By Susan Blumenthal, M.D., M.P.A. and Jennifer X. Cai*
This June marked the 25th anniversary of the discovery of HIV/AIDS, although for all intents and purposes, the brief mention of five cases of rare pneumonia in young homosexual men in the Centers for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report could hardly be called a discovery then, as the disease it documented had no name, no treatment, and provided no hint at the worldwide devastation the illness would cause in the next quarter century. Since that fateful report on the 5th of June, 1981, HIV/AIDS has claimed the lives of over 25 million people worldwide.
40 million are living with the disease today, including 2.3 million children. 95% of people living with HIV/AIDS are in low and middle-income countries. Since 1995, there's been a doubling in the number of infected people worldwide. UNAIDS estimates that every day 8,000 people die of the disease and 14,000 are infected with HIV, the virus that causes AIDS. This disease does not discriminate. It has afflicted every corner of our globe, crossing cultural, geographic, governmental, racial, ethnic, gender and socioeconomic boundaries. In the United States alone, 1.6 million people have been infected to date and our Nation's capital, Washington, D.C., ranks as number one in the AIDS case rate in the United States according to a 2004 CDC report. The illness has had a particularly staggering impact on the African continent where life expectancy has declined to what it was in medieval times in some hard-hit countries such as Botswana.
Reflecting on the fight against HIV/AIDS over the past 25 years reveals that tremendous scientific and public health advances have been made, but also, importantly, underscores the enormity of the challenges that lie ahead. Last month, more than 20,000 patients, scientists, political activists, and clinicians met in Toronto at the 16th International AIDS Conference to mark the progress that has been made and also to discuss the shortcomings in the fight against HIV/AIDS. The theme of the conference, "Time to Deliver," highlighted a critical challenge today---to translate what is known about treatment and prevention methods for the disease into lifesaving actions globally as well as to accelerate efforts to develop new tools to eradicate AIDS. While no blockbuster breakthroughs were presented this year at the Conference, the meeting underscored the continually evolving advances in prevention and treatment that urgently need to be shared with people worldwide.
Since the first reported case in 1981, returns on investments in AIDS research have been significant. Within three years, the virus that causes the syndrome, HIV, was discovered and risk factors and methods of transmission identified. In 1984, a sensitive and specific diagnostic test for antibodies to HIV was developed and used to screen the U.S. blood supply, ensuring its safety since 1985 in the U.S. The widespread availability and use of diagnostic and screening tests, including new rapid HIV tests and mail-in home sampling kits, have promoted increased individual knowledge of HIV serostatus. However, among the 1.6 million Americans living with HIV/AIDS in the U.S., an estimated 25% are still unaware that they are infected and may be unknowingly passing the disease along to their partners. This problem is exacerbated in the developing world where lack of access to health care and means of transportation to testing facilities as well as stigma, fear of AIDS-related violence, and discrimination prevent many individuals from returning to find out their test results, or worse yet, from being tested at all.
The Food and Drug Administration (FDA) approved the first antiretroviral, AZT, in 1987 and the subsequent decade ushered in a new era of AIDS research resulting in the discovery of protease inhibitors a decade ago and in combination with some of the older drugs, produced what is known as highly active and effective antiretroviral therapies (HAART). In most cases, HAART can prolong life significantly. A recently approved once a day polypill that combines several anti-retroviral (ARV) drugs should help promote adherence. At the Toronto Conference, scientific findings were presented about the effectiveness of a new class of medications called integrase inhibitors that appear to be powerful blockers of the virus in early tests. But the increasing effectiveness of treatments that have saved over 3 million years of life in the United States, with a dramatic decline in death rates over the past decade, has lulled the nation into a false sense of complacency. In reality, the infection rate in the U.S. is still high with over 40,000 new cases last year alone. Moreover, 6.5 million HIV-infected individuals living in low- and middle-income countries urgently need ARV medication, but only one in five currently have access to these life-saving drugs. Many countries with the most need for medication are often the least able to pay for them, even at the discounted prices of generic brands. Other barriers to access to medications include the lack of public health infrastructure and delivery systems, where donated and purchased drugs are not being efficiently distributed to clinics and patients. A high priority for NIH sponsored and other drug research continues to be the development of new medications that are less toxic, have fewer side effects, limit drug resistance, and facilitate easier adherence. The need for less expensive and more readily available medications is an urgent priority in the fight against HIV/AIDS if we are to meet the G8's announcement last year to make available by 2010 ARV drugs to all who would benefit from them.
