The greatest challenge in trying to develop a perspective on HIV/AIDS, especially for those of us who worked to investigate the "new" disease in the early days of the epidemic in the United States, is to get far enough away from it to allow objectivity. For all practical purposes, AIDS is still a "new disease" among humankind.
Keeping the perspective of newness is important, especially for those working to develop prevention interventions for a disease that cannot yet be controlled using traditional technological methods: vaccines are not yet available, treatments are limited, and a cure is still a vision for the future.
Our successes have been real but counted in small increments, with measurement difficult and skepticism abundant. The numbers present a formidable obstacle to our confidence in the effectiveness of prevention efforts. The first 100,000 AIDS cases in the United States were reported over a period of eight years, the second 100,000 cases in a period of only 26 months. By 1996, more than half a million AIDS cases were reported, and more than 300,000 people had died.
Although the number of cases reported each year are expected to level off in the United States, the toll of 60,000 to 80,000 annual new cases and more than 50,000 deaths each year represent by far the highest number and rate of cases in any industrialized country. Because millions of additional adolescents and young adults become potentially at risk each year, the challenge of reducing the number of youths infected with HIV (who will develop AIDS years hence) depends upon continued efforts to educate and provide skills and upon continued availability of resources for prevention.
It may provide perspective on the short history of AIDS since it was first reported in 1981 to examine these years more closely. The first five years of the epidemic can be called the era of discovery. Scientific advances were remarkably rapid -- the first cases were identified and described, modes of transmission were documented, the etiologic agent was discovered, tests were developed for screening the blood supply, and AZT, the first antiviral agent for HIV, was licensed.
Only 22 months after the first cases were reported, this devastating syndrome was named and the likely cause and modes of transmission were recognized; as a result, recommendations for preventing AIDS from being transmitted through sexual contact, blood transfusions, and injecting drug use were published. The recommendations, based on carefully studied epidemiological patterns, were published in March 1983 when there were only 1,000 reported cases of AIDS in the entire United States and before the virus causing AIDS was isolated.
Discovery of the virus that caused AIDS led to the development of diagnostic tests. The isolation of the virus and licensing of the HIV antibody test in March 1985 were true prevention successes, with procedures to protect the blood supply in place in all U.S. blood banks just two months later. In addition, uses of the antibody tests in population surveys showed that the virus was much more common than the numbers of reported AIDS cases indicated. The visible AIDS epidemic had often been referred to as only "the tip of the iceberg," and the new data proved it to be a much more substantial public health threat.
Around 1986, we entered a new era -- this was the beginning of what I call the era of growth. At a Public Health Service-wide planning meeting, it was projected that from 1986 through the end of 1991 about 270,000 AIDS cases would be reported. This prediction made people confront the future: AIDS was not going away. Thousands of people would become sick and die, and increasing services would be required to care for them.
These projections were accompanied by expressions of fear and uncertainty from the public as well as from professionals. AIDS was looked upon as "different" from other public health problems, and we were forced to confront the need for a comprehensive and imaginative response to disease prevention. The rapid growth in numbers of HIV-infected persons who were seriously ill was accompanied by fear, uncertainty, and a recognition of the need to do more to prevent infection and treat HIV disease.
During the mid-1980s, the international epidemic of HIV/AIDS was recognized. At the First International Conference on AIDS in Atlanta, Georgia, in 1985, prominent scientists who attended described the extent of AIDS in sub-Saharan Africa. Throughout the decade, HIV/AIDS spread explosively across the continent.
Fed by the rapid scientific discoveries of the early 1980s, optimism about "conquering AIDS" grew as well. There were promises from the scientific community that a vaccine would be developed shortly. The discovery of AZT made us believe that AIDS soon would become a manageable illness, like diabetes. Government AIDS research, prevention, and care budgets expanded, and the number of people working on the problem grew rapidly.
So much was happening between 1986 and 1991. Government agencies began working with nongovernmental organizations as they realized that community involvement would be a necessary component of successful prevention efforts. Governments and community-based organizations collaborated to provide services in the area of prevention and in providing medical care and social services for the increasing numbers of people with HIV-related disease. Sadly, many of the hundreds of thousands of people hidden below the iceberg's tip became ill and died-those who were infected during the first five years of the epidemic but didn't know it.
