Earlier this week, I had the honour of being invited to Canada’s Parliament Hill for a very important discussion on the topic of HIV/AIDS and tuberculosis.  The forum was being offered by the HIV/AIDS/TB caucus, made up of Lois Brown from the Conservative Party, Ruby Dhalla from the Liberal Party, Megan Leslie from the New Democratic Party and Johanne Deschamps from the Bloc Quebecois, and focused on the need for increased innovation and integration for health infrastructure, capacity and resources in the third world.  Groups from all sectors of HIV research were there including Dignitas International who inspired us with presentations of their work in the 3rd world to combat HIV/AIDS.

The meeting was in fact one of the most exciting times I have had in many years.  Yes, it had to do in part with the fact that I once worked with HIV and it also had to do with the realization that the problems in places like Malawi are so much worse than here in Canada that we are not all that badly placed in the world of infectious disease.  But the most revealing aspect of the meeting was the fact that in many ways, I found a missing link to an issue with which I have been struggling for years:

Did HIV cause the infection problems that we face today?

What I learned was that in one way, the answer is yes but in another way, it perhaps was not the right question.

To defend the reasons for HIV being the cause, consider the following.

Back in 1980, prior to the first documented wave of HIV and AIDS, there were only a handful of infectious diseases that caused us any real problems.  I still remember the big disease of the day was genital herpes.  In comparison to some of the big guns we have faced in the recent past (and you know who you are MRSA, VRE, Acinetobacter, avian flu, SARS, and of course, Toxoplasma), humanity wasn’t really all that badly off.  But once HIV started to spread, the world changed.

But here’s the thing that surprised me.  The real problem with HIV wasn’t the virus itself but rather the problems that resulted after infection.  Once infection had taken hold, it was the increase in other infections, many of which were not normally pathogenic, that led to the reduction of life expectancy and the health crises.  It wasn’t the HIV infection that was killing people, it was something else.

It was the immunosuppression.

HIV leads to a reduction of the immune function.  Infected individuals are more likely to get sick from less harmful microbes, and in turn, will need more severe measures to get rid of the bugs after they infect.  How does one accomplish that?  Antibiotics and antivirals, of course.  And since the immune system is not a significant partner in these battles, especially in advanced HIV infection, then the pathogens have an easier fight.

Evolution, which can occur in as little as a few minutes to a few hours allows for mutation and changes to the overall biology.  In some cases a minor shift, such as an amino acid change can drastically reduce the effectiveness of a drug.  This resistance can then spread from the individual to others who may or may not be immunosuppressed.  With time, a single mutant can find its way into an entire population of individuals.  If the mutation is strong enough, the pathogen may even be able to infect and cause disease in healthy individuals.  In a rather short period of time, say a few years, the infection can become widespread (or endemic).  We’ve already seen this with C. difficile, Toxoplasma, and Acinetobacter baumanii.  In the case of tuberculosis, a re-emergence has occured that has led to drastic consequences such as multi-drug-resistant TB (MDR-TB) and extremely drug-resistant TB (XDR-TB).

In essence, the question should have been:

Has the increase in immunosuppressed individuals has led to the development of pathogens that can infect healthy individuals?

And the answer is concretely:  Yes…thanks in great part to HIV.

So, here’s the dilemma.  If the world had taken the time to focus less on the virus and more on both education to prevent viral spread and proper health response to those who are infected, could some of the emerging pathogens we see today been prevented?  Perhaps. But hindsight is always 20/20 and the reality is that this is 2010 and we’ve been dealing with HIV and AIDS for over 30 years.

I do think however, that with the knowledge gained, there can be a change for the future.  I would propose that we look at the following as a way to combat not only HIV but the immunosuppression that affects HIV+ individuals as well as so many others who suffer from a weakened immune system.

There needs to be a more consolidated effort on the part of all researchers, regulatory officials and organizations to combat HIV not as an individual science, but as a part of a greater study on immunosuppression and the consequences of a weakened immune system.

As a researcher, this inevitably leads to the more problematic question of how does this translate into funding?  In my estimation, the current emphasis on the HIV virus, which I admit continues to be important, needs to destabilize somewhat to include other sectors of research that have little to do with the virus itself.  We need to focus on the individual-based and population-based ecology that surrounds immunosuppression.  This encompasses education, social determinants, existing and emerging pathogen mitigation, and greater linkages to other immunosuppression conditions such as autoimmune diseases, organ transplantation and cancer therapy.

The world has traveled a long journey in the last 30 years and our health problems have significantly increased.  HIV has played a significant role in this but the true problem has been the rise in immunosuppression.  By using immunosuppression as a basis for research and funding, I believe that work to solve the problems faced in the first world can be linked to ongoing system approaches that are being used in the 3rd world to solve their crises. And through proper translation of the good and by avoiding the pitfalls already encountered, overall health will improve worldwide.

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