After 25 Years and 25 Million Deaths, AIDS Pandemic Rages On

ATLANTA, June 9 ? They were the seven paragraphs that changed the world.

In the June 5, 1981, issue of Morbidity and Mortality Weekly Report, seven paragraphs detailed five cases of Pneumocystis carinii pneumonia in gay men in three Los Angeles hospitals.

The following month, a second shoe dropped. The CDC reported that 26 cases of Kaposi's sarcoma had been diagnosed among gay men in the previous 30 months. Eight had died.

The virus that became known as HIV had begun to make its presence felt.

Twenty-five years later, the AIDS pandemic has killed more than 25 million people around the world; and in 2005, nearly 40 million people are living with HIV. While there are some hopeful signs, there is little indication that the pandemic is burning itself out.

"The latest statistics offer a ray of hope," says Mark Wainberg, Ph.D., of Montreal's McGill University, but "we have not really turned any kind of corner, as long as several million people still die each year of HIV disease." Dr. Wainberg, a former president of the International AIDS Society, is a co-developer of the anti-retroviral drug 3TC (lamivudine).

He quoted from mortality statistics from the Joint United Nations Program on HIV/AIDS (UNAIDS). As well as compiling the latest death and infection tolls, UNAIDS also reported at the end of May that there has been "important progress" in treatment and prevention in some countries, even while new epidemics are raging in others.

Some key findings:

• International funding for the public health response to HIV/AIDS grew from .6 billion in 2001 to .3 billion last year, and domestic resources in heavily impacted nations added another .5 billion. But the need continues to grow, and UNAIDS estimated that starting in 2008, about billion a year will be needed.
• Six African countries reported declines of 25% or more in HIV prevalence among 15- to 24-year-olds in their capital cities.
• Access to antiretroviral therapy in low- and middle-income countries has expanded from 240,000 people in 2001 to 1.3 million people in 2005. However, HIV treatment coverage varies considerably: in sub-Saharan Africa. For instance, treatment coverage ranges from 3% in the Central African Republic to 85% in Botswana.

The pandemic has two faces. On one hand, there's the desperate battle in the developing world, where in some countries more than a quarter of the population is HIV-positive, there is little access to medications, and what drugs are available have serious toxicities.

And there's the developed world, where a wide range of medications exists ? convenient to take, easily tolerated ? and the pandemic has largely faded from public view.

Taking care of patients is enormously better than it was at the start of the pandemic, says Joel Gallant, M.D., a researcher and HIV specialist at Johns Hopkins Baltimore. "The treatments are incredibly effective, they're much better tolerated, and they're much simpler."

At the beginning, of course, there were no treatments for what was initially called Gay-Related Immune Deficiency (GRID), simply because no one knew what was happening. In 1983 and 1984, labs in France and the U.S. located the causative agent ? the lentivirus HIV ? and in 1987, the first antiretroviral, AZT or Retrovir (lamivudine) was approved.

Retrovir had to be taken every four hours and was, in the last analysis, not effective, simply because the highly changeable HIV just evolved resistance and kept on attacking the immune system. Other drugs followed, but it was not until 1995 and 1996 that researchers showed that a combination of three anti-retrovirals, from different classes, could beat back an HIV infection and prevent death from AIDS.

The era of highly active anti-retroviral therapy (HAART) had begun and ? in the U.S., Canada and Western Europe ? the death rates began, for the first time, to drop.

"People who become HIV-positive these days have every reason to expect a fairly full lifespan, with a fairly good quality of life," says Dr. Gallant.

One worrisome side effect of that expectation, he says, is that many people in the developed world no longer fear HIV.

According to the CDC, more than one million people are living with HIV or AIDS in the U.S., and about 40,000 will be infected this year. Between 252,000 and 312,000 people in the U.S. are HIV-positive but unaware of it, putting them at high risk to spread the disease unwittingly. And some subpopulations are at increased risk:

• Men who have sex with men (MSM) account for about 45% of newly reported HIV/AIDS diagnoses.
• During the years 2001 to 2004, in 35 areas with HIV reporting, 51% of all new diagnoses were among blacks, who are only about 13% of the U.S. population.
• Women now account for 25% of all new HIV/AIDS diagnoses.
• In 2002, HIV infection was the leading cause of death for black women between ages 25 and 34.

While the pandemic rages in the developing world, "we're not doing such a good job of prevention either," said Dr. Gallant. "Even in the gay community, which seemed to have things under control, we're seeing a resurgence of new cases among young gay men."

"I'm seeing more and more people who just don't seem to be afraid of this disease."

A solution would be a vaccine against the virus, but researchers ? although they're still trying ? have made little progress.

Dr. Wainberg says an HIV vaccine is not on the horizon any time soon. "We probably won't have one for another 100 years," he says. "This is why we now need to put so much effort into microbicides and pre-exposure prophylaxis."

The pandemic will also need new therapeutic options, he says. "The need for new drugs will always be with us," Dr. Wainberg says, so long as the virus continues to evolve resistance to the medications.

"I believe that the best short-term hope will come through introduction of massive treatment programs in Africa, that will diminish viral loads on a population basis, and that this will translate into diminished rates of new infections," Dr. Wainberg says.

Indeed, says Dr. Gallant, drugs in the developed world are likely to continue to get better and better. Already, the toxic, inconvenient, and complicated regimens that were common only a few years ago have been replaced by regimens that require patients to take one or two pills a day.

But in other countries, he says, "we're being forced to use drugs we would never consider using here, because of cost." The best new drugs will probably never reach the millions of people who need them the most.

"It's inconceivable that we're going to control this epidemic with treatment alone," Dr. Gallant says.

Instead, what's needed is to prevent new infections and to treat those already carrying the virus. But public health programs ? as the UNAIDS report points out ? are patchy. Some countries have good prevention programs, but poor access to treatment. Some have good access to treatment, but are doing little to prevent new infections.

And some countries ? usually the poorest of the poor ? have neither.

"This is the most devastating epidemic in the history of the planet and will continue to be so for the foreseeable future," Dr. Gallant says.