American Journal of Ophthalmology
Volume 129, Issue 1 , Pages 1-8, January 2000

The ophthalmologist and the global impact of the AIDS epidemic LV Edward Jackson Memorial Lecture

Presented at the Joint Meeting of the American Academy of Ophthalmology and the Pan-American Association of Ophthalmology, October 24–27, 1999.

  • Rubens Belfort Jr, MD, PhD

      Affiliations

    • Federal University of São Paulo, Department of Ophthalmology, São Paulo, Brazil
    • Corresponding Author InformationReprint requests to Rubens Belfort, Jr, MD, PhD, Professor of Ophthalmology, Federal University of São Paulo, Department of Ophthalmology, 822 Rua Botucatu, São Paulo, Brazil 04023-062; fax: 55-11-573.4002

Accepted 15 June 1999.

Article Outline

 

Iam grateful to the American Journal of Ophthalmology, the American Academy of Ophthalmology, and especially to those of you who have selected me to give the LV Edward Jackson Memorial Lecture.

An invitation to deliver the Jackson Memorial Lecture is one of the highest honors an ophthalmologist can receive. There are many reasons for this: First, it is a tribute to one of the great ophthalmologists of this century, Dr Edward Jackson; second, the status of the previous lecturers and the excellence of their presentations; and third, the enormous respect that I and the whole world of ophthalmology have for the American Journal of Ophthalmology and the American Academy of Ophthalmology. (See also pp. 9–15.)

Presenting the Jackson Memorial Lecture also provides an opportunity to look back on the history and the memory of Edward Jackson, who was born in 1856 and died in 1942. Dr Jackson was the inventor of the Jackson cross-cylinder and was also the first president of the American Academy of Ophthalmology and Otolaryngology, the father of the American Board of Ophthalmology, and the founder of the present series of the American Journal of Ophthalmology. After Dr Jackson’s death, his friends established this lecture to be presented each year at the Annual Meeting of the American Academy of Ophthalmology and to be published in the American Journal of Ophthalmology.1, 2

Therefore, I am humble and honored to present this lecture.

The invitation to give this lecture honors Brazilian ophthalmology, the Pan-American Association of Ophthalmology, and most particularly the Federal University of São Paulo, which has provided the environment and support for me and my work all these years.

Dr Jackson was a clinician, scientist, writer, organizer, and champion of investing in science and education. He always included himself in major aspects of life and its problems. Because of his special interest in strengthening the concept of ophthalmology as part of medicine and because of his lifelong endeavor to research, I decided to present this lecture on acquired immunodeficiency syndrome (AIDS).

The value of organizing cooperative work between clinicians and scientists and the necessity to extend our workplaces by reaching out to and educating the public, both constant themes in Dr Jackson’s life, are also cornerstones of the fight against AIDS.

This lecture is not supposed to be just another review of ocular involvement in AIDS. Many recent reviews already exist.3, 4, 5 Instead, I want to present some public health and socioeconomic aspects of the AIDS pandemic, the most fascinating battle of medicine against disease and suffering in the twentieth century. There is an emerging global ethics of solidarity in which the best guarantee of public health is a strong societal respect for civil rights.

To begin, I wish to thank three investigators who have contributed immensely to the field and have nurtured me and many others with their knowledge and commitment to science and to the fight against AIDS: Dr Robert B. Nussenblatt from the National Eye Institute, National Institutes of Health; Dr Gary N. Holland from the University of California, Los Angeles; and Dr Cristina Muccioli from the Federal University of São Paulo–Brazil. They are examples to be followed, and this lecture is dedicated to them and to people like them.

AIDS, the end-stage disease of human immunodeficiency virus (HIV) infection, was first identified in 1981,6 and few at that time could have imagined the magnitude of the AIDS pandemic to come and its impact in society.

Since HIV was first identified, more than 47 million people have been infected, 14 million of whom have died. The disease now ranks fourth among the world’s largest killers, after respiratory infections, diarrheal disorders, and tuberculosis. If India, China, and other Asian countries do not take it seriously, the number of infections could reach “a new order of magnitude” in the next 5 years.7

In April 1982, Holland and associates8 published the historic first article describing ocular disorders associated with AIDS. That was the first of thousands of papers. There is no other example in which so many new advances occurred so quickly in medicine.

Human immunodeficiency virus was identified as the probable cause of AIDS by 1984.9 Basic knowledge about the natural history of AIDS had already been established, and medicine had already started progressively to prolong survival and to improve the quality of life for AIDS patients by that time.