These years were also characterized by growing news media interest. This interest was accelerated by Rock Hudson's announcement that he had AIDS and his subsequent death, followed by the saga of Ryan White, a teenager with hemophilia who acquired HIV from infected blood products and was banned from his school out of fear and ignorance. His pioneering and well-documented battle with school discrimination and with the illness itself focused the United States on the need to know more about AIDS-and on the need to be more compassionate.
By the 1990s, increases in the number of reported AIDS cases had slowed in the United States, even though AIDS cases worldwide continued to increase rapidly, particularly in Africa, Southeast Asia, and South America. In the United States, however, the horizons were becoming clearer, and many Americans began to accept and expect AIDS as part of life. For many, this led to complacency or relapse into high-risk behavior, while for others, concerns about AIDS were more strongly inculcated.
In 1992, what I called the era of the "long haul" began. HIV became the leading cause of death among men between the ages of 25 and 44 in the United States, and the fourth leading cause of death among U.S. women in this same age group. Even though AIDS was "leveling off," 50,000-60,000 young Americans were dying each year of an illness that was, and still is, preventable.
As a result of this "leveling off," budgets grew smaller, and HIV/AIDS now competes for prevention and research dollars with many other important health issues. At the same time, it has become clear that HIV is a complicated public health problem, one that is intertwined with many other serious medical and societal problems -- multidrug-resistant tuberculosis, poverty, drug use, domestic violence and abuse, and the crumbling infrastructure of public health services.
The HIV epidemic is not one, but many epidemics that are changing and evolving. While the earliest cases were nearly all among white homosexual and bisexual men and male injecting drug users, there has been a marked growth in the proportion of cases among women, infants, and minorities. Public health HIV prevention strategies will have to take into account these complexities, just as the basic science strategies must consider the complex pathogenesis of HIV.
Ongoing efforts continue to focus attention on several key points to maximize prevention effectiveness.
First, AIDS is a devastating disease that prematurely robs people of their health and lives.
Second, HIV infection is preventable. Our detailed knowledge about modes of HIV transmission and about biological and behavioral risk factors guides us in prioritizing prevention efforts. Scientific studies of condom effectiveness, preventing transmission from nonsterile injection equipment, and, especially, the discovery that AZT therapy can reduce the rate of perinatal transmission, provide us with powerful prevention tools.
The coming years should see a dramatic decline in pediatric HIV infection in the United States due to effective prevention efforts. Successes in decreasing sexual transmission of HIV among adult gay men in the United States and among heterosexual men and women in Thailand are dramatic examples of how prevention works. Several studies extend and explain the reasons for these and similar successes. School programs that emphasize knowledge and training in communication and other skills are being shown to delay the onset of sexual activity and alter high-risk behaviors among adolescents, the next generation at risk for AIDS.
Over the course of the epidemic, the successes have been gratifying and have given us strength, but they have been and continue to be pitted against the foes of HIV prevention: denial, discrimination, and scarcity. HIV prevention efforts must be strong enough and remain visible enough to warn and protect current and future generations of young men and women. These prevention efforts will be successful only if they are coupled with sustained, visible efforts to prevent discrimination against those who are infected and at risk.
The third and final lesson is that, particularly on a worldwide basis, we have not done enough. The onslaught of HIV infection continues to overwhelm prevention efforts in most developing countries.
HIV prevention cannot be viewed as a one-time intervention; it must be accepted as a continuous, multigenerational effort that extends well into the lifetimes of our children and their children. Thinking long-term and remaining committed are the key characteristics needed in both science and prevention in order to maximize the chances of conquering HIV.
James W. Curran, M.D., M.P.H., is Dean of the Rollins School of Public Health at Emory University in Atlanta, Georgia. He was formerly director of the Division of HIV/AIDS for the U.S. Centers for Disease Control and Prevention (CDC) and Assistant Surgeon General of the U.S. Public Health Service. This foreword was written in collaboration with Linda Elsner of the CDC.
The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright © 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.
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