The AIDS epidemic: 20 years and counting

July 2001

Readers could hardly have missed the fact that June 2001 marked a 20th anniversary of sorts, though hardly the occasion of celebration. Rather, the 20th anniversary of the first MMWR publication on what we now know as AIDS was the occasion of reflection, stocktaking, reassessment, and re-energizing. The occasion was marked with a series of reports in MMWR, multiple articles in the June 7, 2001, issue of The New England Journal of Medicine (NEJM), and numerous reflections in other professional journals. The public media, notably the New York Times, also marked the occasion with review and commentary.

I occasionally find myself called upon – as I’m sure you often are, too – to talk to various groups of adolescents about STDs and HIV — mostly in junior high/senior high schools or in various church-related groups. It never fails to astonish me to realize that these young people have never known a world without HIV and AIDS. By the same token, it is equally astonishing to realize that there is now a whole generation of infectious disease physicians out there who have never practiced in a world without HIV infection. These kinds of reflections are a luxury available only to the elderly among us, who spend increasing amounts of time reflecting on the past.

Lessons learned

None of us, reading the original MMWR description of 5 cases of Pneumocystis carinii in previously healthy young men, could possibly have predicted the global devastation brought about by this virus in 20 years. There has, in those 20 years, been enormous progress, many setbacks, and innumerable lessons learned along the way. Space will permit only very limited comment on my part. I will not reiterate the dismal litany of numbers of people who are HIV-infected or dead in the United States or in the world after 20 years; the numbers simply beggar complete comprehension. I would, however, encourage all readers to take the time to read the June 1, 2001, issue of MMWR, and the four articles dealing with the epidemic that appeared in the NEJM; they are “must” reading for any serious students of this pandemic.

Physician attitudes appear to have changed considerably over the past 20 years. In the mid- to late-1980s, as the basic routes of transmission of HIV were clarified, we heard a great deal about physician refusal to provide care to HIV-positive patients. These refusals seemed to be focused mostly in the surgical specialties and among dentists — obviously, individuals who performed invasive procedures. But it was by no means limited to them; in fact, at one time the IDSA directory even contained an entry denoting which IDSA members would or would not provide care for HIV-positive patients. Fortunately, this is no longer an issue, but the fact that it was an issue at all did not reflect well on the medical profession.

One of my own more vivid memories is of the last day of the Third International Conference on Nosocomial Infections, held in Atlanta in June (I think) 1990. That was the occasion for representatives of the AIDS Program and the (then) Hospital Infections Program at NCID, CDC to publicly reveal the story of the Florida dentist, Dr. David Acer, and the investigation of HIV-infected patients in his practice. It did not take long for the audience to grasp the enormous implications of this investigation. This led, as most readers will recall, to all manner of mostly counter-productive political posturing and ultimately to some CDC recommendations to prevent transmission of blood-borne pathogens in the health care setting which still remain to this day. These recommendations clearly represented what was then politically possible, even if moderately dysfunctional. The concerns about transmission by HIV-infected health care professionals have subsided considerably after study upon study has revealed no evidence of such transmission. Today, only a few remember the name Kimberly Bergalis.

There is good news

One of the bright spots to emerge during the 1980s was the persona of the Surgeon General Everett Koop. In an administration which, at least publicly, seemed hardly to acknowledge the existence of a problem, Dr. Koop spoke out to the American public in a most unambiguous way. In a manner somewhat reflective of that level of honesty, the present Surgeon General, David Satcher, has again spoken out with a level of candor that may make the current administration somewhat uncomfortable.

Another professional group that took a hit in the AIDS epidemic was the blood-banking community. They did not buy into the mounting evidence that HIV was transmitted by blood, and were eventually criticized heavily for their inaction. These events were well-documented in Randy Shilts’ remarkable book, “And the Band Played On.” Perhaps partly as a result of that misstep, the blood-banking community now appears to lean over backward to safeguard the nation’s blood supply against anything that may even potentially be blood-borne. Elsewhere in this issue of Infectious Disease News is a story on new donor deferral policies to prevent transmission of vCJD to illustrate the point.

The enormous strides that have been made in the treatment of HIV infection is, I believe unarguably, the greatest triumph of the last 20 years. Although the “cure” paradigm appears now to have been only a fond hope, HAART has succeeded in recasting the disease from a certain death sentence into a chronic disease that is yet compatible with an extended and productive life. A vaccine, however, in sharp contrast to what the then Secretary of DHHS (then DHEW), Margaret Heckler, said in 1984 “we’ll have a vaccine in five years,” five years has come and gone several times over and a vaccine is still well over a decade away, at a minimum. The public health efforts in which CDC has taken the leadership role have been effective, but could be vastly more effective if Americans, particularly those in the U.S. government, could get over their political and moral hang-ups about sexuality, condoms, needles and the like.

Globally, of course, the challenges are huge. It will be up to the developed world to provide the resources to the developing world, on a scale we have not yet seen, before we can think about global control of HIV transmission. If the United States does not step up and lead this effort — who will? If we don’t, the next 20 years of HIV infection will be a transcendent disaster.