- Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
Thirty years ago, on 4 June 1981, the Centers for Disease Control and Prevention published a small case series of previously healthy homosexual men in Los Angeles who had contracted pneumocystis pneumonia.1 A month later, 26 more cases were described, from New York as well as California, and including Kaposi’s sarcoma as one of their opportunistic diseases.
So it began.
Gay men were the initial focus, but then people with haemophilia, others receiving transfusions, and injection drug users were stricken. And stricken was the appropriate word. In those early days almost everyone with AIDS died, and most died within months of the appearance of symptoms. Many of the deaths were horrible: pneumonia, complicated by intractable diarrhoea, severe stomatitis, skin lesions, and more. Drugs commonly used to treat their infections and cancers didn’t work. I took care of a few early AIDS patients during my residency, and it was awful and frustrating for them, their loved ones, and their doctors and nurses.
It is stunning to look back and realise that in 30 years more than 60 million people have been infected with HIV and at least half of them have died from it.
In context, the medical reaction to the epidemic was remarkably rapid, but it seemed very slow at the time. In 1983, HIV was discovered, and by the next year was proved to cause AIDS. By 1985 we had a diagnostic test for HIV, so infections could be discovered in much earlier stages.
No treatment was available then, but the modes of transmission were clear and behavioural change in populations at risk became the prevention strategy of choice. Activists in the gay community led the fight for behavioural changes as well as in demanding more funding for research, speedier drug trials and licensing, and increased participation by patients and their carers.
In a recent reminiscence, Anthony Fauci, then (as now) leading research on AIDS at the National Institutes of Health, recalls being “vilified” by AIDS activists for not moving fast enough to address the crisis.2 As a minor government functionary in the middle and late 1980s, I watched the drama unfold, attending coordinating meetings led by Fauci as pickets marched outside our building. Everyone was trying hard, but people were dying horrible deaths as the clock ticked on.
In 1987, zidovudine (then AZT) was licensed, and finally we had a drug that would help. Lives were prolonged, and some patients did very well indeed. However, the early drugs were toxic, and had to be taken many times a day on a very demanding schedule.
Almost 25 years after zidovudine, we have come a long way. Dozens of antiretrovirals are now in use, and their side effects and dosage regimens are much more tolerable. Many patients can take a single combination capsule once or twice a day. At the emergence of clinical symptoms 30 years ago, life expectancy, measured from the initial diagnosis of asymptomatic HIV infection, was six months. Today, with appropriate treatment. life expectancy has increased to perhaps 50 years. HIV infection has changed from a death sentence to a disease managed like many other complex conditions: routine appointments in primary care combined with regular consultations with specialists.
To complement treatment we now also have a large armamentarium of proven prevention strategies in addition to abstinence and condoms: needle exchange for injection drug users, post-exposure prophylaxis for medical personnel, maternal drug treatment to prevent transmission to newborns, blood bank testing to prevent transfusion associated cases, circumcision, and topical microbicides.
These are crucial, because we are still seeing two to three new infections emerge for every person put on lifesaving treatment.2 Worldwide, it is estimated that there were 2.6 million new infections in 2009. Ninety per cent of people with AIDS are living in developing countries. Huge progress has been made in providing antiretroviral treatment for millions of them, through the generosity of large charities and Western governments. Some 85% of antiretroviral treatment in the developing world, at a cost of $8.3bn dollars (£5.1bn, €5.7bn), was provided from these sources.3
Much more needs to be done, especially since the treatment and prevention worlds have now merged with the dramatic announcement last month of the early results of the National Institutes of Health’s HIV Prevention Trials Network (HPTN) 052 trial.4 This randomised controlled trial, mostly among heterosexual couples in the developing world, found that early treatment of HIV dramatically decreased transmission of the virus to regular sexual partners. As has been long suspected from observational data, the best prevention turns out to be early and effective treatment.
Prices for antiretroviral treatment in the developing world have dramatically decreased due to the availability of inexpensive generic drugs. Even so, in light of the results from the National Institutes of Health trial, the potential costs for treating all infected patients, while maintaining other prevention programmes and research, is likely to be staggering. National Institutes of Health scientists are modelling what it would cost to treat everyone and how various strategies would affect transmission and thus the emergence of future new cases. The costs are likely to be in the hundreds of billions of dollars.
The challenge confronting us soon will be how to find the resources to treat everyone (or almost everyone) in order to bend the incidence curve and write the final chapter of the AIDS story.
Cite this as: BMJ 2011;342:d3512