<p>Photo: An AIDS patient's weekly dose of testosterone</p>

Washington, D.C., artist and AIDS patient W. Maxwell Lawton gives himself a weekly testosterone injection and takes a plethora of prescription pills. Though fighting the disease was "a full time job," Lawton lived more than a decade longer than doctors predicted. He died in 2006.

Photograph by Karen Kasmauski

Written by Michael Klesius

Republished from the pages of National Geographic magazine

On a sweltering morning last February, a stray dog lay panting in the doorway of Clinic 17 of the Bangkok Vaccine Evaluation Group. Inside, the drone of an air conditioner filled an upstairs room where a handful of Thai nurses bustled around a 37-year-old heroin addict on an examination table. Injections had so scarred the veins in his arms that the nurses had turned him onto his stomach to draw blood from a vessel in the back of his knee. As the dark liquid trickled into the syringe the man smiled, baring gray teeth.

"This is going to be very beneficial for society," he said.

Or so he hopes. His blood, drawn and tested twice a year, is contributing to the worldwide search for a possible preventive vaccine for HIV, the virus that causes the disease AIDS.

Some 2,500 injecting drug users in Thailand, like the man at Clinic 17, have enrolled in a trial of the first potential HIV vaccine to reach the third and final stage of clinical testing. By the beginning of last year the Thai participants were part of a group of almost 8,000 people in Thailand, Europe, and North America—all at high risk for HIV but all HIV-negative at the start of three-year trials—who volunteered to receive either injections of the vaccine, called AIDSVAX, or a placebo, without knowing which they would be given.

In high-risk groups a predictable percentage of participants—from 1.5 to 6 a year, depending on sexual or drug habits—would be expected to become infected with HIV over the course of a trial, even with thorough counseling in risk reduction. To determine if AIDSVAX might lower the percentage, follow-up blood testing takes place at six-month intervals. If the vaccine group shows a lower infection rate than the placebo group, there is evidence that the vaccine is working. But we won't know for certain until the end of the year, when we have results from the first trials, begun in 1998-99, in Europe and North America.

What we do know is that more than 36 million people worldwide carry HIV, although 95 percent of them are never officially diagnosed HIV-positive. Every 24 hours 15,000 more become infected with the virus, while 8,000 others die of the resultant AIDS. And we know that AIDS victims suffer merciless deaths when their disabled immune systems allow otherwise treatable ailments to become fatal.

As I traveled from orphanages in Africa to hospices in Russia to clinics in Thailand, I saw the tortured face of AIDS. It grimaced with the pain of fever and nausea. It gasped with fluid-filled lungs. It wore huge, open sores that emerged from deep in the throat and spread over the lips, neck, and torso. In advanced stages of the disease, the central nervous system can begin to deteriorate, leaving some victims powerless even to close their eyes and mouths. Nerve endings in the extremities go numb or tingle as if pricked by thousands of needles. AIDS robs the brain of its cognitive functions, leaving patients raving with dementia. It saps the body's protein, wasting muscles to the bone. Draped in nothing but skin, 20-year-olds look 70. Even then the release of death can lie weeks or months away.

Three million people died of AIDS in 2000. As the pandemic grows, it forces the world to see what it may not want to see: That diseases arising among specific populations—prostitutes (known to HIV/AIDS specialists as "sex workers") and their customers, drug users, and gay men—can flare into greater pandemics. That women in the developing world have little leverage to negotiate safe sex with their partners and are often abused for trying. That poverty, more than any single factor, drives the spread of AIDS by forcing young people into sex work or, as in Eastern Europe, leading them to the trap of injecting drugs. And that rich nations are often insensitive to the health problems of impoverished ones. Ninety-four out of every hundred HIV-infected people live in developing nations, where currently available drug therapies are largely unaffordable. While such medicines do not prevent infection, they do lower the level of virus in the body and may, according to some experts, thus reduce transmission rates. Many public health officials say that the drugs coupled with prevention programs in developing nations could slow the pace of the pandemic.

