More so than the other historical summaries in this course, defining a history of AIDS is a difficult task. Epidemics of the disease have taken different forms based on their geography, and the human elements of this story are inseparable from the scientific search for a cure. What follows are two stories from two continents: one is the spread of AIDS in Sub-Saharan Africa and policy measures to confront it. The second is the development of the AIDS epidemic in the US. Together, intermingled, these histories comprise at least a partial image of the much larger story of AIDS.

Origins of the HIV Virus

Where did HIV come from? The answer to this question was long unknown. While one of the first recorded cases of HIV infection occurred in 1959 in Kinshasa, Democratic Republic of Congo, the virus’ ultimate source remained mysterious⁷. Scientists now believe that they have traced the origin of HIV-1 to chimpanzees in Western and Central Africa⁸. While strains of Simian Immunodeficiency Virus (SIV) were previously discovered in primates, these pathogens were not particularly similar to HIV. However, a SIV strain much closer to HIV was found in a species of chimpanzee that lives primarily in Western and Central Africa – the place where human cases of HIV infection were first reported⁸. Thus, HIV appears to have begun in an animal reservoir from which it jumped to infect humans.

However, the mechanism by which the virus transferred to humans remains unknown. One explanation is that an infected chimpanzee was consumed by a hunter, who subsequently became infected with the virus himself: this first human case allowed HIV to then be transmitted between people⁹. On the other hand, another hypothesis asserts that the conditions of African colonialism – the economic and political system under which many European powers divided up the African continent into territories under their control – favored the species jump between humans and chimpanzees¹⁰. One piece of evidence for this theory is that the institution of labor camps, where malnourished Africans would work for long periods, coincided with the rise of HIV. Perhaps the weakened immune systems of these abused workers made it easier for the virus to infect humans.

In addition to these suggestions, inaccurate and/or scientifically refuted explanations have been offered. One such hypothesis proposed that a native ritual involving human consumption of ape blood caused the virus to infect humans¹¹. Anthropology scholars have pointed out that this idea is based on a prejudiced view of Africa as a culturally backward nation. There has never been any evidence that rituals of this kind actually existed. Another persistent myth suggests that HIV is a biological weapon designed by the US Government to wipe out homosexuals and African Americans¹². Yet another inaccurate hypothesis asserts that infected chimpanzee cells were used in preparations of polio vaccine, thereby spreading the virus to poliov accinated patients. Incidentally, this claim was later refuted through laboratory analysis of the vaccine preparations¹³.

The story is further complicated by scientific evidence that HIV may have been present even earlier than 1959 in the human population. Examples of HIV-like infection crop up as early as 1939 in Germany¹⁴. Even earlier cases may have occurred in West Africa in 1930¹². Though such early instances are not plentiful, each possible “first case” inevitably complicates the exact mechanism by which HIV became transmissible within the human population.

The Sails Come In: 1976

Whatever the ultimate origins of the virus, HIV’s introduction to the US might have coincided with July 4th Celebrations in New York City during the bicentennial¹⁵. While epidemiologists certainly have not resolved the issue, the conjunction of people from all over the world might well have allowed HIV to enter the US population. Years later, evidence of this new pathogen would begin showing up in clinics from New York to San Francisco Bay.

Strange Purple Spots: 1981

St. Francis Hospital physicians were surprised to see the symptoms. The patient, a 37-year old homosexual resident of San Francisco, had suffered from mild stomach problems for two years before the purple splotches began appearing on his skin. Finding that the patient’s lymph nodes were swollen, a biopsy was sent to a pathologist at UCSF, who provided the diagnosis of Kaposi’s Sarcoma (KS), an extremely rare form of cancer typical of much older patients. This was the first diagnosis of KS in San Francisco. Meanwhile, the patient was worsening, and tests revealed that his headaches were caused by Cryptococcus, a common (and normally harmless) fungus found in pigeon droppings. Something odd was going on, but physicians at St. Francis could not tell what it was.

PCP at UCLA: 1981

Among the first hints of the coming epidemic were the increasing number of homosexual patients with Pneumocystis carinii pneumonia (PCP) seen in UCLA in early 1981. PCP was a highly rare infection, making the volume of cases peculiar. Initially, high levels of cytomegalovirus (CMV) in the blood of these patients made doctors think that the virus was somehow involved, though it was proving more harmful than usual. As additional cases from the county Public Health department were announced, doctors at UCLA decided to publish a report about these findings. They initially approached the New England Journal of Medicine, but after learning of the slow turn-around time, opted instead for the Morbidity and Mortality Weekly Report, a publication delivered to thousands of hospitals and other health care providers. The report, published on June 5, 1981 by the CDC, would later become a well-known starting point of the AIDS epidemic.

