1. “Are you unaware that vast numbers of your fellow men suffer or perish from need of the things that you have to excess, and that you required the explicit and unanimous consent of the whole human race for you to appropriate from the common subsistence anything besides that required for your own?” Jean-Jacques Rousseau, 1775

2. Leading causes of death in Sub-Saharan Africa, South Asia, and Southeast Asia for persons age 0-44 (World Health Organization) As you now know, in the developing world treatable infectious diseases remain big killers

3. Leading causes of death in Sub-Saharan Africa, South Asia, and Southeast Asia for persons age 0-44 (World Health Organization) HIV/AIDS and AIDS related illnesses are among the largest killers

4. “Tropical Medicine and Parasitiology” 1997 Untreated AIDS is a devastating disease that inevitably leads to an early death

5. The virus kills people indirectly, by destroying the immune system

7. With a disabled immune system, other infections take off

8. As you already know…

9. HIV and AIDS by the numbers UN AIDS press release 11/20/2010 33 million people worldwide living with HIV 2.5 million new infections in 2009 2.1 million people died of AIDS in 2004 --this dropped to 1.8 million in 2009

10. It is estimated that 5 million individuals were newly infected with HIV during 2001. Once again, AIDS and the deaths it causes are not evenly distributed around the world

11. Sub-Saharan Africa is the epicentre 68% of HIV-infected people live there 1/3 in just 8 countries UN AIDS press release 11/20/2007

12. This has had dramatic effects on the life expectancy of those in sub-Saharan Africa 2005 Economic report to the US President, Council of Economic Advisors

13. What is your picture of the average HIV positive person?

14. In the developing world, HIV is becoming a disease of children! New HIV Infections in 2002 by Age Group

15. In the developing world, HIV is becoming an infection of children! UN AIDS press release 11/20/2010 Global Trends

16. We can also see these differences when we return to our comparison of the US and Haiti

18. HIV prevalence in the Caribbean ranges from 0.1% in Cuba to > 3% in the Bahamas and Haiti UNAIDS 2006 Report on the Global AIDS Epidemic And BBC November 2003

19. HIV prevalence in the Caribbean ranges from 0.1% in Cuba to > 3% in the Bahamas and Haiti UNAIDS 2006 Report on the Global AIDS Epidemic And BBC November 2003 One in 20 Haitians has the disease, and it is the main cause of death among women of reproductive age.

20. HIV prevalence in the Caribbean ranges from 0.1% in Cuba to > 3% in the Bahamas and Haiti UNAIDS 2006 Report on the Global AIDS Epidemic And BBC November 2003 Region-wide, fewer than one in four people needing antiretroviral drugs received them One in 20 Haitians has the disease, and it is the main cause of death among women of reproductive age.

21. AIDS is not on this list! In contrast, in the US….

22. The development of effective treatments turned the tide in the US

23. Percentage of Patient-days on HAART Deaths per 100 Person-Years 0 5 10 15 20 25 30 35 40 1995199619971998199920002001 Deaths per 100 person-years 0 25 50 75 100 Percentage of patient-days on ART DEATHS USE OF ART Mortality vs. ART utilization Palella F et al. 8th CROI 2001; abstract 268b. This becomes even clearer if we focus in on the key years

24. However major disparities in AIDS incidence occur even within our nation

25. Top 10 States by AIDS Case Rate per 100,000 Population, 2004 U.S. Rate = 15.0 Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.

