Jan Albert: “HIV is an infectious disease like any other”

Text: Cecilia Odlind, photo: Martin Stenmark. First published in Swedish in Medicinsk Vetenskap, No 4/2018.

In the early 1980s, the first cases of AIDS were reported in the media. In those days, contracting HIV was a death sentence. Knowledge of the virus was very limited. Around the same time, in 1985, the newly certified doctor Jan Albert happened to end up at what is now the Public Health Agency of Sweden to complete part of his specialist training. He was one of the people who started investigating HIV and AIDS.

“In terms of research, it was pioneering work, since there was so much we didn’t know and at the same time, the consequences were dire and attracted a lot of attention. I also worked for some time at Roslagstull Hospital, where I had the difficult task of caring for some of those the first HIV patients who died, and there was nothing we could do. Those experiences have stayed with me. The patient and the person behind the samples and the research is always what matters,” says Jan Albert. The outlook for those who contract HIV has changed dramatically since then, thanks to the research.

Today, the HIV infection entails lifelong drug treatment, but otherwise the infected person can go about their life like most other people. Jan Albert has primarily looked at how the virus functions and how it changes over time. An inherent characteristic of the HIV virus is that it is constantly changing. This is an important reason for why there is still no vaccine. It also explains why it took so long to discover an effective treatment: Each time the virus changed, it evaded the treatment and developed resistance.

Several different drugs

The current treatment consists of a combination of several different drugs, usually three different kinds. The virus remains in the body, but the treatment prevents the production of new virus particles. The fact that the virus changes so often also means that each individual patient has a unique virus variant.

“It’s like a fingerprint. By investigating the genome of the virus, we can monitor its current and past spread,” says Jan Albert.

One important question is how many people there are in Sweden carrying the virus without knowing it. Why is it that some people are not diagnosed? They are an important group, as they are not receiving treatment and therefore risk infecting others and spreading the virus unwittingly.

“The aim of our research is to find out when the infection was transmitted, which gives us information about how long the person has been among the undiagnosed cases. We also try to estimate how many individuals are in this group,” says Jan Albert.

By finding out more about these individuals, the researchers are trying to understand why they have not been diagnosed. Hopefully, this will help to find them to offer treatment. Mapping the spread of the virus in this way is called molecular epidemiology, and according to Jan Albert, it is an underused tool in limiting the epidemic.

“But in order to trace these individuals to a higher extent, we need attitudes to change in society and in the legal system; to start viewing HIV as an infectious disease like any other,” says Jan Albert.

Jan Albert's current research also investigates a significantly lesser known virus, enterovirus D68. “On two separate occasions, in 2014 and in 2016, this virus has caused large global outbreaks of respiratory infections. But in a small number of individuals, it has led to polio-like paralysis and also to death,” says Jan Albert.

The spread and evolution of the virus

In order to understand the spread and evolution of the virus, the research group uses techniques similar to the ones they have developed in their HIV research. Another area that Jan Albert is part of developing together with researchers at the research center SciLifeLab is diagnostics.

“Today, doctors order certain tests based on the illness they suspect. But future methodology, so-called metagenomics, will allow us to get all the information from a single test. This increases the possibility of arriving at the right diagnosis, for example in cases where you suspect an infectious disease but are unable to determine which one. Using this new diagnostics, we will have the answer right away,” says Jan Albert.

He enjoys doing research closely associated with clinical reality. The fact that Jan Albert is concerned with the patients’ situation is also clear from his active involvement in the public debate on several important issues surrounding HIV, for example how it is transmitted during sex. Today, there is well-documented evidence that the risk of transmission during effective HIV treatment is non-existent. The awareness that it is safe to have unprotected sex as long as you are taking your medications has emerged gradually, but already in 2011, there was a study showing such unambiguous results in this regard that it had to be prematurely interrupted for ethical reasons.

“In the same year, this discovery was named Breakthrough of the Year in Science magazine. This summer, another study was presented which showed that the risk of infection is as close to zero as is possible. And yet this is not a very well-known fact among the general public,” says Jan Albert.

Did not contract the disease

And even though this is known, it is not clear what responsibilities a person infected with HIV has. Recently, there was a case that went all the way to the Supreme Court, where a person receiving correct treatment had had sex with another person without disclosing his/her status. The other person did not contract the disease. The defendant was acquitted. It has thereby been established that this is not a criminal offence. However, Jan Albert says that comments and appendices to the Communicable Diseases Act, which has no punitive function, are still worded in such a way that makes it unclear what a doctor must tell their patient in this regard and what the patient must disclose to sexual partners.

But with the correct treatment, there is no risk of infection, so what exactly is there to disclose?

“It is perfectly clear that you are obligated to inform a sexual partner if you have untreated HIV. But with effective treatment, there is no risk of infection, so what exactly is there to disclose?”

The question of criminalisation is particularly close to Jan Albert’s heart. Over the years, he has been called as an expert witness and carried out several forensic examinations to determine the probability that a certain infection has been transmitted from a certain person. He is very clear on his position in this matter.

“Of course, it’s never okay, from a moral or social perspective, to expose others to infection. But we’re not talking about hardened criminals here. Sure, they may have acted selfishly or carelessly, but most of all, they have been living in denial. And we don’t deal with any other infectious diseases this way. We wouldn’t put someone in prison for infecting old people with influenza, for example, even though that too could be lethal. And so I don’t believe that unintentional transmission of HIV should be considered a crime,” he says.

Sweden has also received criticism from UNAIDS, the Joint United Nations Programme on HIV and AIDS, for the large amount of legal cases in the country, especially in proportion to the small number of people with HIV. One important goal for Jan Albert has been to reduce the social stigma for people living with HIV.

“What patients struggle most with today is not the medical issues, but the reactions from people around them. By putting them on trial and differentiating HIV from other infections, we are feeding that stigma. That is something that I have long felt we need to counteract,” he says.