HIV Through the Ages - A U.S. Perspective

Date of Report: 11/2007
Source: Delta Region AETC

As the AIDS Education and Training Centers (AETCs) near their 20th anniversary, HIV providers, educators, researchers, consumers, and others throughout the U.S. also mark the 26th anniversary of the initial reports. It was in the early eighties when providers in New York and California began to find cases of an unusual lung infection, Pneumocystis carinii (PCP), and a type of skin cancer, Kaposi sarcoma (KS), in previously healthy gay men. On June 5th, 1981, the first report of these findings was published in Morbidity and Mortality Weekly Review (MMWR). This denoted the beginning of the epidemic.

Initially the disease was labeled Gay- Related Immune Deficiency (GRID). Patients were found to have a decrease in their cell-mediated immunity, particularly in the T-helper cells or CD4+ lymphocytes. Within a month after the initial reports, cases of Pneumocystis began to show up in intravenous drug users (IDU). Theories for causes of the disease were very widespread, ranging from the use of "poppers" to having multiple sex partners to intravenous drug use.

By 1982, the disease was thought to be due to a viral infection and the search to isolate the virus was on. By March 19th of the same year, 285 cases had been reported to the Centers for Disease Control and Prevention (CDC) from 17 states; cases were also reported in five European countries. Panic quickly began to build in the gay community as the number of people getting sick and dying rapidly grew. Also during this time, cases were reported in the U.S. among women, heterosexual men, hemophiliacs, and Haitian immigrants. In late 1982, the first cases of perinatal transmission were recorded.

Theories began to surface by scientists that the disease may be caused by Human T-Cell Leukemic Virus (HTLV), a retrovirus. Drs. Robert Gallo and Luc Montagnier are dually credited with first isolating the virus in 1983, originally called HTLV-III but renamed to HIV. In early 1985, the first antibody tests for HIV were developed and it was projected that only 5-10 percent of people who tested positive for the antibody would ever develop AIDS.

In 1987, the Federal Drug Administration (FDA) approved the first medication, AZT or zidovudine, for the treatment of HIV. The initial dosages for this medication were found to cause severe anemia and significant amounts of nausea. Many people felt the treatment was worse than the disease. More nucleoside analogues were developed over the next few years. Patients were treated in a sequential manner with monotherapy when it seemed that the current medication was no longer working. Meanwhile, cases were being reported from around the globe.

In 1993, the O76 study was released. This was a multi-national study that looked at the use of AZT in pregnant women infected with HIV. Results showed a nearly twothirds drop in perinatal transmission with AZT alone when given to both the mother and child. This was the first study to show a marked decrease in transmission of HIV from the use of any medication.

In 1994, AIDS became the top cause of death in the U.S. population between 25 and 44 years of age. The following year, indinavir, the first agent in a new class of medications called protease inhibitors, was FDA approved and the "HIV Cocktail" was born. Providers were beginning to pair the new medicine with one or two of the nucleoside analogues and were finding better responses. Optimism was rampant that a "cure" had been found. The first non-nucleoside reverse transcriptase inhibitor, nevirapine, was approved the following year. Patients who had been ready to die suddenly became healthier and had a renewed outlook on life. Unfortunately, resistance to the new medications was also found to occur with eventual loss of efficacy. In 2003, yet another approach to fighting the virus was approved with the release of enfuvirtide, which is an entry inhibitor.

Many features of the HIV epidemic have markedly changed over the past 25 years. For example,

	The face of the epidemic has shifted from gay white men to women and minority communities, disproportionately affecting African-American and Hispanic communities.
	The current estimate for the lifespan of a person infected in their twenties has risen from 7-10 years to 25-35 years with the current medications.
	Three to four drug regimens are the norm to decrease the development of resistance by the virus.
	Medications have been found to have significant long term effects, including insulin resistance, increase in cardiac disease, osteopenia, body shape changes with abnormal fat loss in some places and fat deposition in others, and lipid abnormalities.
	Transmission of resistant virus to naïve patients is prevalent.

Over the past twenty years, the AETCs have been providing education and training to healthcare providers throughout the U.S. As the epidemic has changed over the years, the AETCs have successfully adapted to the needs of providers and will continue to fight this disease through education and training to assure that quality care is given to all patients.