26. There are also major disparities along ethnic lines (largely but not entirely reflecting poverty) White, non-Hispanic African American Latino Asian/Pacific Islander American Indian/ Alaska Native Percent of AIDS Diagnoses Note: Data are estimates. Source: CDC, Data Request, 2006. 2004

27. Notes: U.S. Population estimates do not include U.S. dependencies, possessions, and associated nations; persons who reported more than one race were included in multiple categories. May not total 100% due to rounding. Total AIDS diagnoses in 2004 include persons of unknown race or multiple races. AI/AN = American Indian/Alaskan Native Sources: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005; U.S. Census Bureau, Population Estimates Program, 2004 Population Estimates. 1% 4% AIDS Diagnoses Disparities, 2004 49% 13% 28% 69% 20% 14% White, non-Hispanic African American Latino Asian/Pacific Islander AI/AN <1% 1% AIDS Cases 42,514 U.S. Population 293,655,404

28. As with TB, the impact of AIDS Is not limited to illness and death

29. As with TB, the impact of AIDS Is not limited to illness and death Worldwide >16 million children have been orphaned by AIDS Swaziland Lesotho Rwanda UN AIDS press release 11/20/2010 Global Trends

30. More than 11 million Of these children are in Sub-Saharan Africa Newsweek, Vol. CXXXV, No. 3, 17 January 2000

31. More than 11 million Of these children are in Sub-Saharan Africa UNICEF 2006

32. There is some good news to which we’ll return later UN AIDS press release 11/20/2007 and UNAIDS/WHO/UNICEF report 4/17/2007

33. There is some good news to which we’ll return later UN AIDS press release 11/20/2007 and UNAIDS/WHO/UNICEF report 4/17/2007 Global HIV prevalence=% of people living with HIV leveled off in 2007 and and number of new infections has fallen In part as a result of the impact of HIV programs.

34. There is some good news to which we’ll return later UN AIDS press release 11/20/2007 and UNAIDS/WHO/UNICEF report 4/17/2007 Global HIV prevalence=% of people living with HIV leveled off in 2007 and and number of new infections has fallen In part as a result of the impact of HIV programs. Access to retroviral therapy increased sharply in 2006 From 1.3 million to 2 million, a 54% increase in one year However, this is still only 28% of those in need of treatment

35. Let’s return to the impact of AIDS on Haiti the US and Haiti

36. AIDS and the fear of AIDS have had a major effect on Haiti since the dawn of the epidemic

37. Let’s go back in time and see how things began

38. 1981 Doctors in California and New York note increase in cases of Kaposi’s sarcoma and Pneumocystis carinii pneumonia in gay men The first H: Homosexuals

39. They first noticed the disease based on: a handful of cases of Pneumocystis pneumonia And 8 cases of Kaposi’s sarcoma and Why did they suspect a new disease? A remarkable tribute to epidemiology! Kaposi’s sarcoma lesions

40. Because you NEVER see these diseases in patients who are not immune-compromised. Their hypothesis: A new sexually transmitted disease. A remarkable tribute to epidemiology!

41. http://www.avert.org/his81_86.htm In July 1981 Dr Jim Curran of the CDC summarized what we knew: "Dr. Curran said there was no apparent danger to non homosexuals from contagion. 'The best evidence against contagion', he said, 'is that no cases have been reported to date outside the homosexual community or in women'" - The New York Times

42. Then came the first reports of similar outbreaks In those injecting illegal drugs

43. Then came the first reports of similar outbreaks In those injecting illegal drugs The second H = heroin-users

44. By mid 1982 the third and fourth H’s were added:

45. Haitians and hemophiliacs

46. In March 1983 this was formalized by the CDC "persons who may be considered at increased risk of AIDS include those with symptoms and signs suggestive of AIDS; sexual partners of AIDS patients; sexually active homosexual or bisexual men with multiple partners; Haitian entrants to the United States; present or past abusers of IV drugs[heroin]; patients with hemophilia; and sexual partners of individuals at increased risk for AIDS”.

