AIDS at 25

[Angel]

Twenty-five years ago, U.S. public health officials reported the first known cases of a disease that would come to be called AIDS. Since then, AIDS has grown into a global pandemic that governments and donor agencies are spending billions of dollars to try to control. Medical science has delivered the tools to tame the virus, but its biological nature causes experts to fear it will not soon be eliminated.

It was 1981 and American doctors were mystified by what they saw. Young, previously healthy homosexual men were suffering from a rare and often deadly form of pneumonia. When the U.S. government's disease tracking agency, the Centers for Disease Control, first reported the mysterious cluster of cases on June 5, 1981, two of the young men had died.

These were the first reported fatalities of an illness initially considered by many to be one of only gay men and people who injected illegal drugs. But the chief of U.S. government AIDS research, Dr. Anthony Fauci, notes that they were only the vanguard of a pandemic that would sweep across continents.

AIDS Pandemic
A model of the H.I.V. virus "So now we fast forward 25 years and we see that what people were somewhat skeptical about, whether this was going to be anything but an epidemiologically restricted disease, has exploded into one of the most devastating pandemics in the history of civilization," says Dr. Fauci.

Since 1981, AIDS has infiltrated all segments of society and claimed the lives of 25 million men, women, and children. The United Nations AIDS Program says 40 million are living with it and eight-thousand are dying daily, mostly in developing countries,"... which means that H.I.V.-AIDS has now transcended malaria and tuberculosis as the leading cause of microbial death in the world," says Dr. Fauci. "Remember, malaria and T.B. were the two big killers before then, and just a couple of years ago, H.I.V.-AIDS superseded them."

Because the first AIDS patients were people with unorthodox lifestyles, politicians ignored the disease, but Fauci and other researchers strove to understand it. Within a few years, scientists identified the H.I.V. virus that causes AIDS and developed a rapid blood test to detect it. They also began revealing its molecular structure, a necessary step in designing drugs to block it.

As a result of that work, current medicines can subdue H.I.V. to undetectable levels in the blood, extending patients' lives indefinitely from an initial life expectancy of two or three years.

Dr. Paul Stoffels of Tibotec Pharmaceuticals Limited says that is the good news. "Today, H.I.V. patients theoretically should not die anymore from the disease if therapy is correctly administered and there is good infrastructure to do the follow up of the patient. So there was a massive evolution by making new drugs available from a deadly disease to a chronic infection," Dr. Stoffels.

Little Hope for a Cure
An H.I.V. infected family in TanzaniaBut the bad news is that drugs cannot yet cure H.I.V. Stoffels says patients will probably have to take them for decades to stay alive, an enormous challenge even in the most highly developed societies.

This is because when H.I.V. enters a person's cells, it is tenacious, despite the onslaught of medicines. Anthony Fauci's studies have showed that it can hide for years at undetectable levels, but is never gone and is ready to multiply at high levels again if drugs are stopped. He holds little hope that drugs will ever cure AIDS.

"I'd have to say that you never say never in biology, but if in fact we do it, it's going to be very, very tough to do. So I am not totally optimistic that we are going to be able to truly eradicate virus from huge numbers of infected people. We may do it rarely in an individual at first, but I don't see this happening as a routine phenomenon," says Fauci.

The Quest for a Vaccine
As a result, the search for an H.I.V. vaccine assumes tremendous importance. Many experimental vaccines are in development, with some being tested in Africa and Asia.

But vaccine research is another big challenge, according to Mitchell Warren. He is the Executive Director of the AIDS Vaccine and Advocacy Coalition, a private group promoting vaccine research.

"Every time we think we've learned one more piece of the puzzle around this virus, and we have unlocked and uncovered many of those puzzle pieces over 25 years, every time we do that, we continually are defied in turning that information into a vaccine," says Warren.

But Warren says vaccine research is coming to an important juncture. He believes that within three to five years, scientists will have discovered which vaccine concept works best and will focus on that. But don't hope for a vaccine for at least another decade.

Expensive medications prolong life, but a vaccine may be at least a decade away"I can tell you we won't have the ultimate vaccine, the one that we really long for -- a safe and efficacious vaccine delivered once, ideally without a needle, delivered cheaply with 100 percent prevention. That won't happen within the next decade. We might be further along the way. That may sound rather cynical, but what I want to make very clear is I think we are at a really critical turning point in the search for an AIDS vaccine," says Warren.

But even if a vaccine becomes available, Warren says it will not be a panacea because the H.I.V. pandemic will not be stopped by one technology or any other single approach, be it therapeutic or behavioral.

The chief of the World Health Organization's H.I.V. Department, Dr. Kevin foresees a world still fighting AIDS 25 years from now. "I don't think we will have this problem solved. This is a problem that is going to take generations to address. All of us talking about it now, like you and I, will be gone before the story is finished."

[Angel]

It began innocuously, when a statistical anomaly pointed to a mysterious syndrome that attacked the immune systems of gay men in California. No one imagined 25 years ago that AIDS would become the deadliest epidemic in history.

Since June 5, 1981, HIV, the virus that causes AIDS, has killed more than 25 million people, infected 40 million others and left a legacy of unspeakable loss, hardship, fear and despair.

Its spread was hastened by ignorance, prejudice, denial and the freedoms of the sexual revolution. Along the way from oddity to pandemic, AIDS changed they way people live and love.

Slowed but unchecked, the epidemic's relentless march has established footholds in the world's most populous countries. Advances in medicine and prevention that have made the disease manageable in the developed world haven't reach the rest.

In the worst case, sub-Saharan Africa, it has been devastating. And the next 25 years of AIDS promise to be deadlier than the first.

AIDS could kill 31 million people in India and 18 million in China by 2025, according to projections by U.N. population researchers. By then in Africa, where AIDS likely began and where the virus has wrought the most devastation, researchers said the toll could reach 100 million.

