Thirty years ago this week, researchers and clinicians were putting the finishing touches on an article intended for the June 5 issue of Morbidity and Mortality Weekly Report.
Titled "Pneumocystis Pneumonia - Los Angeles," the seven-paragraph report was the first dispatch from the front lines of humanity's remarkable war against a previously unknown virus.
The war began with a complete lack of good news - the new disease was almost 100 percent fatal, often within weeks or months. No one knew what caused it or how it was transmitted. No one knew how to prevent it, to treat it, and certainly not how to cure it.
Thirty years on, the HIV/AIDS pandemic is still raging, but the news from the front is more and more positive.
Infection can be prevented, if people have the will. The virus is increasingly well understood, as is the immune system and the host-pathogen interaction. The disease can be treated, although a cure remains out of reach.
Perhaps most important - while many people still die because of the virus - HIV is no longer a death sentence.
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In the Beginning
Anthony Fauci, MD, now the head of the National Institute of Allergy and Infectious Diseases, was a 10-year veteran of the NIH at the time, with a lab studying the immune system and host-pathogen interactions.
"I remember quite clearly," he told MedPage Today, as he recalled sitting in his office, leafing through that week's MMWR, and coming across the report from Los Angeles.
He knew Pneumocystis pneumonia - usually abbreviated PCP - as a disease usually seen in people with compromised immune systems, often cancer patients undergoing chemotherapy.
But the MMWR report struck him as a curiosity, until a month later when a second report from the CDC hit his desk.
Now there were 26 patients, not five.
They were from Los Angeles, San Francisco, and New York. They were all gay and previously healthy. And some of them had Kaposi's sarcoma, another disease usually seen in people with compromised immune systems.
"At that point I just got goose pimples," Fauci said. "I said, 'Oh my goodness, we're dealing with something really new here.'"
Despite the horrified reaction of friends and mentors, he made the immediate decision to turn his attention to this new "curiosity of a disease."
It's a story repeated again and again by those who have been involved in the pandemic.
Carol Hamilton, MD, of Research Triangle Park, N.C., is a senior scientist with FHI, a research professor at Duke University, and a clinician with decades of experience in treating HIV. She's also a member of the Infectious Diseases Society of America's Center for Global Health Policy and Advocacy.
But in 1981, she was working in public health in Utah, before going to medical school. And even there, she and colleagues were seeing strange illnesses among gay men - lots of syphilis and gonorrhea, yes, but also a "very worrisome" infection that had no known cause.
"It was frightening, honestly," she told MedPage Today.
She had intended to practice obstetrics, but in medical school she found internal medicine and infectious disease - especially HIV - much more compelling.
"The HIV epidemic seemed to be the important issue of the age," she said.
The early years were both "exciting and fascinating" in a scientific sense, she said, but also unspeakably tragic in a personal and clinical sense.
"Remember, all of our patients died - 100 percent," Hamilton said. All a doctor could do was try to help them die with a maximum of dignity and a minimum of suffering.
Looking back from 2011, it seems as if progress was relatively swift. After the initial report, it was only three years until, in 1984, the virus was isolated. A year later, the first diagnostic test was licensed and in 1987 AZT, the first anti-HIV drug, was approved.
But at the time, it seemed horribly slow, according to Sten Vermund, MD, PhD, a pediatrician at Vanderbilt University School of Medicine in Nashville, Tenn., and also a member of the IDSA Center for Global Health Policy and Advocacy.
In the 1980s, when Vermund was working in New York, "things looked like they were progressing very slowly because of the death that just permeated our city," he told MedPage Today.
"HIV washed over us like a slow tsunami," he said.
There were treatments for the various opportunistic infections that were killing HIV-positive people, he said, but the drugs "just didn't get a clinical response."
Now, of course, we know why - HIV had knocked out the immune system cells that are the key allies of any drug therapy.
Then, in 1996, doctors could suddenly offer long-term hope, with the advent of highly active anti-retroviral therapy, or HAART. Drug "cocktails" could now keep people with HIV from progressing to AIDS and dying.
The End of the Beginning
To paraphrase Winston Churchill, the battle against HIV/AIDS was not at an end, nor even at the beginning of the end. But it was, perhaps, at the end of the beginning.
For people like Carol Hamilton, it was "miraculous." From helping people to die - she once said she felt like a "midwife of death" - she could now help them live.
Although the early years of the pandemic were terrifying and frustrating for those on the front lines, it's fair to say that scientific progress over the past 15 years has been constant.
Indeed, Fauci goes so far as to call it "breath-taking" as dozens of new drugs were developed and several new methods of prevention were discovered and shown to work.
Indeed, within the past month, a landmark study has shown that treating people with HIV can reduce the chance they'll transmit the virus by 96 percent.
Michael Saag, MD, of the University of Alabama Birmingham, says that finding puts an additional value on treatment.
"Not only can we treat people and keep them alive for a normal lifetime," he told MedPage Today, but as an "added bonus" the treated people will be highly unlikely to transmit HIV.
"To me, treatment is prevention," he said.
But getting advances to all the people who need them remains a challenge. There are still 2.6 million new infections a year around the world and 1.8 million deaths from HIV/AIDS.
Even in the U.S., there are 50,000 new infections each year, and more than a million people live with HIV, with an estimated 25 percent of those completely unaware they have the virus.
Despite the availability of treatment, there are even deaths in the U.S. and other advanced countries, Hamilton noted - usually those who can't or won't for some reason take their medications.
What's needed now is a program of research that will overcome barriers to care and treatment, Vermund argues, as well as a renewed emphasis on preventing its transmission.
The past 15 years have seen a steady increase in the number of prevention methods available, Vermund noted. To abstinence, being faithful, and condoms - the so-called ABC of prevention - we can now add male circumcision, microbicides, and early HIV treatment.
Combination therapy "knocked the socks off" HIV on an individual basis, he said, and what's needed now is research into combination prevention strategies.
"Sadly," he said, "we are trying to do this in an era of global fiscal restraint" where international funders "no longer have the fire in the belly" needed to undertake the struggle.
Saag, a former chair of the HIV Medicine Association, said scientifically the past three decades have been "stunning" and unique in the history of medicine.
"In the 30 years since the first description, we've taken something that was previously totally unknown as a disease entity and converted it into a chronic manageable condition," he said.
As long as HIV-positive people are found, cared for, treated, and adhere to their therapy, he said, they can look forward to an essentially normal lifetime.
But again, those conditions have to be met and all too often they aren't. Saag said what's needed is a "new era of translational medicine - not just bench to bedside but also bedside to community."
The Final Lesson
In the last analysis, it's very possible we now have the tools to control HIV around the world, even if we don't know yet just how to use them best and even if we may not have the will and the cash to find out.
But, Hamilton said, it's unlikely that HIV is the last unknown pathogen lying in wait for humanity.
"Will we have learned? Instead of it taking 15 years (to get effective treatments), will we take seven years?"
"I would say yes, we have learned."
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