In 1985, diagnostic tests for the HIV infection opened the possibility of screening patients and diagnosing the infection many years before the clinical appearance of the clinical disease.

Antiretroviral drugs have been introduced with increasing success since 1987, when the first nucleoside analog, zidovudine,10 became available. From 1987 through September 1998, 37 products had been approved: 12 drugs to treat HIV infection and 25 for the treatment of HIV-related diseases.11

In 1995 the first test to monitor HIV levels in the blood became available,12 which was another important breakthrough; instead of just measuring the body’s response to infection, medicine was now able to directly assess the amount of infectious particles in the blood and directly evaluate the viral load. This ability was also of paramount importance in clinical trials because the action of drugs could now be directly evaluated and conclusions of the studies obtained much sooner.

Also in 1995, the first protease inhibitor was introduced and the “cocktail” of nucleoside analog with protease inhibitors generally known as highly active antiretroviral therapy (HAART) came into wide use. The results of antiretroviral therapy became even better when non-nucleoside analogs were developed and added to the therapy.15, 16 These therapies created a revolution in the treatment of HIV disease.13, 14 It took 15 years of research, but finally the control of HIV replication was possible, which offered the best chances for survival and a productive life.

Highly active antiretroviral therapy prolongs life, reduces opportunistic infections, and has led to the apparent cure of, until then, untreatable diseases.14, 17, 18, 19 Long-term remission of chronic infections, such as cytomegalovirus disease was finally obtained, and specific drugs targeted against those infections could be suspended.17, 20 In rich countries, AIDS is no longer a death sentence. Expensive drugs keep HIV-positive patients alive and healthy, perhaps indefinitely. In developing countries, by contrast, the disease is continuing to spread like nerve gas in a gentle breeze. The poor cannot afford to spend $10,000 a year on these wonder pills. Millions of Africans are dying. For many poor countries, there is no greater or more immediate threat to public health and economic growth.

In the beginning, HAART was also expected to eradicate HIV from the host. It was shown later that HIV eradication is not possible, although the suppression of HIV replication results in dramatic decreases of the plasma viremia.18, 21 With HAART, there is initially an increase in both naive CD4+ and CD8+ T-lymphocytes and a redistribution of the remaining lymphocytes, including B cells. It is usually only after 3 to 6 months that one sees a slow second phase in which there is an increase in the number of naive CD4 and CD8 phenotypes, and the consequent normalization of the immune response occurs.18, 19, 22 There is indeed an improvement in host responses and a reduction of opportunistic, secondary infections. Nevertheless, restoration of the immune system is partial, and there is a possibility that clones will be lost forever with consequent “fractures” and “holes” in the immune response, with specific defects.19

Unfortunately, virus resistance and mutations occur, and the control of HIV viremia by HAART fails in as many as 40% of patients.23 The massive decrease in morbidity and mortality suggests that HAART may sustain its beneficial effect, even without efficient suppression of the virus.14, 24

Adherence to HAART is difficult because the drug regimens are highly complex. Many patients are homeless and lack the support provided in clinical trials to ensure adherence. Patients have to be committed and organized. Missing doses frequently leads to virus resistance.24, 25 Side effects are many, including nausea, diarrhea, headache, neuropathy, hepatitis, and vascular and metabolic changes, such as diabetes and elevated lipid levels.12, 18, 26, 27

In 1996, for the first time in history, mortality and morbidity related to AIDS declined everywhere that HAART was being used.14, 18, 28 Hospitalization decreased up to 80%, and there was a reduction of ophthalmic involvement by 50% to 70%.29, 30, 31

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Ocular impact 

Since the first cases of AIDS were reported, the importance of ocular involvement became evident because a large group of patients have been seen with blinding infections.3, 32, 33, 34 Also, for a whole generation of ophthalmologists, especially for those dealing with infectious diseases, uveitis, and retinitis, the impact was profound. Nothing was known about AIDS in the beginning, including its mode of transmission. Patients were discriminated against. Physicians, technicians, and nurses were scared. Gowns, masks, and gloves were used during eye examinations, and even shaking hands with patients was avoided by some. It took many years until the risk of transmission was finally assessed, and the Centers for Disease Control and Prevention established rational universal precautions to prevent spread of many infectious agents.35, 36

Classically the ophthalmic manifestations of HIV disease cover almost all parts of ophthalmology and belong to the following four major groups: microvasculopathy, opportunistic infections, neoplasms, and neuro-ophthalmic disorders.3, 36, 37, 38, 39, 40 Patients may also have iatrogenic disorders develop.