Debate over social and economic issues surrounding AIDS lay years away when the U.S. Centers for Disease Control and Prevention (CDC) sounded the first alarm in June 1981. That month the agency issued a warning about an unusual cellular-immune dysfunction found in "five previously healthy individuals without a clinically apparent underlying immunodeficiency," and a year later the term AIDS was coined. As the disease took on the dimensions of a plague, it swept away notions that great pandemics belong to history. It added to the understanding that an exotic family of viruses called retroviruses, more commonly seen in animals, could infect humans and cause disease. And it confirmed growing data that viruses could cause cancer in humans.

Some 20 years later "we know more about HIV than we know about any microbe ever studied," says Robert Gallo, who headed the National Institutes of Health (NIH) team that contributed to the discovery of HIV in 1984. But we still don't understand exactly how the virus causes disease.

HIV seems full of contradictions. It can overwhelm the human immune system, yet the virus itself is fragile. Cold viruses linger on hands, and sometimes for days on doorknobs, but fresh air dries and destabilizes HIV in hours or even minutes. Contact with rubbing alcohol or chlorinated water quickly renders it inactive. Simple bar soap neutralizes HIV by breaking the chemical bonds of its lipids, or fats. And because so few cases of oral transmission have been documented, doctors conclude that the same antiviral compounds in saliva and stomach acids that protect us from a host of germs prove very effective against HIV in low concentrations.

Once a person is infected with HIV, however, the virus attacks the very immune cells, called T cells, meant to fight it. "Think about trying to invade a fortress," said Gary Nabel, director of NIH's Vaccine Research Center. "Would you start by setting off a grenade in front? No. You would sneak in quietly, penetrate the nucleus, and sit there. You'd clone yourself. You'd make lots of copies. Then, when an opportune occasion came along, when there was a lot of commotion and people were distracted, you'd say, 'Boom! Here I go.'

"That's what HIV does. That's what has allowed it to become so successful from its perspective and so tragic from ours," said Nabel. During a period of typically eight to ten years HIV lurks in the body, mutating rapidly and thus avoiding recognition. It reproduces massively, and waits. Finally, at the introduction of a disease that an unimpaired immune system would normally control—tuberculosis or pneumonia, for example—the immune system is overcome by HIV so that it cannot fight, and the disease kills.

"Nineteen ninety-six was the year the thunder came," Igor Ivanov said, and "the Russians heard it, and they crossed themselves."

Ivanov, a doctor at the Kaliningrad Regional Infectional Hospital, was referring to the year HIV cut loose in Russia amid the chaos of a collapsing economy. Unemployment shot up, and with it alcoholism and crime. Drug dealers began to create a heroin market in Russia. Through shared needles, HIV reached far beyond its African origins into a country that during Soviet times had tightly controlled what crossed its borders.

"I got HIV by using a friend's syringe," said Dennis, 22, a patient at the Anti-AIDS Center in the Kaliningrad hospital. "I was 14 when I started shooting. I had no idea of the risks. It was cool. It was in fashion." Dennis stood tall with broad shoulders and red hair. He wasn't sick yet but claimed he had been suffering chest pains. "Now my friends are gone," he continued. "They don't want to shake my hand. My only friends now are HIV-positives."

"We knew we were on the edge in 1995," said Tatiana Nikitina, chief doctor at the Anti-AIDS Center. The region already suffered Russia's highest rates of syphilis and hepatitis. Prostitution, common to many port cities, complicated the picture. "AIDS started to spread not only among men but among women too, as drugs and prostitution are linked," said Nikitina. "It's all connected to the period when the free market made many things available for the first time, including drugs."

If 1996 brought AIDS to Russia, the same year saw the advent in the West of protease inhibitors, drugs that suppress the ability of HIV to replicate.