Patient Zero

Ultimately, many of the early HIV victims were revealed to have been partners of Gaetan Dugas, an airline steward from Quebec who frequently traveled between NYC, San Francisco, and other cities. He became known as “Patient Zero” in reference to an epidemiological starting point of the AIDS epidemic. Of course, the disease predated him, but Dugas has nevertheless acquired historical importance as the common relation between many infected with HIV during the early years of the epidemic. He could ultimately be connected to 9 of the 19 cases in Los Angeles, 22 in NYC, and 9 cases in 8 other cities in the US. As a result of this analysis, it became clear that the disease was transmissible. However, the many routes of infection were only hinted at by clinical observations at the time.

Bad Blood

The parents of a baby boy who had received a recent blood transfusion at UCSF were dismayed. After receiving the transfusion, the child was now suffering from what appeared to be an immune dysfunction. Medical records revealed that a 47-year-old man with swollen lymph nodes had donated recently, and that whatever had infected the boy probably originated in this older patient. The potential contamination of the blood supply was just becoming clear, and new safety precautions would have to be taken following the rise of HIV in the US population. At the height of the scare, 194 such cases were reported across 30
states, with infants accounting for 10% of incidents¹⁶.

Perhaps the most famous victim of infection through blood transfusion was Ryan White, a teenaged hemophiliac who was diagnosed with AIDS in 1984¹⁷. Attempting to return to school after receiving this news, Ryan continually confronted fear and misunderstanding – his school system initially wished to prevent him from attending, and many of his classmates chose to become homeschooled rather than share a classroom with an AIDS patient¹⁷. Ryan ended up switching to a more tolerant school system, and began appearing on national news programs to promote understanding about the disease¹⁷. Dying at age 18, his funeral was attended by many celebrities, including Elton John, who dedicated the song “Candle in the Wind” to the deceased teen¹⁷. A national AIDS care program now bears the teenager’s name, the Ryan White Care Act¹⁷.

As physicians became aware of this route for HIV transmission, donors were more carefully screened before their blood was added to the transfusion pool. Doctors began performing laboratory tests to check for evidence of HIV in samples from potential donors, and the procedures for such tests improved over time. A retrospective study indicated that these measures have been effective: the estimated risk of being infected with HIV through a blood transfusion is 1 in 677,000 units of blood¹⁸. Further, routine testing of first-time donors over the interval 1991-1996 suggests that these individuals have a much lower prevalence of HIV infection than the general population¹⁹. What is more, that prevalence declined further over the five years considered in the report¹⁹. However, there is still cause for concern: research has also demonstrated that routine blood tests can sometimes miss viruses present in blood samples if the amount of virus is too small²⁰, which can occur with HIV when the virus has not yet begun replicating at full capacity inside its host. Clearly, vigilance is still necessary.

Theories of Transmission 1981-82

Initially, it was unclear exactly how this new disease was transmitted between patients; the initial article in MMWR merely mentioned a correlation between homosexual lifestyle and the new outbreak of PCP. The pieces of the puzzle began to fall into place at San Francisco’s Public Health Department when reports accumulated showing a pattern of infected lovers, roommates and friends. Though lacking hard proof, scientists began to believe that the condition was probably transmitted through sexual contact. At nearby UCSF, researchers had similar thoughts, suspecting that the label the disease had acquired – Gay-Related Immune Deficiency (GRID) – was misleading. For the time being, Washington wasn’t funding research into the new epidemic, even though, as an angry newspaper in San Francisco pointed out, millions had been spent only years earlier on the relatively rare Legionnaire’s disease. This theme would continue throughout the early years of the AIDS epidemic, with the virulence of HIV compounded by the stigmatism initially attached to the illness.

