I'm Philip Johnson, and I'm a physician at Carle Clinic Association in Urbana, Illinois. I specialize in internal medicine. I've been taking care of AIDS patients for many, many years, and we've been fortunate here to have access to all the medications as soon as they're available anywhere in the world. The patients have benefitted greatly and have been able to have their lives prolonged and their quality of life to be enhanced greatly by these medications. Unfortunately, despite those advantages we've still seen problems with new infections. People whose whole life have been spent in the era of AIDS. We've grown up knowing from their littlest memories about that there is such a thing as AIDS, and how eventually if they get old enough they learn how it's spread in school and so forth, and yet they still come in with infections they've acquired through practicing unsafe sex in particular, or sometimes through injection drug use, sharing needles, or having sex with people who share the needles. Point is that education and awareness are important lessons and important benefits, however they have to be practiced, and they have to be repeated to be internalized and the proper behaviors. And it's very difficult when most of the world has no inkling of what safer sex really is and why it's important, and who in the course of their sexual activities thinks that this person really must not be infected. They look fine, if they knew they were infected they surely would tell me, and so forth and so forth. And the end result is either through ignorance, or denial, or through outright malice many people have gotten infected and it continues to this day even in areas where there has been widespread education. In most of the world, probably in something like 80 percent of the world's population, has no access to prevention services. They don't have the access to the information that this video project is attempting to give them. Hopefully with the Internet it will be more able for these people to get information that's accurate and up-to-date. Hopefully through this method people's attitudes and can change so that the communities will be not subjecting HIV patients to stigma which is another way of saying they won't make them cast out or afraid if they have HIV. Likewise, if people talk about sexual activities, they will likewise not be stigmatized. Likewise, if people attempt to use condoms that they will not be hindered in a major way. It's certainly fine for a partner or a potential partner to turn down sexual contact with or without a condom. However, we know that in many parts of the world sex is coerced. It is a common, albeit tragic, experience for many young women to have their first sexual exposures to be forced upon them at some young age, 10, 11, 12, 13 years old having sex forced upon them by an older relative, or acquaintance, or a school teacher, someone who can force them or entice them in some fashion to coerce them into having sexual exposure. And the unfortunate fact is that many of the women living with HIV, specifically in the ages of 15 and 24 in sub-Saharan Africa is a large fraction of those women who have HIV. In other words, it is a disease of younger women and of a little bit older men. For any particular age group, let's say 15 year old girls in a school compared to the 15 year old boys, there'll be a greater chance that the 15 year old girl will be positive for HIV, and sometimes not because she voluntarily had sexual intercourse. So far as prevention efforts go, we've had ever since the first cases of AIDS, what we now call AIDS, were reported in 1981, soon thereafter it was established that it was a sexually transmitted disease and we've had the means to stop much of the sexual transmission. Simply put, if someone would use a condom for each and every sexual act, almost all the sexually transmitted HIV could be prevented. Therefore the women would not be infected; therefore women who became pregnant, not using these perhaps from time to time, in essence would be not giving birth to infected children. So the important thing is to understand that it doesn't take high technology or mass amounts of money to prevent HIV. It's behavior can be changed, hopefully with some societal changes to change behavior in societies as well as to change behavior in individual lives. If these things occur then HIV can be prevented. Unfortunately, we are far too late in applying ruthlessly the lessons that we've learned. Forty million people are now on this planet with HIV and that's best estimates, in some areas the estimates are underestimates. In any event, the numbers of cases is going to continue to rise and it is a tragedy that it's allowed to happen. Society includes governments. Governments have been notoriously slow in taking any part in HIV detection, prevention, or even discussion. Some areas of the world where HIV was rampant early on denied that there was any HIV when it came to the presidents of some countries. The president in this country in the 1980's was Ronald Reagan, and he never mentioned the word AIDS in public for at least 5 or 6 years into the epidemic. In other words, by about 1986 or 1987, somewhere in there, was his first public utterance of the word AIDS, and it was, you know of course, logical that there would be little funding, no programming and so forth. If the government wouldn't