AIDS in Women and Children
Over the past twenty five years, AIDS has spread from what was originally thought to be a disease affecting only gay men, to an illness where 48% of cases worldwide and 59% of adults living with HIV/AIDS in sub-Saharan Africa are now women. This dramatic increase in AIDS in women has been in part due to the lack of focus in the past on women's health in research, prevention, and service delivery and in access to services, their apparent heightened biological vulnerability to the disease, coupled with gender inequities in social and economic status. Additionally, the epidemic has had other effects on women including more responsibilities for caring for sick family members, loss of property if widowed, and violence. These issues underscore the importance of ensuring that programs target women's unique needs.
The rise in HIV/AIDS rates in women has had another effect: the spread of the virus to children through perinatal transmission and breast feeding. However, in just over one decade, the United States experienced a dramatic decline in mother-to-child HIV transmission (MTCT) from its peak at 1,650 infections in 1991 to almost an eradication of pediatric AIDS with fewer than 250 new MTCT infections in 2002. Hailed as a major public health achievement, the virtual elimination of MTCT in America and other high-income countries is attributed to routine HIV screening of pregnant women, access to antiretroviral therapy, avoidance of breastfeeding, and safe delivery practices, including elective cesarean delivery. But from a global perspective, it is a very different story. That's because 90% of all MTCT infections occur in the developing world, where in contrast to the U.S., less than 10% of pregnant women are being offered interventions to prevent transmission of HIV to their infants in part because of stigma, lack of resources and trained health personnel, and difficulty reaching people in rural areas. An estimated 2.3 million children under the age of 15 around the world are infected with HIV and more than 800,000 require ARV therapy to stay alive yet only 60,000-100,000 of them are receiving medication. While children account for 14 percent of AIDS deaths, they comprise only 6% of those receiving the drugs. In developing nations, the impact of AIDS is reversing decades of steady progress in increasing childhood survival, threatening the ability of countries to recover and respond to the pandemic in the years to come. That is why an important component of initiatives including PEPFAR (the President's Emergency Plan for AIDS Relief) a $15 billion, 5-year program that provides resources to 15 countries, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Health Organization (WHO) efforts is to provide pregnant women and children with these lifesaving medications so the next generation can have a healthier future.
After 25 years, 25 million deaths, and billions of dollars spent on research, the only real "cure" for AIDS is still prevention - both behavioral and biological. One of the landmark public health accomplishments of the 20th century has been vaccinations to prevent diseases like smallpox, polio and diphtheria from happening in the first place. Unfortunately, the quest for an AIDS vaccine, while ongoing, has been elusive. Since 1987, researchers have studied more than 50 different vaccine candidates to prevent HIV/AIDS in more than 80 NIAID-funded clinical trials without success yet. The challenge in producing an effective vaccine lies in the biology of the disease itself. HIV (Human Immunodeficiency Virus) is constantly mutating, resulting in many different strains within each individual; vaccines against other viruses have only had to protect the person against one or a limited number of strains. The disease also destroys the very immune cells (called CD4 lymphocytes) needed to fight the virus. Furthermore, because no one has ever recovered from HIV, researchers have no model, human or animal, to imitate in designing an effective immune response to the disease. The search for a vaccine is a top priority and that's why the NIH is putting billions behind CHAVI (The Center for HIV/AIDS Vaccine Immunology) and a new $287 million grant from the Bill and Melinda Gates Foundation will support a large-scale innovative collaboration among 19 countries to develop an AIDS vaccine, synergizing ongoing efforts at the NIH and other institutions. Scientists from four continents are also studying whether the same medications that transformed AIDS from a death sentence into a treatable condition a decade ago, may have promise in preventing the disease as well. An estimated $54 million is being spent on the quest to discover a prevention pill to block infection by HIV in several clinical trials worldwide. Researchers at the 16th International AIDS Conference presented their work suggesting that some AIDS drugs used in HAART might be also used to prevent the disease. In the developing world, the virus spreads to 4 million adults and children every year. The idea is to create a hostile environment for any virus that enters the bloodstream. However, some researchers caution that if a person becomes HIV positive while taking a prevention pill, resistance might develop making these drugs ineffective as a treatment. Additionally, efforts to develop microbicides that could prevent HIV infection have also proved elusive. Here, again, the NIH, Gates Foundation, and other organizations are investing in the development and testing of microbicides to fight the virus, especially to help protect women who now constitute 50% of infected people worldwide.