Studies of the ocular complications of HIV disease in underdeveloped countries are only beginning to appear but suggest that cytomegalovirus retinitis is less frequent than observed in the Western industrialized countries; in contrast, other ocular opportunistic infections, such as toxoplasmosis and tuberculosis, affect 2% to 10% of patients with AIDS in these areas of the world.41 The reasons for such an altered spectrum of ocular disease in developing countries are almost assuredly related both to poorer medical care with subsequent patient death at higher CD4+ T-lymphocyte counts and to higher rates of endemic exposure to the agents responsible for toxoplasmosis and tuberculosis.

Human immunodeficiency virus infection is the strongest known risk factor for tuberculosis in the United Kingdom both within the general population and within specific minority groups.42 Tuberculosis accounted for 27% of initial problems in black Africans with AIDS in London compared with 5% in non-Africans.43 Tuberculosis is the major opportunistic infection associated with AIDS in many parts of the world, including India,44 Brazil,40 and Africa, where in Abidjan, for example, 35% of tuberculosis in adults is related to HIV infection.45

Unfortunately, the field of medicine has not advanced in the development of noninvasive diagnostic tests for intraocular infections, and the clinical picture is still fundamental for making diagnoses. In special cases, intraocular biopsies are necessary to differentiate between the infectious agents and intraocular tumors.46

Another example of HIV-associated disease that has an important geographic variation is conjunctival squamous cell carcinoma. In recent years an increasing rate of conjunctival squamous cell carcinoma has been noted in Rwanda, Uganda, and Malawi, as well as in Brazil,47, 48 with a strong association with HIV infection. Ultraviolet light has previously been implicated as the major risk factor for these tumors, which have been more common in equatorial Africa than in Europe or North America. The added importance of HIV infection is now becoming clear.

The prevailing ocular manifestations of conjunctival squamous cell carcinoma differ in some developing countries. These differences most likely result from different socioeconomic conditions and basic health care availability and from different patterns of endemic disease present before the HIV epidemic.49 Conjunctival squamous cell carcinoma and intraepithelial neoplasia in HIV-infected patients show similar clinical characteristics to those reported in immunocompetent persons but occur in a younger age group and the tumors are more aggressive.50

Recently the role of human papillomavirus as a cofactor has also been studied because of its relation with anal and cervical carcinoma in patients with HIV infection in some countries.48

I will briefly discuss the three typical HIV-related ocular infections: cytomegalovirus retinitis,32 varicella-zoster virus retinitis,34 and ocular toxoplasmosis.33

Cytomegalovirus retinitis is the most common ocular infection and is the leading cause of blindness in patients with AIDS.32, 51 The CD4+ T-lymphocyte count, until recently, provided a reliable predictor of the risk of ocular complications.52, 53 With HAART, though, the epidemiologic and clinical features, as well as the natural history and the therapy for cytomegalovirus retinitis, have changed.54, 55 In many cases HAART cures the cytomegalovirus retinitis, and patients receiving these drugs may be protected even at lower CD4+ T-lymphocyte levels. Unfortunately, approximately 90% of the world’s AIDS population has no access to HAART and therefore continues to present the classic, brutal ocular impact.56

Several approved systemic and local treatments for cytomegalovirus retinitis are now available, but we also know that none of them is completely satisfactory.5, 32, 55 Without HAART, cytomegalovirus retinitis requires lifelong treatment with high cost, inconvenience, and the potential for severe side effects.57, 58 Intravenously administered drugs have been the mainstay of therapy, but local therapy is also available. It began with intraocular injections of ganciclovir and foscarnet and was followed by the introduction of the ganciclovir intraocular implant that confers longer retinitis inactivity.58 However, the high cost and ocular complications make it unavailable for most patients. These are also the disadvantages of fomivirsen, a member of a new breed of DNA drugs called antisense drugs, which was approved for intravitreal injection59 in August 1998. Fortunately, most of the patients that respond to HAART do not have to continue receiving specific medication against the cytomegalovirus infection for life because immune reconstitution usually protects them against relapses.17

