Acquired Immunodeficiency Syndrome AIDS

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Vincent Keane
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National Association of Community Health Centers

• Vince Keane is a former Catholic priest who has
  dedicated himself to the issue of health care for
  the homeless in D.C. He is a previous winner of
  NACHC's John Gilbert award for his championing of
  community health care.

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National Association of Community Health Centers

• Among his successful achievements are increased
  services for homeless patients raising the
  profile of non-profit clinics through his
  leadership role in DC Primary Health Care
  Association (DCPCA) and the Non-Profit Clinic
  Consortium turning around the fate of Federally
  Qualified Health Centers in the city and more
  recently taking on the gargantuan task of
  assuring service amidst the change, once again,
  of the citys public health system.

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Acquired Immunodeficiency Syndrome (AIDS)

• Stuart Henochowicz, M.D., M.B.A., F.A.C.P.

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AIDS- Basic Facts

• Retrovirus that infects T Lymphocytes
• Progression from virus infection to full blown
  AIDS can be 10 years
• Severity of infection correlates with CD4 count
  (T helper cell)
• Destruction of T cells predisposes patients to
  opportunistic infections

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AIDS-Basic Facts

• Opportunistic infections
• Viral- CMV,EBV
• Mycobacterial- TB
• Fungal- Candida, Aspergillus
• Parasitic- Pneumocystis
• Cancers
• Kaposis Sarcoma, Lymphoma, Cervical

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AIDS-Basic Facts

• Transmission-
• Sex- anal more effective route than vaginal
• more effective transmission in presence of
  other STDs
• Blood- 1980s- Transfusion of blood products
• Infected Needles- IV Drug use, Needlestick
  injuries

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AIDS- Basic Facts

• Origin-
• Equatorial Africa
• 1959-HIV positive blood sample- Congo
• Transmission to North America in the late 1970s-
  Homosexual activity
• Transmission accelerated by promiscuous sex in
  Gay bathhouses
• Patient Zero- Gaetan Dugas- male airline steward

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Source New York Times, Jan. 30th, 2005
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And The Band Played OnRandy Shilts

• African origins of AIDS-
• Kinshasa, Congo-
• Grete Rask- surgeon contracts AIDS
• Dies in 1977
• Family from Kinshasa dies in Belgium- 1978

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And The Band Played OnRandy Shilts

• Portuguese veteran of Angolan Civil war treated
  in Paris- Dies in 1980
• 2 women from Zaire die of Pneumocystis at
  Claude-Bernard hospital- 1980

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And The Band Played OnRandy Shilts

• Patient Zero-
• Gaetan Dugas- flight attendant
• 40/248 gay men diagnosed with GRIDS had direct
  or indirect sexual contact with Dugas
• CDC- Los Angeles Cluster Study

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Knowledge about contact patterns leads to insight
into transmission routes

• Contact network AIDS cases (Auerbach et al. 1984)
• Probability that cluster of cases is connected by
  contact on the basis of random events
• timing of contacts and onset of disease
• Hypothesis AIDS is transmitted by homosexual
  contact

Source dimacs.rutgers.edu/Workshops/
WGVaccination/slides/kretzchmar.ppt
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Cluster of cases of the acquired immune
deficiency syndrome. Patients linked by sexual
contact Auerbach et. al. Am. J. Med. 1984

• The possibility that homosexual men with the
  acquired immune deficiency syndrome (AIDS) had
  been sexual partners of each other was studied.
  Of the first 19 homosexual male AIDS patients
  reported from southern California, names of
  sexual partners were obtained for 13. Nine of the
  13 patients had sexual contact with one or more
  AIDS patients within five years of the onset of
  symptoms.

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Cluster of cases of the acquired immune
deficiency syndrome. Patients linked by sexual
contact Auerbach et. al. Am. J. Med. 1984

• Four of the patients from southern California
  had contact with a non-Californian AIDS patient,
  who was also the sexual partner of four AIDS
  patients from New York City. Ultimately, 40
  patients in 10 cities were linked by sexual
  contact.

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Cluster of cases of the acquired immune
deficiency syndrome. Patients linked by sexual
contact Auerbach et. al. Am. J. Med. 1984

• On the basis of six pairs of patients, a mean
  latency period of 10.5 months (range seven to 14
  months) is estimated between sexual contact and
  symptom onset. The finding of a cluster of AIDS
  patients linked by sexual contact is consistent
  with the hypothesis that AIDS is caused by an
  infectious agent.