Education, behavioral, and community-based interventions are critical components of AIDS prevention. Over the past 25 years, behavioral interventions have played an important role in the fight against the epidemic. In recent years, the "ABC" behavioral prevention approach has been promoted (abstinence, be faithful and use condoms if engaging in high risk behaviors) especially in the developing world but these programs have had mixed results. Evaluations of effectiveness are underway. The media, in partnership with public health organizations, has played an important role in disseminating life-saving information regarding the transmission and prevention of the disease in the United States and in other areas of the world. After all, even with effective medicines and methods to prevent HIV/AIDs, none will be effective unless people use them. That is where marketing comes in. A ruggedly handsome movie star, Rock Hudson was perhaps the first celebrity to bring this disease to widespread public attention in the United States. His death was a significant factor in President Reagan's decision to mobilize against the growing epidemic. During the Reagan Administration, an unprecedented Surgeon General's brochure was sent to every household in America about the public health threat of AIDS. Over the years, celebrities in the United States like Magic Johnson, redefined the face and body of HIV/AIDS for many Americans as a disease that can afflict anyone. Elizabeth Taylor, Bono, LL Cool J, Salma Hayek, Meryl Streep, Robert DeNiro, Sharon Stone and Angelina Jolie have used their star power to help shatter the stigma surrounding HIV/AIDS. Media campaigns have mobilized people to take action with memorable Public Service Announcement (PSA) taglines such as "AIDS is preventable. Apathy is lethal" or "We all have AIDS...If One of Us Does." These health marketing campaigns in the United States helped to increase awareness: by June of 1985, public opinion data from the Gallup Organization estimated that over 95 percent of Americans had heard of AIDS. But knowing the name of a disease does not cure the fear and discrimination associated with it nor does it ensure that people will change their high-risk behavior, get tested, or seek treatment. In a recent poll, more than a third of Americans say they would be uncomfortable living with someone infected with HIV/AIDS. In the most highly affected areas of the world, many individuals still lack basic knowledge about the disease, operating on myths that lead to social and familial isolation especially among women and AIDS orphans, loss of employment, stigma and even punishment.
There are several lessons to be learned from the successes and failures described above. First, the fight against HIV/AIDS has sometimes occurred on two isolated fronts: prevention and treatment. In the early days of the disease, before the development of antiretroviral drugs, prevention--changing behavior-- was all that public health officials and physicians had to offer. Then, when drug therapy became an important option in the 1990s, both Federal dollars and public enthusiasm were directed towards treatment, sometimes at the expense of fostering preventive interventions including education and condom distribution programs. Today, a dangerous misconception exists that drugs have rendered HIV/AIDS a "chronic disease" in the United States. In reality, while death rates due to AIDS have dramatically decreased in the U.S. and other industrialized nations with access to life-saving medications, new HIV infection rates remain relatively constant in America, a grim consequence of ignoring the power of preventive interventions. If HIV/AIDS is on track to become the worse pandemic in history, then it will require a sustained, two-pronged, integrated attack emphasizing and implementing effective treatment and behavioral and biological prevention strategies--mobilizing all sectors of society in a multifaceted approach worldwide.
Furthermore, the tremendous scientific and public health advances in treatment and prevention in America and other industrialized nations have not been shared equally around the world. Twenty five years after the first case was discovered, HIV/AIDS has become a global pandemic with 95% of those infected residing in the developing world. In recent years, serious efforts have been made to distribute ARV medications to people in developing nations. The WHO's "3 by 5" Initiative was a global target to provide antiretroviral treatment to three million people living with HIV/AIDS in the developing world by the end of 2005, but ultimately did not meet its goal, reaching only 1.3 million individuals. PEPFAR has made treatment a priority. The Clinton Foundation has focused its attention and support to help people in Africa, the Caribbean, and Asia, implementing replicable models for the scale-up of integrated care and treatment programs. In 2003, the Foundation announced an agreement with five suppliers of generic ARV medications that dramatically cut the price of the most commonly used triple drug therapy to less than $130 per person per year providing drugs to hundreds of thousands of people.
