It began with the first five cases reported by the CDC on June 5, 1981.1 What would become known as HIV/AIDS struck fear in healthcare workers (HCWs) possibly only rivaled by Ebola virus.

HCWs worked at mortal risk, with some dying after needlesticks or other sharps injuries that exposed them to patient blood. What was essentially a terminal diagnosis became treatable when the first antiretrovirals were developed in 1995-1996.

“Of the adults reported with AIDS in the United States through Dec. 31, 2002, 24,844 had a history of employment in healthcare,” the CDC reported. “These cases represented 5.1% of the 486,826 AIDS cases reported to CDC for whom occupational information was known.”2

At this time, the CDC reported 57 HCWs in the United States are documented as having seroconverted to HIV following occupational exposures via needlesticks, cuts, or mucocutaneous exposures. In addition, 139 other cases of HIV infection occurred among HCWs with no reported risk factors for infection and who reported a history of occupational exposure to blood, body fluids, or HIV-infected laboratory material. The difference in these cases is their HIV seroconversion after exposure was not documented.

Occupational HIV infections diminished sharply with the development of post-exposure prophylaxis, the effectiveness of universal/standard precautions, and safer sharps devices. Only 12 occupational HIV infections were documented by the CDC between 2003 and 2013.3

Going back to the beginning of the AIDS pandemic, the CDC reported gay men in New York and California with an aggressive cancer called Kaposi sarcoma.4

“The first U.S. cases in women were reported later that same year,” CDC Director Rochelle Walensky, MD, MPH, said in an email statement. “Over the next five years, 29,000 cases of HIV/AIDS were reported in the U.S. With no effective treatment available for 15 years, death was the only certain outcome.”

As a young physician, Walensky saw patients dying of AIDS when the medical community could provide little but supportive care.

“The epidemic raged in the halls of the hospitals and the streets of Baltimore where I worked,” she wrote. “Fifty thousand people were dying each year. Then, we reached a turning point. In December 1995 and in 1996, the FDA authorized the first combinations of highly effective treatment. My message at the bedside changed: You can live.”

No Vaccine

A constantly mutating retrovirus that attacks the immune system directly, HIV was isolated as the cause of AIDS in 1984. There was initial optimism that a vaccine could be developed, but it was not to be. The quest continues, with millions of dollars of research ongoing. The threat of HIV to healthcare workers remains to this day.

“HIV challenges the standard vaccine approaches first and foremost because, unlike diseases such as measles and chickenpox, no one naturally recovers from infection with HIV,” researchers noted. “Without a model for natural immunity, researchers do not have a way to identify an immune response that would be effective against HIV, and thus developing an HIV vaccine is much more difficult.”5

HIV incidence decreased by 73% in 2019 from the 130,400 reported in 1984, but about 70% of cases today are occurring in Black and Hispanic people, according to the CDC.

“The proportion of infections attributed to heterosexual contact was higher in 2019 (22%) than in 1981 (2%),” the CDC reported. “[T]he proportion of infections among persons who inject drugs was lower in 2019 (7%) than in 1981 (22%).”6

“It is unacceptable that 37,000 people are newly diagnosed with HIV each year in the United States,” Walensky wrote. “Disparities in diagnoses and access to treatment and prevention persist. More than half of new HIV infections are in the South, and new infections remain high among transgender women, people who inject drugs, and Black/African American and Hispanic/Latino gay and bisexual men.”

The CDC has come a long way since that first 1981 report, when it described the five men as “active homosexuals” in the first sentence. Thus began the long-standing stigma against those with “gay cancer” or the “gay plague.” This stigma further undermined the tepid federal response. It bears repeating the well-documented observation that then-President Ronald Regan did not say the word “AIDS” publicly until four years into the pandemic.

“This public health crisis triggered unprecedented activism that drove support for the thousands of people dying from the virus each year,” Walensky said.

Much has been gained in research and treatment, but it is hard to see the glass half-full when there are about 34 million dead worldwide since that first report of five hospitalized men in Los Angeles. With the amazing effectiveness of antiretroviral therapies, people with HIV/AIDS can live long lives similar to their uninfected peers.

Still, in some sense, HIV remains much as it began: a story of the haves and the have-nots. Some infected people are living normal lives with almost complete viral suppression; others wither for the lack of that same treatment.

Monica Gandhi, MD, an HIV specialist at UC San Francisco, is passionate about the discrepancy between those who can access care and those who still die of AIDS, untreated.

“There are 38 million people living with HIV worldwide, and only 26 million of them have access to antiviral therapy,” she says. “I know that is called a success — I call that a total failure. Knowing that in the world we have 12 million people who don’t have HIV therapy that we have had since 1996 — I call that a massive failure.”

There are great disparities in populations with infectious diseases, much as we are seeing now with COVID-19, Gandhi says. Even in the United States, where treatment is available, “the people who are doing poorly despite having access are those in overlapping pandemics of homelessness, mental illness, and now COVID,” she says. “Those are a lot of the people I treat.”

It is well to remember that driving the fear and stigma of HIV in the early 1980s was the lack of understanding about transmission routes. Some provocateurs said it was spread by casual contact, an unnerving consideration for what was then a terminal disease. With all the current discussion and controversy about the origins of SARS-CoV-2, note also that HIV has long been questioned as a man-made virus.

“Throughout the history of AIDS, that has been brought up multiple times in the context of oppression and racism,” Gandhi says. “I have been studying AIDS a long time. No one has been able to create a virus.”

These pandemic viruses arise out of nature, she says. This pattern is likely to continue as humans encroach on animal habitats or unsafely farm them in a time of rapid global air travel. HIV arose in Africa in the last century, and its natural reservoir is Pan troglodyte chimpanzees in Cameroon and the Republic of the Congo, researchers reported.7 Slaughtered for bushmeat, these viruses — including related strains of simian immunodeficiency virus — in chimpanzee blood found their way into humans.

REFERENCES

  1. Centers for Disease Control (CDC). Pneumocystis pneumonia — Los Angeles. MMWR Morb Mortal Wkly Rep 1981;30:250-252.
  2. Centers for Disease Control and Prevention. Surveillance of health care personnel with HIV/AIDS as of December 2002. Dec. 1, 2003.
  3. Joyce MP, Kuhar D, Brooks JT. Notes from the field: Occupationally acquired HIV infection among health care workers — United States, 1985-2013. MMWR Morb Mortal Wkly Rep 2015;63:1245-1246.
  4. Centers for Disease Control (CDC). Kaposi’s sarcoma and pneumocystis pneumonia among homosexual men — New York City and California. MMWR Morb Mortal Wkly Rep 1981;30:305-308.
  5. The History of Vaccines: An educational resource by the College of Physicians of Philadelphia. The development of HIV vaccines. Last updated Jan. 10, 2018.
  6. Bosh KA, Hall HI, Eastham L, et al. Estimated annual number of HIV infections — United States, 1981-2019. MMWR Morb Mortal Wkly Rep 2021;70:801-806.
  7. Keele BF, Van Heuverswyn FV, Li Y, et al. Chimpanzee reservoirs of pandemic and nonpandemic HIV-1. Science 2006;313:523-526.