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Cluster of AIDS patients
number order of diagnosis 0 index case
A.S. Klovdahl. Social networks and the spread of
infectious diseases The AIDS example. Soc. Sci.
Med. 21 (1985) 1203-1216.
A.S. Klovdahl. Social networks and the spread of
infectious diseases The AIDS example. Soc. Sci.
Med. 21 (1985) 1203-1216.
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Small World Networks

• Milgram- 1967- He selected random people from
  locations like Kansas or Nebraska, and had them
  start a chain of letter-forwarding. The targets
  of the letters were in Cambridge, MA and Boston.
  Each starter was to send a folder through the
  mail to the target person.

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Small World Networks

• But the game had rules. The starters could only
  mail the folder to someone they knew on a
  first-name basis. That person was to mail the
  folder on to another first-name acquaintance,
  etc.Returned tracer postcards tracked the
  progress of each chain.

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Small World Networks

• Milgram found that the very first folder reached
  her in just four days and took only two
  intermediate acquaintances. In the second study,
  the starters were located in Nebraska, and the
  target was from Sharon, MA, working in Boston.
  Milgram reported that chains varied from two to
  ten intermediate acquaintances, with the median
  at five. Any person appeared to be able to reach
  the target with an average of six jumps.

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Progressive transition between regular and random
graphs
Source Watts and Strogatz 1998
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Maybe Its not such a Small World After
All Spatial Networks and Complex
Contagions Michael Macy Cornell
University Based on Complex Contagion and the
Weakness of Long Ties with Damon Centola,
Cornell University
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A few long ties

• A few bridge ties between otherwise distant nodes
• Create shortcuts across the graph

• While preserving the clustering of a small
  world.
• Spread of disease

Infectious diseases spread more easily in
small-world networks than in regular lattices.
-- Watts Strogatz, 1998
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A few long ties

• A few bridge ties between otherwise distant nodes
• Create shortcuts across the graph

• While preserving the clustering of a small
  world.
• Spread of disease

Infectious diseases spread more easily in
small-world networks than in regular lattices.
-- Watts Strogatz, 1998
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CDC Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care Settings

• For patients in all health-care settings
• HIV screening is recommended for patients in all
  health-care settings after the patient is
  notified that testing will be performed unless
  the patient declines (opt-out screening).

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CDC Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care Settings

• Persons at high risk for HIV infection should be
  screened for HIV at least annually.
• Separate written consent for HIV testing should
  not be required general consent for medical care
  should be considered sufficient to encompass
  consent for HIV testing.?

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CDC Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care Settings

• Prevention counseling should not be required with
  HIV diagnostic testing or as part of HIV
  screening programs in health-care settings.

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AIDS in the City

• I heard a presentation on HIV/AIDS management.
  Much of the discussion revolved around getting
  the patients to come for their clinic visits, and
  thinking through techniques where important
  interventions such as PAP smears and dental care
  could be accomplished all in one day.

Source http//burkemed.blogspot.com/2006/10/aids-
in-city.html
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AIDS in the City

• To my surprise, I learned that dental care,
  offered for free to a population in desperate
  need of such care, is frequently skipped, even
  when a same day appointment is arranged.

Source http//burkemed.blogspot.com/2006/10/aids-
in-city.html
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AIDS in the City

• We heard a wonderful and comprehensive
  presentation from the HIV/AIDS service at Unity.
  A few interesting facts emerged from this
  presentation
• One out of every twenty people in the District of
  Columbia are HIV positive (a number comparable to
  that of the developing world).
• 30 of HIV positive patients in D.C. are women.
  Women generally get infected from sexual contact
  with men who are either IV drug users or MSMs
  (men who have sex with men) who are on the down
  low (new terms for closeted gays).

Source http//burkemed.blogspot.com/2006/10/aids-
in-city.html
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AIDS in the City

• There are a growing number of HIV positive
  patients who are over the age of 50. Part of the
  growth represents a positive development-
  patients with HIV/AIDS are surviving for more
  than a decade now. They are actually able to age.
  But the other reason for the growth is truly
  disturbing. It was explained to us that young,
  drug addicted HIV positive patients are
  prostituting themselves to older people who have
  money to spare, thereby exposing the older folks
  to the virus.

Source http//burkemed.blogspot.com/2006/10/aids-
in-city.html