Third, the global HIV pandemic has had a profound multisectoral impact on many nations affecting their development, economic growth, communities, families and individuals. Many of the nations where AIDS has been most devastating also struggle with food insecurity, unsafe water, and other infectious and chronic diseases. AIDS is a national security threat with the potential to destabilize governments. That's why the fight against AIDS today must occur on many fronts and be multisectoral in nature. Affected countries, governments and societies have a critical role to play in their national response to the epidemic. Greater attention must be brought to the fight against HIV/AIDS by the international community as well. More than ever, innovative public-private sector partnerships including the Global Fund to Fight AIDS, Tuberculosis and Malaria, PEPFAR, the Clinton Foundation, UNAIDS and others, that marshal resources across various sectors and fields are needed to provide critical mechanisms to cross-cut governments, politics, cultures, and communities to defeat this deadly disease. In the future, these global partnerships will be especially crucial in the pandemic's "next wave" as it hits the shores of countries with relatively low prevalence rates today, but that have the potential to be hotbeds of the disease tomorrow. China, with its 1.3 billion population, suffers from massive under-reporting of HIV/AIDS, fueled by stigma and a shortage of testing facilities and trained health staff, especially in rural areas. Without increased public awareness and intervention, by 2010, there could be an epidemic with between 10 and 20 million HIV-positive Chinese people. Initially there was denial about the disease in China but recent governmental actions, with high-ranking government officials shaking hands with AIDS activists and meeting with AIDS patients, along with outreach efforts such as the China AIDS Media Project, suggest that attitudes are beginning to change. India has already become the "HIV/AIDS Capital of the World" with 5.7 million infected individuals, more than any other nation on the planet. In a country as diverse as India, HIV is manifesting as multiple epidemics with differing transmission routes in different states, ethnic groups, and cultures, creating serious prevention challenges for public health officials. In Russia and other Eastern European countries, HIV/AIDS is heavily concentrated among young people, where those between the ages of 15 and 29 make up 80% of all infected individuals, a sobering fact that threatens the work force and economic security of the country and its future generations. Efforts to combat this pandemic in the 21st century will inevitably be measured by how effective we are as a global community in fighting the disease in these "next wave" nations.
Clearly, the push ahead is going to be expensive but inaction will be more costly in terms of the health, societal and economic toll. Most people at risk for HIV and those living with the disease do not have access to prevention, care, and treatment. Wealthy nations and philanthropies have begun to mobilize resources to support AIDS treatment and prevention programs in the developing world - an estimated $8.9 billion this year alone. But UNAIDS calculates that at least $6 billion more is needed this year and the funding gap will increase to $12.1 billion by 2008, when at least $22 billion will be required to effectively fight the AIDS pandemic. The U.S. is a key player in the global response, contributing the highest amount to the fight against this disease but it is still only a fraction of a percent of our country's GDP. We as a nation must do more. In a recent Kaiser Foundation survey, 6 out of 10 Americans polled agreed that the U.S. has a responsibility to fight the epidemic in foreign countries compared to 44% in 2002.
So let's use this 25th AIDS anniversary landmark not just as an evaluation of past successes and failures, but as an opportunity to further strengthen the public health infrastructure in the United States and abroad, to accelerate research advances and to use the best public health practices and cutting-edge technologies to ensure that treatment advances and preventive interventions reach all nations.
While 25 million lives have already been lost, there are 25 million reasons to learn from the public health lessons of the past and apply them to a global strategy to action to fight HIV/AIDS in the future. This call to action means harnessing every nation's leadership, political will, scientific innovation, media, and individual and community awareness so that 25 years from now at the 41st International AIDS Conference, we can commemorate another discovery: how to eradicate AIDS worldwide.
* Jennifer X. Cai, a senior at Harvard University, is President of the Harvard Pre-Medical Society and served as Special Assistant to Dr. Blumenthal at the Center for the Study of the Presidency in Washington, D.C.
The timeline below charts some important milestones of the AIDS pandemic:
- 1959 - The oldest believed specimen of HIV ever detected in a blood sample from a man in The Congo
- 1981 - CDC reports 5 cases of rare pneumonia in June 5th MMWR, marking the beginning of the epidemic
- 1982 - "AIDS" is defined for the first time; modes of transmission identified
- 1984 - Robert Gallo of the National Institutes of Health in the U.S. and Luc Montagnier of the Pasteur Institute in France isolated the HIV virus
- 1985 - First HIV test licensed by FDA
- 1986 - President Reagan first publicly mentions the word "AIDS" in a letter to Congress
- 1987 - First therapy for AIDS, AZT, is approved by the FDA for use in the U.S.
- 1994 - AIDS becomes the #1 cause of death for Americans ages 25-44
- 1995 - Beginning use of highly active antiretroviral therapies (HAART)
- 1995 - First White House conference on HIV and AIDS convened by Clinton Administration.
- 1997--AIDS related deaths in the U.S. decline by more that 40 percent compared to the prior year, largely due to HAART. WHO estimates that 30.6 million people are living with HIV/AIDS worldwide.
- 1999 - First large-scale human trials for a vaccine begin
- 2000 - Millennium Development Goals include reversing the spread of AIDS, TB, and malaria as one of eight key objectives.
- 2001-- United Nations General Assembly convenes first special session on AIDS
- 2002 - Global Fund to fight AIDS, malaria and tuberculosis established
- 2003 - President Bush announces PEPFAR; WHO announces "3 by 5" Initiative
- 2006 - 25th anniversary of the pandemic
For a more comprehensive history of the AIDS pandemic, please visit:
Milestones in the U.S. HIV Epidemic (CDC):
AIDS Policy Timeline: