Lessons Learned from the Early Days of HIV/AIDS

Harold W. Jaffe, MD

By looking back on the early days of the HIV/AIDS epidemic, the medical community can learn many lessons, including the value of multidisciplinary teams, the vital role of acute care clinicians, the insight that can be gained from simple studies, how to properly engage infected communities, and how to address the fears of the public.

“Given that emerging infections continue to surprise, are we now more prepared than we were in the early days of AIDS?” Harold W. Jaffe, MD, said in a presentation at the 25^th Conference on Retroviruses and Opportunistic Infections (CROI), in Boston, Massachusetts. “In some ways, I think the answer is yes.”

When the Centers for Disease Control and Prevention (CDC) published its weekly morbidity and mortality report on June 5, 1981, Jaffe said, “Neither I nor my CDC colleagues were prepared for what crashed down on our heads.”

That year, Jaffe, an infectious disease specialist with the CDC, was working with colleagues on suppressing a reemergence of syphilis in the United States. At the time, physicians in the US believed the end of infectious disease was in sight. Just 3 years prior, Robert G. Petersdorf, MD, had written that “even with my great personal loyalties to infectious disease,” he could not fathom the need for more of these specialists.

Yet, as Jaffe would point out, they were faced with a new pestilence, one they could not have prepared for: human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).

Originally believed to be complex cases of Pneumocystis pneumonia (PCP) and Kaposi sarcoma (KS), within a month, more reports of patients with the condition were coming from Los Angeles, New York City, and San Francisco. Some of these patients were dying, most were of the men who have sex with men (MSM) population, and all were found to be immunodeficient, which confused physicians at the time, Jaffe said.

In order to determine what was occurring, the CDC began collecting systematic reports, developing a case definition of KS/OI (Kaposi sarcoma/opportunistic infections). “Soon we began receiving reports of KS/OI in gay men from additional American cities,” Jaffe said. “We also noticed that a small number of cases had been diagnosed in 1979 and 1980 but had not been reported.”

Born forth of this puzzling and alarming scenario were 3 major theories, Jaffe said. They were the sexually transmitted infections (STI) theory, the environmental theory, and the immune overload theory.

“Given the high rates of sexually transmitted infections seen in MSM at the time, a [sexually transmitted disease] was a prime suspect,” Jaffe said. “The environmental theory postulated that an immunosuppressive drug or chemical was the cause, and here, the leading suspects were nitrite inhalants, known as ‘poppers,’ used to enhance sex with men. Finally, there was the immune overload theory, that suggested there was no single ideology—rather, immunodeficiency resulted from the cumulative effects of multiple infectious agents, environmental toxins, and perhaps other factors, such as exposure to semen.”

After a CDC-run trial revealed that this patient population was more likely to have more sexual partners and that ‘poppers’ were not immunotoxins, as believed, the STI theory gained traction, and the condition became known as AIDS.

The public reception of the condition that seemingly only impacted MSM was mostly flippant, Jaffe said, until January 1983, when the CDC revealed a wider population of at-risk patients, which included those who were transfusion recipients, patients with hemophilia, injection drug users, female sex partners of men with AIDS, and those born to mothers with AIDS.

Then, on March 4, 1983, the CDC published its first guidelines for prevention of AIDS, which recommended that sexual content avoided with those with AIDS, that high-risk group members should be aware that increased sexual partners raised their risk, and that those at-risk should refrain from blood and plasma donations.

“In retrospect, these key recommendations related to sexual activity and blood donation were essentially correct, and were based entirely on epidemiologic studies,” Jaffe said.

Just 2 months later, François Barré-Sinoussi, Luke Montagnier, and colleagues in Paris, reported isolating a novel retrovirus that they called LAV (lymphadenopathy-associated virus), from the lymph node of a homosexual man, Jaffe said. A year after that, Robert C. Gallo and colleagues demonstrated the virus that they called HTLV-III (human t-lymphotropic retrovirus type III), which they claimed was the cause, and subsequently helped to develop the first diagnostic test to screen antibodies of the virus in the blood.

Meanwhile, Jaffe noted, African patients with AIDS began to appear in European clinics, bringing the infectious disease community’s attention to central Africa, where yet another epidemic was underway. These patients were remarkably heterogeneous compared to previously noted populations—the male to female ratio was approximately 1 to 1. Additionally, homosexuality, intravenous drug use, and blood transfusions were not found to be risk factors among this population.

By 1985, the concern about the virus in the United States quickly became fear. People began to believe casual contact could transmit the disease.

“This fear resulted in unwarranted discrimination against infected persons,” Jaffe said. “A leading symbol of this discrimination was Ryan White, an HIV-infected teenager with hemophilia who was not allowed to attend school for fear of contagion. As his school attendance was being debated, someone fired a bullet through the window of his home.”

Fortunately, a Montefiore Medical Center and CDC study soon brought forth the guidelines for the education and foster care of HIV-infected children. Coupled with studies dispelling the believed occupational risks of acquiring HIV, they soon became the basis for public health education to destigmatize the disease.

As time passed, more federal programs and funding would lead to antiretroviral therapies and advancements in the treatment of the condition. As important, however, are the lessons to learn from the early days, which “have been and will be tested by new health threats,” Jaffe said.

While it tested the medical community, the epidemic taught lessons to physicians that have advanced the way infectious disease is approached. Jaffe noted that there are now international health regulations which aide in countries’ abilities to respond to and assess health threats.

With the absence of a vaccine or curative therapy, Jaffe said, conventional wisdom says that it is too hard to end the epidemic as a public health threat.

“But looking back on the early days of AIDS, we see the conventional wisdom may be wrong,” Jaffe said. “In speaking about the goals of the US Space program more than 50 years ago, President John F. Kennedy said, ‘We choose to go to the moon not because it is easy, but because it is hard.' I’d like to think that if he were speaking about AIDS, President Kennedy would say we choose to end the epidemic not only because it is hard, but also because it is right.”

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