It must remain clear that even with HAART, cytomegalovirus retinitis will not disappear and therefore much more research is necessary. However, in Africa (where 65% of the world’s HIV-infected population lives) cytomegalovirus retinitis occurs in less than 5% of patients even in the absence of HAART, and we do not know the reasons why. It may be at least partially because patients die of other diseases at higher CD4+ T-lymphocyte levels.60

Herpes zoster seems to be one of the more important and dramatic ocular infections associated with HIV disease in Africa.38 Clinically, the varicella-zoster virus may cause different diseases. Besides the classic picture of herpes zoster ophthalmicus, it has two other clinical forms: acute retinal necrosis syndrome, a necrotizing retinitis that responds well to antiherpetic medication and can occur at any CD4+ T-lymphocyte count, and progressive outer retinal necrosis syndrome, which is associated with low CD4+ T-lymphocyte counts.33

Ocular toxoplasmosis, which affects up to 8.5% of patients with AIDS in Brazil, is the third example I wish to discuss.47 In contrast to the disease seen in HIV-negative patients, toxoplasmic retinitis in patients with AIDS may be focal or diffuse and be active in one or both eyes. The CD4+ T-lymphocyte count is usually not as low as observed with cytomegalovirus retinitis.61 Toxoplasmosis is an example of a disease in which the economic market for effective therapies in developed countries is small. Possibly for that reason, no new drugs have been tested, and nothing substantial has changed with regard to treatment. The almost half-century-old treatment using pyrimethamine and sulfadiazine is still the standard therapy.62

New ocular syndromes have been described recently in patients with preexisting intraocular infections who are successfully treated with HAART. They are associated with immune recovery because they typically appear after a substantial increase in CD4+ T-lymphocyte counts.54, 63, 64 These eyes have higher number of vitreous inflammatory cells, even when the ocular infection has been clinically inactive for many months. Cystoid macular edema, papillitis, and epiretinal membranes, sometimes as isolated findings, can also be present, as can anterior uveitis.65, 66 Some of the patients may respond to corticosteroid treatment with a reduction in inflammation, but in some cases with only partial improvement of macular edema.54

We have also seen an important group of patients who have minimal inflammatory reaction and loss of vision develop with retinal vascular changes and macular edema that does not respond to corticosteroids. Some of these cases may be related to the known vascular and metabolic side effects of HAART itself.18

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The global situation 

Unfortunately, most patients with AIDS are still receiving the medical treatment that was available in the 1980s, long before even zidovudine was available. The numbers are striking. Since the early 1980s, more than 40 million individuals have contracted HIV and 12 million have died, leaving more than 8 million orphans.56, 58 There are now 30 million people with AIDS: 800,000 in North America, 1.6 million in Latin America, half a million in Europe, 21 million in Africa, and 5.5 million in Asia.56, 67 Asia is the next disaster-in-waiting. A recent study in Tamil Nadu found more than 2% of rural people to be HIV positive: 500,000 people in one of India’s smallest states. Because 10% had other sexually transmitted diseases, the avenue for further infections is clearly open. A survey of women with sexually transmitted diseases in Poona, in Maharashtra, found that more than 90% had never had sex with anyone but their husbands and yet 13.6% were HIV infected. China is not far behind.7 In 1997 alone, 6 million people, or 16,000 a day, or 11 per minute acquired HIV, a preventable disease, and 2.3 million died, including 460,000 children.56, 67

Although more than 90% of HIV-infected people live in developing nations, well over 90% of the money for care and prevention is spent in industrialized countries.60, 67 No one knows what AIDS will do to the economies of poor countries, although there is a world of difference between the rich West and developing countries in regard to number of patients and availability and accessibility of care. Moreover, in developing countries the inferior socioeconomic position of women and children substantially impairs effective care programs. Drugs against HIV and against opportunistic infections and means of palliative care are not available and cannot be afforded in these countries. Local initiatives to improve this situation can only succeed given an infrastructure for the care that is supported by the authorities, so that continuity is guaranteed. Structural cooperation between these authorities and international bodies and large-scale support by Western foreign aid services are indispensable.7

Little research has been done on the effects of AIDS on private business, but the anecdotal evidence is frightening. In some countries, firms have had to limit the number of days employees may take off to attend funerals. Zambia is suffering power shortages because so many engineers have died. Farmers in Zimbabwe are finding it hard to irrigate their fields because the brass fittings on their water pipes are stolen for coffin handles.