fund these things than who could do it? Well, private agencies in this country, private organizations and groups of individuals did what they could and continue to do what they can, but it would work better if there was more available funds. And it was incorporated government-controlled media, government-controlled school and programs, etc., etc. So I'm like, many people in the world, hopeful that through the UNAIDS program and through other programs, perhaps through large private organizations like the Bill and Melinda Gates Foundation, that this can be remedied around the world, government by government, county by county, village by village. So far as the high tech part of things, we have, in this country, almost everybody who needs HIV medication can get it. However, testing is required. If you don't know you have HIV how in the world do you know you need to take medication for it? So even in this country where every public health department will provide a free test for HIV, upon request and give it to no names involved, totally anonymous, even in that setting only about half of the people who have HIV know they have HIV. Again this is through estimates through public health and other agencies, but the idea is that many people with HIV don't know they have it and therefore are not taking medicines to get themselves better. It also means they are more likely to spread HIV to their sexual contacts or their needle sharing partners. Again, it can be remedied if more people would understand that if they are men are having sex with men, or people who are injecting drugs in their veins, or sexual partners of either one of those groups that that is a risk behavior and therefore they should seek testing. They know they do the behavior therefore they know, or should know, that it's time to do the test. And the problem is of course denial. People are notorious, all of us about denying things that we don't want to face, and of course no one would like to face the fact that they have HIV, and so they put off, and put off, and put off til they've lost a lot of weight, developed fevers and various other infections. But let's say someone now which has gotten a diagnosis of HIV. What should be done? In this country, what should be done next is of course seeking medical attention and having a history taken, physical examination made, blood testing and X-rays made, and an inventory made of exactly what's going on with their health. This includes substance abuse counseling if necessary and sexual contact tracing and so forth. Amongst the things that happens afterward is some assessment of how much virus is in their body. We use the blood level of virus as our marker, although 98 percent of the virus in the body is not in the bloodstream. Still it's a convenient way to access some tissue in the form of blood to monitor how much the virus is there. This gives us an opportunity then when people are taking medication to see if the medication is working effectively. If someone has a viral load of a half million or so it can be brought down to undetectably low levels within a relatively few weeks with effective medication. The other and crucial thing that we do in HIV work is to look at the immune cell count, in particular something called the CD4 cell count. It's a type of lymphocyte that's involved in arranging and monitoring and orchestrating the immune system. The immune system fights off various germs on an everyday basis and in all of us, even in patients who have HIV. But some particular types of germs are more likely to strike people whose immune system is low, and when that of course occurs, we like to obviously intervene as much and as quickly as we can. We like to prevent some of these infections if possible. So patients often will take HIV medications but will also take antibiotics of various forms to head off other infections. And finally when people do present for medical care they may have in fact established infections of varying sorts that need to be dealt with. In this country probably 30 percent of the HIV patients also have Hepatitis C which is a chronic viral infection that can attack the liver and in the conjunction with HIV, the liver suffers damage more quickly with Hepatitis C than it would otherwise. And there are other varieties of infections. In other countries and in certain parts of this country, tuberculosis is one of those infections that many of the people have, perhaps half the people in some countries have had tuberculosis. Most of the time those are what we call subclinical cases. There's no damage to be seen, a few tiny scars on a chest X-ray perhaps, but they've in essence dealt with the infection and are keeping it under check with their immune system. When the immune system fails because of HIV, then the tuberculosis, for example, can emerge and infect their lungs and be spread to other people and can make them quite ill. Roughly half the people with HIV in Africa also have active tuberculosis and also roughly half the people of have active tuberculosis also have HIV. These are rough estimates but the point is that they often coexist. Depending on where one lives, the most common opportunistic infection may vary from tuberculosis in parts of Africa to pneumocystis pneumonia or candidiasis in the United States. Now insofar as how we deal with those issues in this country, again we