47. As AIDS emerged into the public view discrimination against the 4H’s skyrocketed

48. Our nation’s leaders did not help http://www.avert.org/his81_86.htm "It is true that some medical sources had said that (AIDS) cannot be communicated in any way other than the ones we already know and which would not involve a child being in the school. And yet medicine has not come forth unequivocally and said, 'This we know for a fact, that it is safe.' And until they do, I think we just have to do the best we can with this problem. I can understand both sides of it." - Ronald W. Reagan Sept. 17, 1985

49. This was despite strong scientific evidence to the contrary http://www.avert.org/his81_86.htm "The cause of AIDS is unknown, but it seems most likely to be caused by an agent transmitted by intimate sexual contact, through contaminated needles, or, less commonly, by percutaneous inoculation of infectious blood or blood products. No evidence suggests transmission of AIDS by airborne spread. The failure to identify cases among friends relatives, and co-workers of AIDS patients provides further evidence that casual contact offers little or no risk” MMWR Weekly (1983) 'Current Trends Acquired Immunodeficiency Syndrome (AIDS) Update - United States', June 24, 32 (24); 309-11

50. This sort of fear devastated the Haitian economy

52. "It killed tourism in Haiti," says Dr. Jean Pape, who has been treating AIDS in Haiti since the beginning and who founded the Haitian Study Group on Opportunistic Infection and Kaposi's Sarcoma Tourism formed the backbone of the Haitian economy. "... Within a year the tourism industry decreased by 80 percent, Goods manufactured in Haiti could not be sold in the U.S." PBS Frontline

53. The number of American visitors, who make up more than two-thirds of Haiti's tourists, fell from 70,000 in the winter of 1981-82 to 10,000 in 1983, including travelers on business, according to the Haitian Government

54. This led to a reversal of the official policy but this was too late for Haiti

55. The popular press and some scientists fed fears of Haitians by suggesting that AIDS arose in Haiti “this may be an epidemic Haitian virus that was brought back To the homosexual population in the United States” Dr. Bruce Chabner, National Cancer Institute Dec. 1983

56. The popular press and some scientists fed fears of Haitians by suggesting that AIDS arose in Haiti

57. This initial theory was quickly discredited

58. What is the origin of HIV and how would we determine this?

59. Remember this? E. coli Staph. aureus TB bug Genome Research 12, 1080-1090 (2002)

60. Mutations accumulate over time E. coli Staph. aureus TB bug Genome Research 12, 1080-1090 (2002)

61. We can do something similar with HIV E. coli Staph. aureus TB bug Genome Research 12, 1080-1090 (2002)

62. Retroviruses. CSHL Press Fig. 12-3 HIV is part of a family of viruses affecting monkeys, apes and people

63. Science 28 January 2000:Vol. 287. no. 5453, pp. 607 - 614 HIV is part of a family of viruses affecting monkeys, apes and people Chimps People Chimps

64. Hemelaar J.Trends Mol Med. 2012 Jan 11. Tebit DM, Arts EJ. Lancet Infect Dis. 2011 Jan;11(1):45-56. HIV came from non-human primates 4 times!!

65. Global Distribution of HIV-1 Hemelaar J.Trends Mol Med. 2012 Jan 11. The greatest diversity of HIV sequences is seen in Central Africa

66. Since mutations accumulate over time more variants suggest HIV has been in West Africa for a longer time World-wide West Africa only Nature Reviews Genetics 5, 52-61 (January 2004)

67. Science 28 January 2000:Vol. 287. no. 5453, pp. 607 - 614 HIV has been transmitted between apes and people multiple times Chimps People Chimps

68. The greatest diversity of HIV sequences is seen in West Africa World-wide (especially subtype B) West Africa only Nature Reviews Genetics 5, 52-61 (January 2004)

69. A recent study suggests AIDS may have Passed through Haiti from Africa to the US World-wide West Africa only

70. Sequence analysis also provides evidence for timing of emergence of epidemic

71. There are problems with this analysis

72. Another problem with this analysis: Early cases 1969: “Robert R” 15 Year old American from St. Louis. died of Kaposi’s sarcoma--Later tests reveal HIV-1 in tissue 1969: Norwegian sailor Arvid Noe. He, his wife and daughter die of AIDS in 1976 Later tests reveal HIV-1 subtype O in tissue