Q&A: 40 years with the ‘amazing evil’ of HIV/AIDS
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June 5 marks 40 years since MMWR published a report of five cases of Pneumocystis pneumonia among young men in Los Angeles — the first report of what would come to be called AIDS.
We spoke with Infectious Disease News Chief Medical Editor Paul A. Volberding, MD, a professor emeritus of medicine at the University of California, San Francisco, about the early years of the HIV/AIDS epidemic and what the future holds.
Volberding was at the forefront of the early epidemic in San Francisco as a physician at San Francisco General Hospital.
Healio: Do you remember the MMWR report about the five cases of Pneumocystis pneumonia in Los Angeles?
Volberding: Vividly. So, it came out on the fifth of June, and I started up as a new faculty member at San Francisco General Hospital on July 1, just a couple weeks later. On my first day there, I saw my first patient with a Kaposi sarcoma. A few days after that an MMWR came out with cases of Kaposi sarcoma and I said, “Whoa.” It was a remarkable thing. It didn't take long before the idea that these conditions were linked came around. That was the historic opening of the epidemic here in this country.
Healio: What are your earliest memories of the HIV/AIDS epidemic in the U.S.?
Volberding: I think the most striking thing is how suddenly it all appeared and how it affected such a young group of patients that were previously healthy — and by the time we saw them, they were so amazingly sick. I think what people often forget about untreated AIDS, which is what we were seeing, is just how devastating it is to the whole body — every organ, blindness, dementia and just horrible weakness. It is just an amazing evil.
Healio: What are the great successes and failures of the HIV/AIDS response during the last 40 years?
Volberding: I think the great success has been seeing the value of investing in basic science — the fact that we put a lot of effort into understanding the biology and immunology. It took a few years, but it rather quickly resulted in developing treatments that now are just amazingly effective. We have a better understanding of the immune system in ways that benefited not only our patients with HIV but so many other conditions — including cancer and other diseases — that now have treatments that really are directly from the investment in HIV research.
I think the biggest failure is that we still, to this day, do not have a vaccine, and it looks like we won't for quite a while still. We were pretty optimistic that it wouldn't be that difficult, but it’s proved to be so far impossible. Countering that, though, is the fact that our treatments are so effective — one pill once a day — and lately, we're seeing injectables with long-acting effects. So, I think if it weren't for the fact that our treatments have come so far, we'd be in a very desperate situation, but fortunately, it's something that we're really controlling.
Healio: What is the most pressing concern right now?
Volberding: Well, I think that the most pressing concern right now is not to lose sight of the fact that we still have a very large global AIDS epidemic. I think that the appropriate attention that we have given to COVID-19 is, of course, understandable, but I am a little afraid that we're losing sight of HIV at a time when we really have the tools to control the epidemic. I would like us to come back to it and remind ourselves that we still need to do that.
Healio: What does the future look like?
Volberding: I think it is going to be a very long struggle. We are not going to get rid of this virus — it is with our population now — unless, at some point, we do have a very effective vaccine. I think we're expecting that this is going to be a chronic disease. I think it's one that highlights the need for coordinated global health response, and I think that's another legacy of HIV a good one. We now can make drugs available at such a low cost — again, because of the HIV epidemic — and I would like to make sure that we continue that effort.
Healio: How does the HIV/AIDS epidemic compare with COVID-19?
Volberding: It is an interesting comparison to COVID-19. Both are zoonotic infections, but the thing that most people have forgotten is the incredible mortality from HIV. Untreated, HIV kills about 98% of the people who are infected. It is one of the most lethal infections ever seen in our history. COVID-19, by comparison, is an incredibly widespread and devastating pandemic, but fortunately, it doesn't kill as often as HIV does. That is a very, very important difference.
Reference:
Gottlieb MS, et al. MMWR Morb Mortal Wkly. 1981;30:250-252.
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