have perhaps 10, 20, or more pills per day that people have to take in order to deal with some of those who come in far advanced. But what if, for example, their immune system is only moderately suppressed and they're able to take just HIV medicine? In that case we can give them medicines based on what their virus genotype and phenotype tell us. Again, this is a very expensive test, perhaps several hundred dollars, but it will check the virus' genetics to see if it has already become immune to some of the medications. Again, let's say that the medications all could be used in this particular patient because the patient's virus was not genetically modified in any way to be resistant. It could be as simple as taking 2 pills a day. One pill, for example, could have tenofovir and another drug mixed with it, and the other pill could have efavirenze mixed by itself. Eventually these 3 agents will be put together into 1 pill, hopefully in 2006. So in essence very strong, powerful and enduring treatment for HIV could be as simple as 1 pill once a day. However, for people who don't take the medication religiously, for people who skip doses, who run out and don't hurry to get some more, for people who play with it instead of being devoted to taking the medicine properly, resistance is around the corner. And when we talk about that, the virus that has learned to live in harmony with one or more of the drugs that the patient is on, and no longer is the virus held in check, no longer is the viral load undetectable, and eventually in some point in time the medications have to be changed. We've only got a couple of dozens of weapons and we usually use them 3 at a time or 4 at a time and we can't mix everything together in a, without some care as to what mixes with what. So it is of course in the person's best interest to make the first regimen last for years and years if at all possible. Part of our job is to be coaches, to be encouraging the patients to take their medication exactly as prescribed and to deal with the issue of how many pills they have to take and side effects, but not stop the medicine. When people do that, people can remark- have remarkable recoveries. People who have been unable to get off of my examining table because they were so weak, who were severely lacking in blood because of anemia, who had infections of fungus in their mouth, and throat, and esophagus; people who had various bacteria in their bloodstream and intestines; people who have lost 30 pounds, they can get back to work in 6 weeks with the infections that they have under control and the HIV under control. And that exact scenario, in one of my patients was that way for about, starting about 9 years ago. So the point is people can, can do well if they get a diagnosis, if they are adherent to the medical regimen. However, let's talk about most of the world. Remember I said in this country, one of the wealthier countries in the world, we can get the medications for even people who have no money. There are government sponsored programs to provide these medications. However, something like 93 percent of the people in developing countries have no access to the medications at all. They can't get the first pill, and that's a shame. The medicines are available, if the governments of the world would band together and make things easier instead of harder, we could address this whole issue of treatment of already infected individuals. There are some individuals who are not infected and whose lives will be altered of course greatly if they become infected and unfortunately, and fortunately, it doesn't take much from preventing them from having an infection. Those individuals I'm talking about are the babies developing inside the mother's womb. Babies who have not been born yet, but whom, in whom the mother is infected with HIV, have a large chance of becoming infected if they don't take medication. In other words something like 25 percent of babies born to infected women will have HIV unless steps are taken. These steps include taking various pills the mother would take to fight her own HIV, but which in turn is taken primarily to prevent HIV in the baby. In addition, certain delivery techniques can be employed such as Cesarean section. Certain other things can be done post birth to help reduce the chance of the mother will spread the disease by her breast milk to the baby, assuming the baby did not get infected during its passage through the birth canal during the Cesarean section. Point is that there are ways that the babies can be protected and get the risk of infection something like down to 2 percent instead of 25 percent. And I think this is only going to be possible when medications are available. Now luckily enough it doesn't necessarily take many, many medications to help improve this. AZT alone in this country resulted in a marked drop from 25 percent down to about 8 percent, and that was taken just in the relatively short timeframe. Certain other medications can be added to the mixture to make these transmissions to be even more rare events. And of course that's an important thing; the child who is born with HIV has got a very miserable infection, aches, pains, fevers, and so forth. Their immunity is already not fully developed because of being an infant and then further compromised by having HIV. They may well die without treatment, and