"It is the worst and deadliest epidemic that humankind has ever experienced," Mark Stirling, the director of East and Southern Africa for UNAIDS, said in an interview.

More effective medicines, better access to treatment and improved prevention in the last few years have started to lower the grim projections. But even if new infections stopped immediately, additional African deaths alone would exceed 40 million, Stirling said.

"We will be grappling with AIDS for the next 10, 20, 30, 50 years," he said.

Efforts to find an effective vaccine have failed dismally, so far. The International AIDS Vaccine Initiative says 30 are being tested in small-scale trials. More money and more efforts are being poured into prevention campaigns but the efforts are uneven. Success varies widely from region to region, country to country.

Still, science offers some promise. In highly developed countries, cocktails of powerful antiretroviral drugs have largely altered the AIDS prognosis from certain death to a manageable chronic illness.

There is great hope that current AIDS drugs might prevent high-risk people from becoming infected. One of these, tenofovir, is being tested in several countries. Plans are to test it as well with a second drug, emtricitabine or FTC.

But nothing can be stated with certainty until clinical trials are complete, said Anthony Fauci, a leading AIDS researcher and infectious diseases chief at the U.S. National Institutes of Health.

And then there is the risk that treatment will create a resistant strain or, as some critics claim, cause people to lower their guard and have more unprotected sex.

Medicine offers less hope in the developing world where most victims are desperately poor with little or no access to the medical care needed to administer and monitor AIDS drugs. Globally, just 1 in 5 HIV patients get the drugs they need, according to a recent report by UNAIDS, the body leading the worldwide battle against the disease.

Stirling said that despite the advances, the toll over the next 25 years will go far beyond the 34 million thought to have died from the Black Death in 14th century Europe or the 20 to 40 million who perished in the 1918 Spanish flu epidemic.

Almost two-thirds of those infected with HIV live in sub-Saharan Africa where poverty, ignorance and negligent political leadership extended the epidemic's reach and hindered efforts to contain it. In South Africa, the president once questioned the link between HIV and AIDS and the health minister urged use of garlic and the African potato to fight AIDS, instead of effective treatments.

AIDS is the leading cause of death in Africa, which has accounted for nearly half of all global AIDS deaths. The epidemic is still growing and its peak could be a decade or more away.

In at least seven countries, the U.N. estimates that AIDS has reduced life expectancy to 40 years or less. In Botswana, which has the world's highest infection rate, a child born today can expect to live less than 30 years.

"Particularly in southern Africa, we may have to apply a new notion, and that is of `underdeveloping' nations. These are nations which, because of the AIDS epidemic, are going backwards," Peter Piot, the director of UNAIDS, said in a speech in Washington in March.

Later, at a meeting in Abuja, Nigeria, last month, Piot cited encouraging news including a sharp fall in new infections in some African countries. There also has been an eightfold increase in the number of Africans benefiting from antiretroviral treatment, he said.

But, he warned, "the crisis of AIDS continues and is getting worse and any slackening of our efforts would jeopardize the hard-won gains of each and every one of us."

Besides the personal suffering of the infected and their families, the epidemic already has had devastating consequences for African education systems, industry, agriculture and economies in general. The impact is magnified because AIDS weakens and kills many young adults, people in their most productive years.

So many farmers and farmworkers have died of AIDS that the U.N. has invented the term "new variant famine." It means that because of AIDS, the continent will experience persistent famine for generations instead of the usual cycles of hunger tied to variable weather.

Africa's misery hangs like a sword over Asia, Eastern Europe and the Caribbean.

Researchers don't expect the infection rates to rival those in Africa. But Asia's population is so big that even low infection rates could easily translate into tens of millions of deaths.

Although fewer than 1 percent of its people are infected, India has topped South Africa as the country with the most infections, 5.7 million to 5.5 million, according to UNAIDS.

The astonishing numbers have grown from a humble beginning.

Nobody knows for sure when or where, but the AIDS epidemic is thought to have begun in the primeval forests of West Africa when a virus lurking in the blood of a monkey or a chimpanzee made the leap from one species to another, infecting a hunter.

Researchers have found HIV in a blood sample collected in 1959 from a man in Kinshasa, Congo. Genetic analysis of his blood suggested the HIV infection stemmed from a single virus in the late 1940s or early 1950s.

For decades at least, the early human infections went unnoticed on a continent where life routinely is harsh, short and cheap.

Then, on June 5, 1981, the Centers for Disease Control in Atlanta reported five young actively homosexual men in Los Angeles had a new, mysterious and as yet unnamed illness that attacked the immune system and caused a type of pneumonia. A month later, it reported an odd surge among homosexual men in the number of cases of Karposi Sarcoma, a rare cancer now linked to AIDS.

In the early days of the epidemic, just the mention of AIDS elicited snickers and jokes. Few saw it as a major threat. It was the "Gay Plague," and for some, divine retribution for a lifestyle Christian fundamentalists and other conservatives consider deviant and sinful.

When heterosexuals began to contract the disease through blood transfusions and other medical procedures, they were often portrayed as "innocent" victims of a disease spread by the immoral and licentious behavior of others.

The initial reactions and prejudices associated with AIDS slowed the early response to the epidemic and limited the funding. Too much time, money and effort was spent on the wrong priorities, Stirling aid.

"Over the last 25 years, the one real weakness was the search for the magic bullet. There is no quick and simple fix," he said. "But with the recent successes we are starting to see the end of epidemic."

"There is evidence to suggest we are at the tipping point," said Stirling.

The pace of change over the last couple of years suggests the number of new infections can be reduced by 50 to 60 percent by 2020 - if the momentum continues.

"It is surely possible, it is doable," Stirling said.