The medical community has learned many lessons by looking back on the early days of the HIV/AIDS epidemic, including the value of multidisciplinary teams, the vital role of acute care clinicians, the insight that can be gained from simple studies, how to properly engage infected communities, and how to address the fears of the public.
“Given that emerging infections continue to surprise, are we now more prepared than we were in the early days of AIDS?” Harold W. Jaffe, MD, an infectious disease specialist with the Centers for Disease Control and Prevention (CDC) said in a presentation at the 25th Conference on Retroviruses and Opportunistic Infections
(CROI), in Boston, Massachusetts. “In some ways, I think the answer is yes.”
When the CDC published its weekly morbidity and mortality report on June 5, 1981, Jaffe said, “Neither I nor my CDC colleagues were prepared for what crashed down on our heads.”
That year, Dr. Jaffe, was working with colleagues on suppressing a reemergence of syphilis in the United States. At the time, physicians in the United States believed the end of infectious diseases was in sight. Just 3 years prior, Robert G. Petersdorf, MD, had written that “even with my great personal loyalties to infectious disease,” he could not fathom the need for more specialists.
Yet, as Dr. Jaffe would point out, they were faced with a new pestilence they could not have prepared for: HIV and AIDS.
Originally believed to be complex cases of Pneumocystis
pneumonia (PCP) and Kaposi sarcoma (KS), within a month, more reports of patients with the condition were coming from Los Angeles, New York City, and San Francisco. Some of these patients were dying, most were men who have sex with men (MSM), and all were found to be immunodeficient, which confused physicians at the time, shared Dr. Jaffe.
In order to determine what was occurring, the CDC began collecting systematic reports, developing a case definition of KS/OI (Kaposi sarcoma/opportunistic infections).
“Soon we began receiving reports of KS/OI in gay men from additional American cities,” Jaffe said. “We also noticed that a small number of cases had been diagnosed in 1979 and 1980 but had not been reported.”
Three major theories were born from this puzzling and alarming scenario: the sexually transmitted infections (STI) theory, the environmental theory, and the immune overload theory.
“Given the high rates of STIs seen in MSM at the time, a [sexually transmitted disease] was a prime suspect,” explained Dr. Jaffe. “The environmental theory postulated that an immunosuppressive drug or chemical was the cause, and here, the leading suspects were nitrite inhalants, known as ‘poppers,’ used to enhance sex with men. Finally, there was the immune overload theory, that suggested there was no single ideology—rather, immunodeficiency resulted from the cumulative effects of multiple infectious agents, environmental toxins, and perhaps other factors, such as exposure to semen.”
After a CDC-run trial revealed that MSM were likely to have many sexual partners and that ‘poppers’ were not immunotoxins, as believed, the STI theory gained traction, and the condition became known as AIDS.
The public reception of the condition that seemingly only impacted MSM was mostly flippant, according to Dr. Jaffe, until January 1983, when the CDC revealed a wider population of at-risk patients. These included transfusion recipients, patients with hemophilia, injection drug users, female sex partners of men with AIDS, and individuals born to mothers with AIDS.
Then, on March 4, 1983, the CDC published its first guidelines for prevention of AIDS, which recommended avoiding sexual contact with individuals who were infected, an understanding among high-risk group members that increased sexual partners raised their risk, and that at-risk individuals refrain from blood and plasma donations.
“In retrospect, these key recommendations related to sexual activity and blood donation were essentially correct, and were based entirely on epidemiologic studies,” shared Dr. Jaffe.
Just 2 months later, François Barré-Sinoussi, Luke Montagnier, and colleagues in Paris, France, reported isolating a novel retrovirus they called LAV (lymphadenopathy-associated virus), from the lymph node of a homosexual man. A year after that, Robert C. Gallo and colleagues claimed that a virus they called HTLV-III (human t-lymphotropic retrovirus type III) was the cause and they subsequently helped develop the first diagnostic test to screen for antibodies to the virus in the blood.
Meanwhile, African patients with AIDS began to appear in European clinics, bringing the infectious disease community’s attention to central Africa, where yet another epidemic was underway. These patients were remarkably heterogeneous compared to previously noted populations—the male to female ratio was approximately 1 to 1. Additionally, homosexuality, intravenous drug use, and blood transfusions were not found to be risk factors in this population.
By 1985, concern about the virus in the United States quickly turned into fear. People began to believe even casual contact could transmit the disease.
“This fear resulted in unwarranted discrimination against infected persons,” disclosed Dr. Jaffe. “A leading symbol of this discrimination was Ryan White, an HIV-infected teenager with hemophilia who was not allowed to attend school for fear of contagion. As his school attendance was being debated, someone fired a bullet through the window of his home.”
Fortunately, a Montefiore Medical Center / CDC study soon brought forth new guidelines for the education and foster care of HIV-infected children. Coupled with studies dispelling the believed occupational risks of acquiring the virus, they soon became the basis for public health education to destigmatize the disease.
As more time passed, federal programs and funding would lead to antiretroviral therapies and advancements in the treatment of the disease.
Although the early US AIDS epidemic tested the medical community, lessons learned during that time have advanced the way infectious diseases are approached. For example, Dr. Jaffe noted that there are now international health regulations which aid in countries’ abilities to respond to and assess health threats.
Dr. Jaffe ended his presentation with a quote from who has been called one of the greatest leaders of our time. He remarked on how, without a vaccine or curative therapy, conventional wisdom says that it is too hard to end the epidemic as a public health threat.
“But looking back on the early days of AIDS, we see the conventional wisdom may be wrong,” said Dr. Jaffe. “In speaking about the goals of the US Space program more than 50 years ago, President John F. Kennedy said, ‘We choose to go to the moon not because it is easy, but because it is hard.' I’d like to think that if he were speaking about AIDS, President Kennedy would say we choose to end the epidemic not only because it is hard, but also because it is right.”
An earlier version of this article appeared on MDMagazine.com.
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