But protease inhibitors, often combined with other HIV drugs such as AZT, are far from prevention or cure. Their effects lift the death sentence of an HIV infection only for a time. Furthermore, they cost as much as $15,000 a year, with huge drug-company profit margins, making them affordable in the U.S. and Europe but generally out of reach in developing nations.

In 1998 the Brazilian government began to produce and distribute copies of brand-name AIDS drugs using loopholes in international trade patents held by American and European pharmaceutical companies. Brazil's model has cut the death rate from AIDS in that country by half and stabilized the growth rate for new infections. Recent World Trade Organization negotiations pointed toward increased low-cost availability of AIDS drugs in other developing nations.

While drug therapy results are promising, the use of protease inhibitors and other antivirals, such as AZT, can produce grave side effects that include nausea, bone loss, diabetes, liver damage, raised cholesterol levels, and depression. And doctors do not yet understand why HIV drugs rearrange fat in the body. The face becomes sunken and the limbs wizened while fat piles up elsewhere. To see the bulging belly and the humped back of a patient who has taken antivirals for several years only underscores the need to find another way to inhibit HIV.

"Historically vaccines are the only way to stop an epidemic," said Dr. Peggy Johnston, assistant director for AIDS vaccines at NIH. "But while a vaccine used as a public health tool might slow an epidemic or prevent one from starting, so far vaccines have not helped sick people."

Lusaka, Zambia, is a city where the worst-case AIDS scenario is coming true—HIV has infected one in three adults. There I met Evans Ganzini Banda, a clean-cut Zambian in his late 20s. Not long ago Banda became one of 650,000 people to have lost both parents to AIDS in this country where, like many countries in sub-Saharan Africa, widespread prostitution and multiple sexual partners are common.

Faced with the expense of supporting five sisters, Banda founded a newspaper called Trend Setters, which prints frank articles about the risks of HIV and other sexually transmitted diseases. As further illustration of Lusaka's plight, he ushered me into a taxi one Saturday night for a very uncomfortable exercise.

"The nightclubs are where AIDS is happening," he said as we toured the city.

We pulled up in front of one such club, a cinder-block structure with a corrugated steel roof. A group of teenage girls clustered at the car window. One of them, a gangly adolescent in beat-up high heels and a miniskirt, introduced herself as Adrina and slid into the car.

"How much?" asked Banda.

"It depends on what you want."

He told her.

"Thirty thousand kwacha [about ten U.S. dollars]," she said. "With condom."

"How much without?" asked Banda.

She shook her head.

"Why not?" he asked.

"AIDS," she said.

Banda pressed: "OK, 60,000 kwacha, without condom. "

She hesitated, then answered: "A hundred thousand, without."

Banda looked at me. We had found the value of a life here—about $33.

We told Adrina we were actually taking a survey and asked her why she would risk her life. She said she had no other way to make money for the coming week. She was trying to save $125 to start a business selling secondhand clothes imported from the U.K. In the meantime she had one commodity to sell.

We gave her some money, about twice what she could have expected from a typical customer. Banda implored her to go home. She climbed out of the car counting the cash, leaving us pessimistic about her chances.

On a rainy winter day on the NIH campus back in the U.S., the Vaccine Research Center's Gary Nabel summed it up thus: "The problems of the developing world are our problems too. We're already dealing with more than 36 million incubators walking around with this virus, spreading it to other people. And it's got enormous abilities for adapting to new niches."

Clearly, what causes AIDS and what causes an AIDS pandemic are two very different, intractable problems. But the words I'd heard about vaccines from Peggy Johnston at NIH rang true. A future vaccine will not cure Dennis, already infected with HIV, and offers little hope for Adrina or the Thai man at Clinic 17, in danger of becoming infected soon. But a vaccine might someday make a difference for people like them, for their countries, for the world. Until that day arrives, the AIDS crisis will continue to rampage through developing nations with unpredictable consequences for the future of all humankind.

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