1982-83: A Storm Brews

Through 1981, HIV infection remained a gay-associated disease in the US. Meanwhile, unnoticed by much of the Western world, the first hints of a new African medical epidemic emerged in 1982. Doctors in Uganda reported a new disease they named “slim,” due to the way in which its victims wasted away, losing body weight and, towards the terminal phase, struggling to move²¹. Though the symptoms of “slim” bore similarity to HIV-infected patients in the US, the African cases fell into none of the “high-risk” categories identified in the Western World such as homosexuality and drug use²². The CDC learned of these cases in 1983, and, guessing that these patients represented only a fraction of the infected population in Africa, quickly convened a team to carry out a field study in Zaire²³. Upon arrival, even a cursory examination of the under-equipped hospitals in the region revealed the growing devastation. Dying patients, many with the same Kaposi’s sarcoma seen among homosexuals infected with HIV in the US, lined the infirmaries.

After blood samples confirmed that these patients were suffering from the same immunodeficiency syndrome as “GRID” victims, the CDC team returned to the US with the unprecedented report that the disease was spreading through heterosexual contact. Indeed, the incidence of “slim” among men and women appeared approximately equal, with the main route of transmission being prostitution, a growing problem in the economically disheveled region^24,25. However, the New England Journal of Medicine, a premier medical journal, rejected their findings as the editors remained unwilling to believe that the disease was not specific to the gay population. The data from Zaire would not be printed until 1984. This kind of reaction would characterize much of the early work in international AIDS issues. The US was dealing with its own crisis, and many, like the editors of the NEJM, still believed the disease to be unique to the gay population. The true dimensions of the AIDS crisis in Africa would only become apparent later, after it was too late to save millions of victims.

 

Garnering (Lack of) Support

Though the CDC’s report on Africa was ignored, increasing numbers of KS and PCP cases in cities across the US were not so easily dismissed, and scientists began seeking funding to address the new crisis. However, in these early years they would frequently find the road for support a frustrating and difficult path. Economic policies at the time meant that the medical research budget was just ahead of inflation with no support allocated at all to GRID/AIDS. Anyone who wanted to study the disease would have to find support through odds and ends. At the meeting, speakers described the stigmatism attached to the disease because of its association with homosexuality and pointed out that tens of thousands of dollars were spent on three cases, a cost that would only grow with time. Problems accumulated: in addition to the paltry $1 million offered by the National Cancer Institute (NCI) for KS research, the Hollywood conference was not even picked up by the media, further underscoring the combination of scientific and public policy issues that would reign during the early years of the AIDS epidemic.

Expanding Risk

Clues from African epidemiology notwithstanding, data from other parts of the country began to reveal the larger scope of the AIDS epidemic. By early 1983, for example, gay patients were only a minority of the AIDS cases in New Jersey with intravenous drug users and immigrant Haitians making up large proportions of the incidences. Indeed, AIDS was becoming a disease of many marginalized groups as epidemiologists documented its spread among black and Hispanic residents of the low income areas around New York.

Candlelight March

Confronted by a growing health crisis, activists in the US were challenged to put a human face on the tragedy, and so force the government and public to finally accept the magnitude of the growing epidemic. A major moment in this effort occurred on May 2, 1983 when a crowd gathered on Castro Street in San Francisco and carried candles in a mile-long line in remembrance of lost friends. The event garnered immediate media attention, and similar marches were planned in other US cities.

Policing the Baths

Activism led to increasing awareness of the AIDS crisis, with the response of public health officials not always welcomed by lobbyist groups. In 1983, San Francisco’s government attempted to place restrictions on the city’s bathhouses, the clubs and exercise facilities where the city’s homosexual population met to socialize. Many feared that such places had helped the initial spread of AIDS. Some wished to entirely shut down the facilities, while the mayor and her allies took a more moderate approach, advocating that the bathhouses provide safe-sex information to customers. Though supposedly a health issue, the debate was fueled equally by concerns over whether closing the bathhouses was actually policing gay sexuality. Initially, rather than closing the facilities, high-risk sexual activity within them was banned in 1984, a move that raised objections from both sides of the debate. By October, many baths were officially ordered to shut down, and over the following months, most would close of their own
accord due to declining business.

A House for AIDS

Bathhouses were not the only establishments facing restrictions, as hospitals for AIDS patients also encountered roadblocks. Due to objections from university officials, initial efforts to establish an AIDS clinic at UCSF were unsuccessful, and the unit was ultimately located at San Francisco General Hospital. It was the first of its kind and therefore became a focus of AIDS treatment (and not always in a completely humanitarian way). For example, in 1983 an AIDS patient was sent from a Florida hospital to the San Francisco facility because the original health center estimated that it would cost less money to fly the man to California than to care for him during the terminal phase of the disease.

