Light and dark in life and death

BMJ 1996; 312 doi: (Published 24 February 1996) Cite this as: BMJ 1996;312:466
  1. John Roberts

    Athletic prowess represents the rugged, individualistic, can-do attitude that Americans perceive in themselves. Over the past two weeks the sports metaphor has been particularly poignant, showing the best of America and the saddest. Not surprisingly, the catalyst has been AIDS.

    On 6 February, a few minutes into a basketball game between the Los Angeles Lakers and the Golden State Warriors, a man perceived to be dying of HIV walked on to the court and received a wild ovation from the 17000 fans and three million more watching on television.

    In 1991 Magic Johnson, one of the most talented athletes in basketball, retired because he had tested positive for HIV and because of fears that he might infect other players. But this month Johnson stepped on to the court, supported by fellow players, and scored 19 points. There was little talk about his danger to others, and Americans were proud.

    The good news Johnson brought to basketball was reflected elsewhere. The third annual conference on retroviruses and opportunistic infections, a usually arcane meeting in Washington in early February, heard some astounding news. Short term studies showed that protease inhibitors when combined with older drugs such as zidovudine and 3TC virtually eradicated HIV from patients' blood. As one expert noted, this is not only the first real breakthrough in HIV treatment in three years, it may mark the turning of HIV infection from a fatal to a chronic disease.

    Meanwhile Jeff Getty of San Francisco, who two months ago underwent a bone marrow transplant from a baboon, left hospital feeling well. Although no evidence of baboon immune cells was detected, Getty's own CD4 counts had risen despite (or, it is speculated, perhaps because of) the high dose radiation and chemotherapy that he received before the transplant. His doctors plan more experiments as a result.

    But the sports metaphor also had its dark side. “To all my young fans out there, I ask that you no longer consider me a role model,” said heavyweight boxer Tommy Morrison just hours after a blood test confirmed that he was HIV positive. In a tearful interview Morrison said he “blew it” by contracting HIV through numerous sexual liaisons. As a result, he was banned from the bloody sport.

    Morrison's dark news was reflected at the Washington meeting, where, just after the good news about treatment, the problem of money surfaced. The cost of multidrug therapy for HIV infection, now expected to be the norm, will amount to $20000 (pounds sterling13000) a year, and some estimate that the total cost of caring for each infected person will reach $70000 (pounds sterling45000) a year.

    With about 600000 people now infected, annual costs that will begin at $42 billion (pounds sterling27000 million) will grow as more continue to become infected and the disease becomes long term. What's more, doctors fear that HIV infection will follow the pattern in tuberculosis, where drug combinations given too often and in too low doses have created resistance.

    Experts want to set up large trials to determine the best drug combinations, doses, and timing, but AIDS activists are already protesting that control groups in such trials will be deprived of potentially life-saving drugs.

    Indeed, the debates in the HIV community seem to mimic the struggles of sportsmen. Magic Johnson's joyous return to basketball and Tommy Morrison's departure from boxing are only two examples of athletes and HIV.

    Perhaps the most famous is Arthur Ashe, the black tennis star who died of AIDS two years ago. Ashe's grace represented the best of America, and his memory promises to do even more.

    A statue of Ashe is to be erected in his home town of Richmond, Virginia, the home of confederacy and a city filled with icons of generals who fought the civil war to maintain slavery.

    Ashe's memorial represents a closure of an old schism. The return of Magic Johnson may signal the beginning of a new, more realistic perception of HIV infection among Americans.—JOHN ROBERTS, North American editor, BMJ

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