Three Decades of HIV/AIDS

Historical Overview

HIV/AIDS, unfortunately now a household term, was first described 30 years ago. This year represents an "anniversary" of sorts for the disease, providing an opportunity not simply to look back (which has been done effectively elsewhere), but also to analyze our current approaches in the United States and refocus our efforts on high-risk and emerging groups at risk. Behavior change, the backbone of prevention of new infections, is at risk of being displaced by biomedical interventions. The 30-year mark directs our attention to opportunities arising next year that may help revitalize the national conversation and the agenda for prevention of this disease.

The first report of what we now know as "AIDS" was published in June of 1981 in the Centers for Disease Control and Prevention's (CDC's) Morbidity & Mortality Weekly Report.^[1] This report described a type of pneumonia -- then known as Pneumocystis carinii and since renamed P jiroveci -- that affected mainly immunocompromised individuals. Similar reports quickly followed.^[2,3] Two years later, the virus (HIV) responsible for AIDS was isolated by Montagner and Gallo who share a Nobel prize for that accomplishment.

The initial risk groups that were identified consisted of gay men and injection drug users. Sexually linked cases in gay men, persons with hemophilia, and transfusion recipients demonstrated that, in the United States, transmission occurred by male-to-male sexual contact as well as through blood and blood products. Cases in heterosexual individuals and infants indicated that transmission could also occur through heterosexual contact and from mother to newborn. Incident infections peaked in 1984 and 1985, with about 130,000 cases per year. Subsequently, the rate of new infections dropped significantly, indicating that prevention programs were successful over time. In recent years, however, the incidence of HIV/AIDS has plateaued, with an estimated 56,000 new infections every year.^[4] Other countries (Thailand and Uganda) have been able, with behavior change, to stem the tide of new infections among their populations. Globally, however, the virus still spreads unchecked in many countries.

AIDS, Homosexuality, and Human Rights

Throughout the epidemic, it was clear that homosexual males were at particularly high risk for HIV/AIDS. They were the first group affected, and after 30 years, the one constant in HIV/AIDS work is that gay men remain an important risk group for the disease. More than any other disease, HIV/AIDS became inextricably linked with human rights. It attracted powerful advocates as well as powerful detractors, but became arguably the world's most visible disease. From the outset, HIV/AIDS discussions have been about far more than the science. Any attempt to examine the disease now must take into account the issues of advocacy, male-to-male sexual behavior, interventions targeted at behavior change for heterosexuals and homosexuals, and the unique cultural milieu in which AIDS exists. Unlike malaria, cholera, or influenza, with HIV/AIDS, the politics of science, identity, culture, and even religion become wrapped up in a discussion of policy to combat the disease.

Recent Advances in Treatment

In the last decade, one of the most important scientific advances has undoubtedly been the advent of antiretroviral therapy (ART), also known as highly active antiretroviral therapy (HAART). HAART was used initially as a supplement to prevention, which is the most critical aspect of disease control. However, the discussion on treatment is now in danger of assuming disproportionate importance.

Along with driving down HIV-related death rates, advances in ART clearly suggest that HIV infections can be averted by driving down viral loads. Recent findings, including the Pre-Exposure Prophylaxis (PrEP) study,^[5] the Center for AIDS Program Research in South Africa's 004 Microbicide Study,^[6] and the HTPN052 clinical trial,^[7] have given us new pharmacologic tools with which to control the epidemic. This success comes at a price, overshadowing behavior-change efforts that historically have dramatically reduced HIV infections.^{[8,9,10,11,12,13]} Treatment has become a new tool for prevention, and although new tools are essential, excitement about these therapies and "test and treat" methodologies must not undercut efforts in prevention that have always been, and remain, essential to ending the epidemic.

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