Rock Hudson

A major turning point in the public perception of AIDS occurred on July 23, 1985, when actor Rock Hudson, recognized as a dashing leading man in television and film, was revealed to be ailing from AIDS-related liver cancer. Suddenly, major networks were all covering the story, and AIDS had become not just the disease of the dispossessed but the affliction of America’s leading man. The physicians, who had been battling for such recognition of the disease for years, recognized the announcement as a major change, a fact that would be confirmed by a fundraiser in Los Angeles that made $630,000 in a single day. Michael Gottlieb, the man who had originally reported AIDS in MMWR years earlier, delivered Hudson’s official diagnosis of AIDS to a media conference after seeing the actor at UCLA.

1985: The First International AIDS Conference and False Statistics

A similarly important press conference that year was the first International AIDS Conference convened by the CDC in Atlanta, Georgia. At this event, many leading scientists presented alarming statistics about the spread of the disease in Africa, claiming that over 50% of certain demographics (e.g. children, prostitutes) were infected in some countries. However, many of the figures were unintentionally inflated due to problems with the blood testing methods, since concurrent patient infections could elicit “false positives”. These methodological errors would undermine the credibility of African AIDS epidemiology for years to come, leading US policy makers to think that the problem was less severe than it actually was.

Funding paralleled this false notion: by the end of 1986, when almost 4 million people globally were infected with HIV and a quarter million had actually died of AIDS, the US had donated a grand total of $2 million to relief efforts internationally²⁶. This money was used to begin a global AIDS program under the auspices of USAID, an organization created by the Kennedy administration to assist the development of needy foreign nations. The program faced an uphill battle, as the disease was still highly stigmatized in the US. Activists had their hands full trying to secure relief for patients in San Francisco and New York City, let alone Africa. Next to domestic issues, global AIDS did not register on the national radar.

A Cure? ARVs and the Global Pandemic

Through the end of the G.H.W. Bush administration and Clinton’s first term, little progress had occurred in the treatment of Africa’s growing AIDS epidemic. Political disasters, such as the capture of US Rangers in Mogadishu, Somalia, made African interventions seem less attractive. Congressional focus remained directed inwards towards domestic policy issues, and even as funding for homeland AIDS programs such as the Ryan White CARE act increased, the US hardly supported the global AIDS efforts.

Against this backdrop, the Eleventh International AIDS Conference was convened in Vancouver in 1996. During the event came the historic announcement of the development of antiretroviral, or ARV, therapy, a drug regime that promised to suppress the virus’ effects. Suddenly, AIDS seemed treatable. Deaths from the disease dropped precipitously in the next two years, and many major newspapers ran articles declaring the end of AIDS. The problem seemed to be solved for many Americans, even though access to the promising antiretroviral therapy would remain an impossibility for Africa for years to come.

South African Crisis

In February 1990, only three months after the Berlin Wall came down, Nelson Mandela was released from twenty seven years of imprisonment in South Africa. Apartheid was being dismantled, and it appeared that a new era was beginning for the beleaguered nation. However, the rise of the AIDS epidemic would parallel the country’s new freedom. The roots of the epidemic had been laid in the 70’s and 80’s, when apartheid drove South African freedom fighters into neighboring countries where they contracted the virus. This system of racial segregation also produced a vast migratory labor population who, removed from their families, were drawn to mining towns where prostitution – and HIV – spread rampantly. All these factors combined for imminent disaster when the freedom fighters and laborers returned home after the end of apartheid when they transmitted the virus to their wives (and indirectly, children).

Statistics reinforced the escalating crisis. In 1990, only 1 percent of South Africa’s pregnant women were infected with HIV; only 4 years later, this figure had risen to 8 percent²⁷. Early efforts to raise public awareness about the issue had failed, and Mandela hardly addressed the matter even after assuming the presidency. In 2000, South Africa led the world in most HIV prevalence, topping 5 million HIV-infected individuals²⁸.

