Learning from the Early HIV/AIDS Epidemic

Harold W. Jaffe, MD

Centers for Disease Control and Prevention

Atlanta, GA

1981

The End of Infectious Diseases?

“Even with my great personal loyalties to infectious disease, I cannot conceive of the need for 309 more infectious-disease experts unless they spend their time culturing each other.”

- Robert G. Petersdorf, “The Doctors’ Dilemma”

(1978)

N Engl J Med 1978;299:628

The End of Infectious Diseases?

“Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky”

- Albert Camus, “The Plague”

(1947)

Primary and Secondary Syphilis United States, 1969-1980

MMWR. Sept 11, 1981

The First 1,000 Reported AIDS CasesDistribution by Risk Group

Risk group* Percent of cases

Homosexual/bisexual men 72.7

IV drug users 15.5

Haitians 5.0

Hemophiliacs 0.7

Others 6.1

*Hierarchy of mutually exclusive risk groups

J Infect Dis 1983;148:339-45

MMWR PublicationsDecember 1982 – January 1983

• Update on Acquired Immune Deficiency Syndrome (AIDS) among Patients with Hemophilia A (12/10/82)

• Possible Transfusion-Associated Acquired Immune Deficiency Syndrome (AIDS) – California (12/10/82)

• Unexplained Immunodeficiency and Opportunistic Infections in Infants – New York, New Jersey, California (12/17/82)

• Immunodeficiency among Female Sexual Partners of Males with Acquired Immune Deficiency Syndrome (AIDS) – New York (1/7/83)

Ryan White

The Ray Brothers

HIV Infection in Nonsexual Household Contacts of 39 Patients with AIDS or AIDS-related complex

New York City, 1984-5

Contact group No. screened No. infected

Children <6 yrs. 21 1*

Children 6-18 yrs. 47 0

Adults 33 0

Total 101 1

*5-year-old born to mother with AIDS

N Engl J Med 1986;314:344-9

Public Information

Public Information

Belle Glade, Florida

“AIDS in Belle Glade may be a sign of things to come in the US. because there are hundreds of other poverty-stricken, mosquito breeding towns.”

Dr. Mark Whiteside, Ottawa Citizen, April 17, 1986

A Community Survey of HIV InfectionBelle Glade, Florida, 1985-6

• HIV prevalence in randomly selected persons– Adults: 28/877 (3.2%)– Children: 0/138

• No household clusters (except sex partners)• No infected adults over age 60• No association with antibodies to arboviruses• Infections associated with Haitian origin, low

income, sex with IDU, STD treatment history

Science 1988;239:193-7

Understanding AIDS1988 Brochure

Heterosexual AIDS

Trends in Condom Use by 9th through 12th Grade Students, YRBSS, 1991-2011

1991 93 95 97 99 2001 03 05 07 09 110

10

20

30

40

50

60

70

80

90

100

Year

Us

ed

co

nd

om

s d

uri

ng

la

st

se

xu

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inte

rco

urs

e (

%)

Occupationally Acquired HIV

The Lancet, December 15, 1984

“AIDS: What the Government Isn't Telling You”

“Aerosolized blood can pass through a mask like BBs through a tennis net.”

“…[I] face a 49% risk of becoming HIV-positive in the next five years.”

“Why do I have to take care of a patient with a concealed weapon, AIDS”… [without knowing the results of their blood test]Lorraine Day, Chief, Orthopedic Surgery,

San Francisco General Hospital

HIV Serosurvey of Orthopedic Surgeons, March 1991

87% of participants reported a blood-skin contact and 39% a percutaneous injury in the previous month

2 (0.06%) of 3420 participants tested HIV seropositive

Both reported non-occupational risk factors

Reducing the Risk of Occupationally Acquired HIV

• “Universal Precautions” to prevent exposure to potentially infectious body fluids

• Safe disposal of used needles• Development of safer medical devices• Post-exposure prophylaxis with ARVs

Occupationally Acquired HIV Infections in Health Care Personnel*

United States, 1985-2013

012345678910

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

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2004

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2013Nu

mber

of Co

nfirm

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fectio

ns

Year

*Documented seroconversion temporally related to a specific exposure to a known HIV-infected source

MMWR 2015;63:1295

AIDS Activism

Activism and the FDA

• AZT approved for use 2 years after publication of in vitro studies

• Treatment IND to make experimental drugs available to persons with serious illnesses outside of the clinical trial context

• New regulations to expedite review of drugs designed to treat life-threatening or seriously debilitating diseases

Mortality and HAART Use Over TimeHIV Outpatient Study, CDC, 1994-2003

0

2

4

68

10

12

14

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Dea

ths

per

100

PY

00.10.20.30.40.50.60.70.80.9

Pat

ient

s on

HA

AR

T

Patients on HAART

Deaths per 100 PY

Treating HIV/AIDS in the Developing World

“[Africans] do not know what watches and clocks are. They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain sequence of time during the day and when you say take it at 10:00, people will say what do you mean by 10:00?”

- Andrew Natsios, USAID Administrator, 2001

The President’s Emergency Plan for AIDS Relief

• Announced January 28, 2003

• 15 focus countries• Goals:

− Treat 2 million HIV-infected people

− Prevent 7 million new HIV infections

− Provide care for 10 million HIV-infected people and AIDS orphans

Overall budget for global AIDS: $15 billion over 5 years ($10 billion new money)

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

155,000471,000

822,000

1,450,000

2,100,0002,400,000

3,200,000

3,900,000

5,100,000

6,700,000

7,700,000

PEPFAR Rollout of ART by Year

Number of People

A Tale of Two Viruses

Human Immunodeficiency Virus

Ebola Virus

Emerging Infections

“As the HIV disease pandemic surely should have taught us, in the context of infectious diseases, there is nowhere in the world from which we are remote and no one from whom we are now disconnected.”

- IOM, 1992

.

H. D. Marston et al., Sci Transl Med 2014;6:253ps10

Published by AAAS

The Viruses

HIV Ebola virus

Family Retroviridae Filoviridae

Animal host ChimpanzeesGorillas

Bats (?)

Distribution Global Africa

Latent infection Yes No

Transmission Sexual, Transfusion/IDU Perinatal

Direct contact with blood/body fluids

The Diseases

AIDS EVD

Ave. incubation 10 years 8-10 days

Case-fatality rate >90% ~50%

Cases Millions Thousands

Treatment ARVs Supportive

Vaccine None In clinical trials

HIV/AIDS and the Media

Kaiser Family Foundation. Supplement to March/April 2004 issue of Columbia Journalism Review

Ebola and the Media

New York Times, January 8, 2015

Learning from the Early HIV/AIDS Epidemic

“…we might try to explain the phenomenon of the plague, but, above all, should learn what it had to teach us.”

- Albert Camus, “The Plague”

(1947)