AIDS at 25

Where do we stand?

The 16th International AIDS Conference will be attended by 24,000 researchers, policymakers, and activists this week in Toronto. It's hard to believe that HIV/AIDS has been with us for 25 years now.

By chance I became aware of AIDS early on. For three months in 1980, I lived on the couch of a college friend in New York City while I hunted for lodging that I could afford on my pitiful starting salary as the writer of an in-house newsletter for the advertising department of The New Yorker. My friend was a resident in pediatrics at a city hospital and he was gay. Despite the grueling hours he spent treating sick children, my friend did manage to enjoy the thriving downtown gay club scene with some frequency. This was the heyday of bathhouses and flamboyant promiscuity.

It was during my sofa sojourn that my worried doctor friend alerted me that something very bad was happening: there was a lot of talk about a number of young gay guys who were unaccountably falling ill and dying quickly. He speculated that it might be some kind of infection. It turned out that he was prescient. It was also at about that time that, as I recall, the Village Voice published an article which almost romanticized dying young of the "mauve disease." Any romantic nonsense about dying while young and beautiful was long gone by the middle of the 1980s.

The first cases of what would soon be called acquired immune deficiency syndrome (AIDS) were reported to the U.S. Centers for Disease Control in June of 1981. CDC reported that AIDS is transmitted through sexual contact or infected blood. By 1983, French doctor Luc Montagnier identified the human immunodeficiency virus (HIV) as the cause of AIDS. Frankly, I believed that once the virus causing the disease had been identified that the creation of an effective vaccine would follow in short order. In 1984, Secretary of Health and Human Services Margaret Heckler predicted that a vaccine could be ready for testing in a couple of years. But that optimism was sadly misplaced. By attacking the very immune cells that protect the body against infection, HIV has proven to be a powerful and protean foe of modern biomedicine.

The AIDS epidemic held up a mirror to our attitudes toward homosexuality and drug use. For example, in the mid-1980s, I once expressed my exasperation to an employer that some people thought that AIDS was God's punishment for homosexuality. He looked at me sharply and said, "Ron, how do you know that it's not?" Indeed, I don't know the mind of the Deity, but if He wants me to believe that He punishing gays with AIDS, He'll have to tell me so Himself. In the 1980s, National Review founder William F. Buckley suggested that people infected with HIV be tattooed as a way to warn their potential partners. Buckley recently renewed his call for tattooing HIV infected people.

As the epidemic spread, some Americans panicked. In some cases, children like hemophiliac Ryan White who were infected with HIV were expelled from public schools. For a while, a Manhattan lawyer friend would drink beer only from bottles in the East Village bars where we hung out because he was afraid that he might be infected with HIV from inadequately sterilized beer mugs.

In the early days of the epidemic, the gay communities of major cities were devastated and attending the funerals of friends who died young became a depressingly common ritual. The AIDS Memorial Quilt made of panels to commemorate the lives of those who had died of the disease was first displayed on the National Mall in Washington DC in 1987. It was about the size of a football field. By the time it was last displayed in 1996, it had grown to cover the entire Mall. The AIDS epidemic sparked activism which among other beneficial things was to spur the U.S. Food and Drug Administration to speed up the approval of new drugs.

Twenty-five years later where do we stand? In the United States, an estimated 1.1 million people are infected with HIV and more than half a million Americans have died of AIDS. The bad news is that the rate of HIV infection remains steady at about 40,000 per year and the good news is that number Americans dying from AIDS has dropped for 52,000 in 1995 to 15,800 in 2004. Worldwide between 33 and 46 million people are currently infected with HIV and 25 million have died of AIDS since 1981.

Nevertheless, significant inroads against the disease have been made. Most prominently was the development by pharmaceutical companies of highly active antiretroviral therapy (HAART) in the mid-1990s. These cocktails of three types of anti-viral medicines stymie the HIV virus as it tries to reproduce in the bloodstreams of infected people often reducing the virus to undetectable levels. HAART has slashed death rates by transforming HIV/AIDS into a manageable chronic disease for some people.

Researcher Julio Montaner, the soon-to-be president of the International AIDS Society, believes that widespread deployment of HAART could slash the number of HIV/AIDS cases by more than 98 per cent in just two generations. The idea is that people infected with the virus are much less able to pass it along if it is below detectable levels in their bloodstreams. Of course, the problem is how to get these expensive medications to infected people living in the poorest countries in the world.

Under pressure from health advocates developed country pharmaceutical companies are offering their AIDS medicines at cost and allowing companies in other countries to make copies of their medicines at very reduced prices. But even at $130 to $140 per year, the drugs are still out of reach of millions of the world's poorest people who live on less than $2 per day. Additionally, there is the concern that if pharmaceutical companies are not allowed to profit from the medicines they invent, their incentive produce new ones in the future will be impaired.

The best hope for stopping the AIDS epidemic is the development of an effective vaccine. Researchers have been pursuing this goal for nearly two decades with no luck yet in outwitting the wily HIV virus. More money than is ever is being spent on vaccine research, including a $287 million grant from the Bill and Melinda Gates Foundation. A number of small AIDS vaccine trials are taking place, but it will be many more years before researchers can determine the effectiveness of one or more of them. Nevertheless, thousands of human brains consisting of a 100 billion neurons working together and armed with 21st century biomedical techniques will surely someday defeat a virus that has only 9 genes.

Finally, I can happily (and selfishly) report that after twenty-five years, so far none of my close friends, including my close gay friends, have succumbed to this modern plague. One hopes that the efforts of the researchers meeting in Toronto this week will sooner rather than later make HIV/AIDS an historical curiosity like smallpox.