There are many gaps in AIDS, and the last years have seen the gaps widen28: the gap between what can be done and what is being done; the gap between knowledge and action; the gap between scientific clinical trials and the real life of the communities; and the gap between efficacy and effectiveness. One of our most important goals is to reduce these gaps. Consider the bridge between science and profit. Is science for public health to save lives and sight, or is science for the stock market? It is time to eradicate the “aparth-aids.”68, 69

In the last 3 years, 27 countries have seen HIV infection rates more than double. In Asia a doubling of infections has occurred in almost every country. In several Eastern European countries the increase has been six-fold.69 There are an estimated 100,000 intravenous drug users in Moscow. Russia also has all of the ingredients for a severe HIV epidemic, with more than 800,000 HIV-infected people in 2 years.70 Projections show that by the year 2005 there will be 70 million infected people in the world. Asia may have as many cases as Africa.71 Again, it will be too late when the visible cases start to increase.

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The control of the pandemic and socioeconomic aspects 

We must not be fooled. There is no treatment yet for HIV infection or for most of its associated opportunistic diseases for more than 90% of the world’s patients with AIDS. Chances are that most will die without receiving any of the advances that have occurred in medicine in the last 15 years. Only prevention and, perhaps someday, a vaccine are likely to make a difference. The best hope for halting the epidemics is an inexpensive vaccine. Efforts are under way, but a vaccine for a virus that mutates as rapidly as HIV will be difficult and expensive to develop. At present, there is no proof that even efficient vaccination against HIV will ever be possible. The trials will take several years, and it will probably not bring full protection.72 For poor countries, the only practical course is to concentrate on prevention.

With no vaccine in sight, behavioral changes remain the best way to limit transmission. Prevention is a less exciting topic than wonder drugs or vaccines. Yet effective behavioral and policy intervention are the best available tools. The need to develop more effective behavioral interventions is urgent. The global prevention strategy for AIDS, as for many diseases, is based on human rights73 because groups whose human rights are less respected are the most affected everywhere. The most vulnerable are the poor, young children, and women.68 Women in most of the world, for instance, lack the power to insist on the use of condoms and other safe-sex practices.

Myths abound. Some young African women believe that without regular infusions of sperm, they will not grow up to be beautiful. Ugandan men use this myth to seduce schoolgirls. In much of southern Africa, HIV-infected men believe that they can rid themselves of the virus by passing it on to a virgin.7

The guarantee of universal access to assistance, including specific medications and prevention, are ethical and political principles. Good examples have been learned in sexual education. There are many points to approach and change. For instance, many people believe that condoms make sex less enjoyable, and some Christian and Islamic groups are against it because they view condom use as encouragement of promiscuity. Alcohol consumption is also a worldwide problem, because intoxicated people are less likely to remember to use condoms.7

Because celibacy is not followed by most people, public health policies focus on safe sexual practices, notably condom use.68, 74 They work. Frank presentation of sexually oriented materials and availability of condoms, even for young teenagers, have shown to promote safer sex, decrease rates of infection, and even delay sexual activity among youngsters, with a tendency to have fewer sex partners.75 Social marketing programs have been shown to work in more than 60 countries.67 The situation is even more complex and difficult, however. Not only do cultural and political aspects have to be accessed but the most difficult is probably the economic aspect.76, 77, 78

Many noncommunicable diseases are set to increase dramatically during the twenty-first century. In particular, the prevalence of diabetes mellitus may double from 124 million people worldwide in 1997 to 220 million by 2010.79 Regions with the greatest potential increases will be Asia and Africa, precisely the areas with the greatest potential increases in the prevalence of HIV infection and AIDS.79 The population in many countries will increase at a slower rate because of the HIV epidemic. South Africa’s annual growth rate, which was 1.9% in 1995, is expected to decrease to 0.3% in 2010. Without HIV it would be 1.5%. The age-adjusted prevalence of type 2 diabetes will increase from 1.7% to 3.7%, by 2010. When the effect of HIV on population growth is calculated, this number of diabetes cases will have a 3% reduction.79 The toll of HIV on mortality, population loss, and diabetes prevalence may even be greater elsewhere in Africa.79 This fact highlights the need to adjust for the impact of HIV when projecting the prevalence of chronic diseases and national health budgets into the next century.