Magic Johnson

A world away from South Africa, the LA Lakers were dealing with their own crisis. In an announcement with as much social impact as Rock Hudson’s diagnosis in 1985, NBA star Magic Johnson revealed that he was HIV-positive to a press conference at the Laker’s stadium in 1991²⁹. Johnson had learned of his infection during a routine blood test and believed he had contracted the virus from a female lover during his promiscuous early years. Retiring from the NBA, Johnson became a leading advocate for HIV/AIDS prevention and treatment through the charitable foundation he created, using his celebrity status to reach vulnerable sections of the US population such as inner city youth.

AIDS in the Real World: Pedro Zamora

Eventually, HIV/AIDS would appear not just on the silver screen in the form of Rock Hudson, or on the basketball court in the case of Magic Johnson: it struck every media, entering America’s households weekly during the second season of MTV’s hit reality show The Real World. The 1993-94 season, filmed, appropriately perhaps, in San Francisco, featured a gay Cuban immigrant among its cast, who revealed both his sexual orientation and HIV-positive status to his housemates³⁰. Pedro Zamora had decided to be a part of the show in order to raise awareness about the disease³¹, and in addition to the regular broadcasts toured high schools to promote greater public visibility for the AIDS epidemic. He became a  spokesperson for those afflicted with the virus, speaking before the US congress as well as on prominent news programs³². He died in 1994, shortly after the filming of The Real World had wrapped for the season, but Zamora remains an important figure in the history of AIDS activism³³.

Pharmaceutical Debate

In 1997, as Johnson encouraged support for AIDS research in the US, Vice President Gore was encouraging South Africa to address their own health epidemic. South Africa responded almost too well, beginning to import antiretroviral drugs from countries where the cocktails were cheaper than in the US. As a result, many major drug development firms filed suits against the patent-defying nation. Gore, who was depending upon financial support from the pharmaceutical industry in the next Presidential election, urged South African leaders to reconsider their decision. Soon after, South Africa appeared on the “watch list” of the US Trade Representative, jeopardizing the nation’s ability to attract foreign investment because of the risk implied by this designation. Ultimately, a deal was brokered in which South Africa was taken off the “watch list,” in exchange for reversing their antipharmaceutical policies. However, members of the South African government also began seeking independence from Western economies, to the point of adopting the use of toxic drugs created in Africa over effective antiretroviral therapies. Even when President Clinton announced that the US would not take punitive action against other nations for importing less expensive antiretroviral drugs in 2000, many South African leaders had already shunned Western medicines.

Growing Crisis: The Expansion of AIDS in Africa

By the time the Eleventh International Conference on AIDS came to Lusaka, Zambia in 1999, AIDS had already claimed 11 million victims in Africa, while 23 million were infected with HIV²³. By the late 1990s, almost ten times as many Africans were dying of AIDS than war, a sobering figure in the midst of war-torn continent³⁴. In 1999, leaders of several southern African nations, including Zimbabwe, Namibia, and Kenya, finally acknowledged that AIDS was a dire issue. Why had it taken so long for the crisis to be publicly recognized? Even more so than the US, sexuality remained a taboo issue in many of these nations. Additionally, leaders did not wish to acknowledge that practices such as prostitution existed within their borders. The leaders of many nations were in their sixties and seventies – elderly and religious men who did not wish to confront the implications of the disease. Further, many feared that admitting the devastation wrought by AIDS might have adverse effects on foreign economics interests or their perceived strength among rival countries. Still, many of these leaders continued to spend more money on defense than public health.

A Global Fund and a New Pledge

The 2001 African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases proved a momentous event as UN Secretary General Kofi Annan revealed his plans for a Global Fund to battle these illnesses, based on financial counsel from leading US economists. Though Annan had asked for billions in contributions to the endeavor, the US fell short in these expectations, delivering an initial investment of only $200 million. Ultimately, the first substantial pledge of aid to the global AIDS crisis would come in the 2003 State of the Union address, when Bush declared that the US would commit $15 billion over five years to AIDS relief in Africa and the Caribbean. The impact of this Emergency Plan for AIDS Relief remains to be seen.

Comprehension Questions:

1. From which continent did HIV originate? What is a plausible theory for its
emergence?
2. What was the primary clinical indication that HIV had come to San Francisco? In
what group was it seen most prevalently?
3. What are some reasons that AIDS patients were stigmatized during the early years of the epidemic?
4. What are some issues surrounding the distribution of AIDS drugs in South Africa?
5. What celebrities have been infected with HIV? What effect did their infection have on US perception of AIDS?
6. What is the current US plan to confront the AIDS epidemic in Africa?