By the end of 1990, the total number of AIDS cases reported from Malta amounted to 15, with 13 of these individuals succumbing to their disease. The increasing number of cases being seen with the disease, compounded by the untreatability and infectivity of the disease, saw an escalating preoccupation among the public and among the health professions.
This preoccupation stimulated the Union of Government Medical Doctors to organise a day seminar on January 25, 1992 dealing with "Screening for Blood-transmissible disease". This discussed the historical, ethical, epidemiological, and clinical aspects of the problem. In addition, a voluntary community support group called HANDS was set up in November 1992 under the auspices of the Health Education Unit and the National AIDS Committee.
The aim of this group was to serve as the leading non-governmental body providing services like counselling, helpline management and organise educational campaigns in all HIV-related matters. The group initiated a newsletter entitled Hands Across to further their aims. The Health Education Unit in 1992 also published a bilingual patient-oriented publication entitled It-Tixrid tal-HIV u r-Riskji tal-AIDS and another directed at the health professional entitled HIV & the Health Professional. The first World AIDS Day was commemorated in Malta in 1993 with the theme "Time to Act".
By the end of 1992, the epidemic pattern appears to have taken two waves. The first wave occurring in 1984-1988 was made up predominantly by cases infected inadvertently by infected blood products, together with some cases of homosexual practice. After 1988, there was a lull with an absence of reported cases in 1989 and a gradual rise afterwards reflecting increasing infection in homosexual men. By the end of 1991, there had been only one infected female individual reported. There were as yet no cases of AIDS reported in intravenous drug abusers.
The number of individuals falling victim to the infection in Malta in the last two decades 1984-2004 have amounted to 58 cases of which 50 are known to have succumbed to their disease. The mode of transmission has been predominantly homosexual or bisexual activity accounting for 31 cases; with blood product infection accounting for a further 13 cases.
Other modes of transmission have been single cases of homosexual/bisexual contact and mother-to-child transmission. Four cases had other forms of transmission or were undetermined. There were no cases of intra-venous drug abusers infected with AIDS.
By the end of 2003, there were a total of 210 positive HIV tests reported locally. HIV infection was only made a notifiable infection on January 27, 2004.
During the last two years, there have been a total of 26 HIV-positive individuals reported in Malta (17 males and nine females) and a further five cases (including one female) of AIDS. A number of the HIV-positive female individuals were diagnosed during pregnancy thus placing the infants at risk of mother-to-child transmission of infection. With correct antenatal management, none of these infants were infected. The only case of mother-to-child transmission reported in Malta had occurred overseas.
Until this year, the intra-venous drug abuser community seemed to have been spared the ravages of HIV-AIDS, though the large proportion are affected with the other devastating viral infection causing Hepatitis C. This year, the HIV-AIDS virus has made significant inroads into this community with six drug-abusing individuals being found positive for the disease. Experience overseas has shown that once the HIV-AIDS virus spreads to this community, then there is a quickened pace of spread throughout the overall population. The time to act is now!
Prevention
While the prevalence rate of HIV-positive individuals in the Maltese Islands remains low, vigilance must remain the norm to prevent further spread of the infection. The majority of cases in recent years have been transmitted through sexual activity. The ideal situation would be to promote sexual abstinence and faithfulness to one partner.
However, out-of-wedlock sexuality in the Maltese Islands is definitely on the increase. This is reflected in the increasing rates of out-of-wedlock pregnancies and the increasing trends in sexually transmitted disease such as genital warts, syphilis, gonorrhoea and herpes genitalis.
For this reason, in the face of a deteriorating sexual morality, condom use may be considered the lesser moral evil. Despite widespread uninhibited sexual education, "safe sex" is still not the norm. Almost two-thirds of the 1,832 new patients attending the Genito-Urinary Clinic at Boffa Hospital in 2005 admitted to never using condoms; their mean age at first intercourse was 16 years, when three-quarters of them admitted to not having used a condom on that occasion. Almost half (46 per cent) of these individuals admitted to having casual sex. These statistical sexuality trends have been represented throughout the period 2000-2005.
While these data are by no means representative of the Maltese population, they do represent a selected population which knowingly places itself at risk of sexually-transmitted disease including HIV-AIDS. The ideal moral scenario is to abstain from casual sex until one can be faithful to one partner. However, when facing different norms, the only other alternative is regular and correct condom use.
Having chosen to place oneself at risk though a casual sexual encounter, it becomes essential for the individual to identify his infective status as early as possible. Early identification of the infection allows for the timely institution of retroviral treatment which helps delay the progression of the disease. This becomes even more so in the face of pregnancy, since correct management decreases the risks of mother-to-child transmission. Confidential testing and counselling can be availed of at the Genito-Urinary Clinic at Boffa Hospital.
Education remains the key element in the fight against this new plague epidemic. This must be directed at several fronts. The frontline should be safer sex health promotion campaigns in schools. These campaigns should emphasise the benefits of sex abstinence until marriage and in the event of embarking on premarital casual sex to protect oneself adequately. The next educational drive should aim at informing the public on the true status of the HIV-AIDS victim. Casual non-sexual contact will not predispose towards infection transmission and there is no place for ostracising the HIV-AIDS victim from society.
Lowest awareness
Modern society has finally overcome its fears of victims of leprosy; one hopes that it will find the courage to do so with victims of the "new leprosy". One can only hope that the future heralds better medication, new vaccines and improved prevention methods. However, it remains essential for communities to adopt the humility necessary to control a disease that is transmitted by proper society's least favourite topics of discussion - sexual activity and drug abuse.
It must be realised that the prime mover of the epidemic is not inadequate medication, but society's inability to accept the dimensions of a disease that is transmitted by sexual activity and its failure to address the issue adequately and comprehensively. HIV-control programs will only be effective once this reality is accepted and acted upon.
Burying one's head in the sand to the problem of irresponsible sexuality will simply keep society blind to the dimensions of the problem but completely exposed it to the dangers brought on by such activities. In Malta, in accordance with "political" correctness, the attitude towards the problems of HIV-AIDS has been one emulating the ostrich.
The 2005 Eurobarometer Survey on AIDS Prevention has showed that, in contrast to the majority of other European countries, the Maltese scored the lowest level of awareness and knowledge. Approximately 10 per cent of the population are misinformed about the infectivity risks of needle sharing, infected blood, and having unprotected sex with an infected partner; while 42 per cent believed that the virus could be transmitted by casual contact and had changed their behaviour to avoid casual contact with certain members of the community.
A similar proportion reported taking care of what they touch; 29 per centavoid certain establishments. In contrast, only 63 per cent of the Maltese respondents reported taking adequate precautions, when having sex. It is definitely time for the Maltese authorities - political, health, education and ecclesiastical - to shift the educational drive regarding HIV-AIDS to first gear to effectively win the fight against the spread of this disease.