AIDS At 30: Hard Lessons and Hope
Thirty years after the first official reports about HIV/AIDS, we look back on the human devastation and forward to a changed social landscape. The infection has killed more people so far than has any other discrete epidemic, except for the Great Influenza pandemic of 1918–1919 and the Black Death of the Middle Ages. It has destroyed individuals, families, and societies. Yet HIV/AIDS has also raised public health to new levels of science, conscience, and innovation. Review editor Madeline Drexler asked distinguished Harvard School of Public Health faculty and alumni where the epidemic has taken us and where it is headed.
Q: HIV/AIDS has been one of the most catastrophic epidemics in all of history. Despite this tragic human toll, are there ways in which HIV/AIDS changed public health for the better?
Fineberg: Yes, because it was the beginning of a new understanding of global health—a commonality of risk and burden. The U.S. as a wealthy country and Uganda as a developing country: both faced the same disease problem, though in different ways. At the World Health Organization, Jonathan Mann, who would later join the School as founding director of the FXB Center, also helped define a new way of thinking about public health. He tried desperately to mobilize the world, awaken the world, to this looming disaster. He repeatedly described the inseparable nature of health and human rights.
Marlink: The epidemic toppled myths in public health. People said we couldn’t do anything about the epidemic in developing countries—we’ve shown that’s not true. People then said AIDS would pull resources away from malaria or childhood diseases and maternal health—we’ve shown that AIDS has dramatically increased total public health funding in Africa, including in these areas. AIDS has also brought about unprecedented international cooperation, such as the creation of UNAIDS and of the Global Fund to Fight AIDS, Tuberculosis and Malaria, among others.
Walensky: Investments that have benefited HIV/AIDS patients have improved health care in general. What is generally underestimated is what those resources have done for health care infrastructure, worker training, protocol development, clinical care sites, preventing children from being orphaned, preventing mother-to-child transmission, and making drinking water safe.
Essex: I compare our response to HIV/AIDS to President Nixon’s war on cancer in 1972, which opened the floodgates for money on research. Rates of cancer deaths didn’t go down for a long time, but what did happen was a revolution in molecular biology. That revolution led to things that we wouldn’t have anticipated: biotechnology, the rejuvenation of pharmaceutical companies, a renewed emphasis on applied research. That’s where we are today with AIDS vaccines. Whatever knowledge is gained from a war on AIDS will help us make vaccines against cancer, heart disease, and other diseases.
Q: Let’s talk about specific responses to the epidemic. First, what are some things that have gone right?
Walensky: I was on the clinical AIDS service in Baltimore in early 1996 when the first drug cocktail was FDA-approved. Literally, during my residency, HIV-infected patients went from universally dying to living. I probably won’t witness anything like that again in my career. Today, amazingly, there are more antiretroviral drugs for HIV/AIDS—even in its short history—than for all other viruses combined.
Q: Many things also went terribly wrong. Looking back, how would you have rerun the world’s response to AIDS since 1981?
Fineberg: In the United States, the epidemic first became apparent in gay men. Ideally, political leaders, public health authorities, and enlightened gay leaders would have been much more aggressive early in recognizing and working together to control transmission. This idea that public health measures were anti-gay measures—we had to get over that sooner. All of the distractions about condoms, because they carry other connotations, were shameful, because lives were at stake. And we had a president who early on refrained from uttering the word “AIDS.”
Q: What will AIDS look like in another 30 years?
Essex: I’m concerned about the capacity of the virus to evolve. Some of the viruses already in Africa are easier to transmit than the ones in the U.S. If those viruses spread around the world and infect people, it could cause higher rates of infection.
Fineberg: What it will take to turn around the epidemic are breakthroughs in the science. A more available, safer, less expensive treatment that actually interrupts transmission. A reasonably effective vaccine. That would accelerate the downturn.
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