die early. Other people, such as adults, when they get infected may on average go 10 years before they become as severely immune compromised to be diagnosed as an AIDS patient. Studies have shown almost 10 years to be an average in some men in San Francisco. On the other hand, infants would rarely go that long without having severe problems or death. One of the consequences of having a baby who has HIV is not only that the baby could be ill and die prematurely but that the very fact that the mother had HIV can lead to her early death, and in fact that's the rule rather than the exception around the world. We have, of course, as I mentioned only 7 percent of the people in developing countries having access to medication which means they will die of their HIV complications at a much faster rate than people who have access to the medications. That also has consequences for non-HIV infected children of the same woman. Remembering that only about one-fourth of the children born to an HIV positive woman will have HIV. That means three-fourths will not. It's also possible that a woman who is now positive had children in the time before she was infected. In other words she might have 3 or 4 children who are not infected and then 1 or 2 that are infected. What happens though is that she'll be sick and unable to provide for those children in the way that she would normally like to. It may be that her husband or boyfriend is also HIV positive since that's how she undoubtedly would have gotten HIV in most of the world who have heterosexual contact, that he has been ill and not able to provide for the children. In essence the family will suffer financial losses long before people actually die. Financial problems in many parts of the world will mean that the children who are not infected and whose health otherwise would permit them, they would not be able to go to school and get an education because there will be no one to pay the expenses, the tuition, the uniforms, and so forth. No one can be spared from the household to go to school if they have to care for bedridden relatives or to go out and eek out some sort of living from agriculture. The children will be, in essence, deprived of their opportunity to survive in the world. When the parents or mother in particular, does die, then we have AIDS orphans, and in essence there are millions upon millions of children in this world who are orphans because of AIDS. Their lot is not good. Not only do they have poor education therefore they will be more likely consigned to live a poverty-stricken life. They will have no guidance as to proper behavior, and they may in fact engage in behaviors that may lead them to be infected with HIV. It's certainly possible that a female, for example, sometimes a male child will engage in sexual activity in exchange for food or money, or at least be tempted to if they're otherwise in desperate straits. Sometimes that behavior will lead to their own infection with HIV. The critical thing is to support the children who are infected and to treat them with medications. Children who have treatment can survive. They can in fact thrive. They can gain weight. They can develop emotionally and intellectually. They can be contributing members to society. However, that's requires help. Children are children. They cannot develop their own housing, agriculture, or educational systems. In many parts of the world they can't rely on non-parental adults. Part of the problem is that the adults are infected with HIV to a large extent. In some countries 50 percent of the adults are infected with HIV. Again, the vast majority not getting any medical treatment, they become ill, stop working, and then eventually die. This means that teachers, truck drivers, storekeepers, individuals who are involved with government or police, people who keep the fabric of society intact are absent. The children are left and the occasional grandparents are left and with very few people in between uneffective. It's a recipe for disaster. I think we should all think of those children more than we do. Young women may be coerced into sexual activity, threatened into it in some fashion, physically brutalized. Again if the man has HIV, there is a very high chance that she will become infected. Young girls are perhaps 3 times more likely to become infected from a sexual act than older women. In addition, STDs can be spread.  And when STDs are spread through sexual activity, there will be a greater chance of receiving HIV as well. So for example, a person who has a genital ulcer from Herpes Simplex now has a way of receiving HIV or transmitting HIV different than a normal intact genital area. Other sexually transmitted diseases will affect the person with HIV in a more severe fashion. For example, syphilis may attack that person much more rapidly if they have HIV than if they don't have HIV. The women who have infection with human papillomavirus get cervical cancer with or without HIV at some higher rate than normal. However, those women who have HIV and who become infected with the human papillomavirus will develop cervical cancer at a much faster rate at a much earlier age. The human papillomavirus is fairly common. It causes warts. Warts on fingers, but also warts on the genital area, and in particular warts on the cervix of women who have HIV who lead up to cancer of the cervix.