Because most of the cost for HIV disease has been related to opportunistic diseases and hospitalization, several reports have documented decreased costs since HAART was introduced. Although promising, this situation may represent a short-term cost deferral rather than a lifetime cost avoidance.77 The cost-effectiveness of the different treatments has to be determined.78

A matter of great controversy is whether to use HAART in developing countries. Anti-HIV drug costs are currently less than 1% of the gross national product for almost all Latin American countries. In Haiti, it would cost 18% of the gross national product. It is probable that costs will decline with time and wider use. For instance, the cost of making triple-drug anti-HIV therapy available in Latin America may be quite substantial but not outside the financial resources of many countries.80 Brazil has done so since 1997 with excellent results.

Although the United States is still far from guaranteeing universal access to HIV treatments to its residents, the situation there pales compared with that in the developing world. The drugs that have extended the lives of so many Americans are simply unavailable in most other countries. To the extent that they can be found at all, they are generally priced at levels similar to those in the United States despite the fact that average incomes in Africa are a fraction of American wages.

Drug prices are so high because the pharmaceutical companies that develop and market the drugs retain patents to them, with an exclusive right to produce and sell the protected drug for a period of 20 years. In recognition that this patent protection system might result in a grave unavailability of lifesaving medications, a set of measures that allows the protections to be overridden in emergencies has been codified in international law.

The costs of HIV medications in the developing world could fall 50% to 90% if local firms were allowed to produce them. Because so few expensive antiretroviral drugs are currently being sold in poor nations, compulsory licensing would not represent any significant loss in profits to the pharmaceutical companies. The drug companies may be worried that lower prices abroad would generate increased pressure for them to bring down costs for the United States and European markets. They may fear in particular that a global black market would develop for the inexpensive licensed drugs.

Two countries have attempted to bring HIV treatments to affordable levels by means of compulsory licensing, but stiff American opposition has blocked these efforts. Thailand once considered issuing a compulsory license for the antifungal drug fluconazole, but United States trade sanctions forced the country to abandon its plans. Today, fluconazole remains out of reach for most of the estimated 135,000 to 180,000 Thais who suffer from AIDS-related cryptococcal meningitis. Barriers to treatment for the 1 million Thais with HIV disease has increased. The government, financially pinched by economic recession, has removed zidovudine and didanosine from its list of subsidized medicines while dismissing activists’ demands for compulsory licensing. The United States again imposed trade sanctions when South Africa tried to codify the principles of compulsory licensure in a revision of its national Medicines Act.81

What will the future bring? Lack of respect for the poor and ignorant. The burden of care will increase enormously, with more people receiving more complex therapy and for a longer time. Much more research will be required. The epidemic will continue to increase with the development of new treatments and their use in underdeveloped countries and larger groups of patients will live longer and present chronic diseases including those in the eye. The already small number of ophthalmologists in Africa and Asia will continue to be insufficient, and society will have to develop new ways to approach this increasing shortage because of a much larger population of patients who will be living longer and requiring immediate attention. Explosive epidemics will probably occur in Asia, southern Africa, and China. Russia is at high risk.

As terrible as these warnings sound, more terrible is HIV disease as a piece of a larger health problem. How can countries decide among the use of funds? What priorities should be funded? What are the best interventions? Should the reasonable expenses be the same for each country? Should they change? According to what? The gross national product? Should the gross national product be related to what society is willing or can afford to spend for a citizen’s life or sight? The ethical dilemma so vivid in the AIDS epidemic is part of daily medicine.82 It is up to the society to decide. Let us fight for a field of medicine that is aimed more and more at most patients and not at the economic market or just at those who can afford the new treatments.

What will the future bring for the ophthalmologists? Both in countries that can afford and those that cannot afford anti-HIV drugs and modern therapy, the world demand for ophthalmologic care will continue to increase with a great number of patients requiring specific and expensive treatments. We must be able to educate the public, other physicians, and ophthalmologists and to develop systems able to provide highly efficient, low-cost eye care to HIV-infected patients the world over. It is an enormous challenge for the next generation.

Let us hope our national and international medical organizations will be present in the battle, helping society to decide how to have the best medicine. Let us hope physicians remain visible, reliable, respected as leaders, and politically powerful because this process will save more lives than could any single physician in the world working in a hospital or office. We became physicians to fight death and disease efficiently. Ophthalmologists are dedicated to make all people see well. Let us live knowing we are doing our best to make people see, see well, and also see well what to do.

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Acknowledgements 

I thank Dr Philippe Kestelyn and Dr Susan Lewallen, both of whom have worked with HIV-infected patients in Africa, for providing information during the preparation of this article.

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American Journal of Ophthalmology
Volume 129, Issue 1 , Pages 1-8, January 2000

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