André Picard is a health columnist for The Globe and Mail. His latest book is Neglected No More: The Urgent Need to Improve the Lives of Canada’s Elders in the Wake of a Pandemic.
On June 5, 1981, a short article titled “Pneumocystis Pneumonia – Los Angeles” appeared in Morbidity and Mortality Weekly Report, a journal published by the U.S. Centers for Disease Control.
Little did the authors know that the dry case report about a cluster of “5 young men, all active homosexuals” with PCP, a rare form of pneumonia, would herald the arrival of HIV-AIDS, one of the worst pandemics in human history.
Similarly, the moderator who posted chatter on the Chinese social-media site Weibo about an “urgent notice on the treatment of pneumonia of unknown cause“ in Wuhan on Dec. 30, 2019, on the ProMed (Program for Monitoring Emerging Diseases) listserv likely had no idea that it was a harbinger of an earth-shaking pandemic. (China did not formally notify the World Health Organization about the spread of a novel coronavirus until Jan. 8, 2020.)
Today, on its unofficial 40th anniversary, AIDS almost feels like yesterday’s news, overshadowed by COVID-19, an in-your-face pandemic of the digital age.
While AIDS and COVID-19 have both scarred the world, they are very different beasts.
Human immunodeficiency virus, which is spread in bodily fluids like semen and blood, has infected an estimated 76 million people, 33 million of whom have died.
SARS-CoV-2, the airborne virus that causes COVID-19, has infected almost 175 million people and caused more than 3.7 million deaths, making it more easily spread but far less deadly than HIV.
And, of course, no one yet knows how long COVID-19 will be around, or what the long-term health consequences will be, especially for the significant minority of the infected who seem to be developing chronic symptoms.
Still, there are many parallels, many common lessons unheeded, and much to learn about bolstering public health in this tale of two pandemics.
If anything, AIDS should remind us that, for all the havoc COVID-19 has caused, it could have been much, much worse in the short term, and we should not make too many assumptions about how it will play out in years to come.
Dr. Catherine Hankins, a professor of public and population health at McGill University in Montreal, distinctly remembers reading the now-iconic MMWR report 40 years ago. “It was one of those ‘where were you when…’ moments,” she said.
In pre-internet days, medical journals came in the mail and infectious disease experts such as herself read MMWR religiously. An unusual pneumonia in five otherwise healthy men hinted at something new and worrisome. One month later, on July 3, 1981, MMWR published a second report that sealed the deal.
Titled “Kaposi’s Sarcoma and Pneumocystis Pneumonia Among Homosexual Men – New York City and California,” the study reported the cases of 26 gay men who had an unusual combination of a rare pneumonia, PCP, and even rarer form of cancer, KS.
That same day, The New York Times published an article titled “Rare Cancer Seen in 41 Homosexuals,” which is often described as the first coverage of AIDS in the mainstream media. (Gay publications such as the New York Native had already been reporting on rumours of a “gay cancer.”)
“It took a few weeks to realize it was an infectious disease, but it was clearly something new and important,” Dr. Hankins said. All over the world, public-health officials and clinicians began to understand why they were seeing gay men falling ill and dying in large numbers.
The new virus changed the course of Dr. Hankins’s career. She went from working on preventing hepatitis B in babies to studying what was initially dubbed GRID (gay-related immune deficiency), including early work on the spread in prisons and among injection drug users.
Dr. Hankins is still at it four decades later. She is also a key member of the COVID-19 Immunity Task Force, and that’s not a coincidence.
A year prior to the emergence of HIV-AIDS, in 1980, the World Health Organization declared the end of smallpox, the first disease to be eradicated in human history, thanks to vaccination.
It was a heady time. Many scientists believed that the end of infectious diseases was nigh – a rather pompous conviction that there were likely no new pathogens to be found, and if they did emerge, they could be quickly quashed.
AIDS was a brutal wake-up call.
It also spurred a resurgence of interest in epidemiology and immunology, which has paid great dividends since, and especially during COVID-19.
Today, the spread of the novel coronavirus is being tracked around the world virtually in real time and we know more about its immunology than any pathogen in history. Not to mention that the genome of the virus was decoded in mere weeks.
More importantly, there is a COVID-19 vaccine. Several actually, and more than 150 others in development.
On April 23, 1984, Margaret Heckler, the U.S. Secretary of Health and Human Services, told a packed news conference that a team led by American scientist Robert Gallo had discovered HIV, the virus that causes AIDS. (It turned out that a team of French scientists had actually discovered the virus in May, 1983, and shared samples with the Americans. After years of acrimonious legal battles, they are officially co-discoverers, although only Dr. Luc Montagnier, and his colleague Françoise Barré-Sinoussi, were awarded the Nobel Prize.)
What is also memorable about Ms. Heckler’s announcement is that she vowed that an AIDS vaccine would be available within two years, a prediction that turned out to be spectacularly wrong. In 1997, U.S. president Bill Clinton made a similar pledge, but said it would take 10 more years. That goal went unaccomplished, too.
So why have scientists been able to develop COVID-19 vaccines so quickly, but failed repeatedly do to so for AIDS?
The problem is principally the virus itself. HIV is far more complex and wily than SARS-CoV-2. HIV is good at hiding and moves slowly and stealthily. (It can often take a decade before an infected person develops serious symptoms.) Worse yet, HIV infects the very cells a vaccine would need to trigger an immune response, and it can hide undetected in viral reservoirs and resurface again. The coronavirus, by contrast, is easy to detect, stymie and eliminate from the body.
There is also a question of political will. There have been many AIDS vaccine initiatives but never one with the urgency or breadth and financing of Operation Warp Speed, a U.S. initiative to develop COVID-19 vaccines quickly.
Governments around the world signed advance purchase agreements for billions of doses even before COVID-19 vaccines were developed, providing both funding and tremendous incentive for companies to succeed. Canada alone committed to buying 400 million shots.
In contrast, HIV vaccine development remains stalled – but it could be reinvigorated by the success of mRNA vaccines for COVID-19.
“The big and last Holy Grail we have to develop is a safe and effective vaccine,” Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said in an interview with HIV Unmuted, a podcast of the International AIDS Society.
While he has become a household figure during COVID-19, Dr. Fauci is also a lodestar of AIDS, having started researching the disease just weeks after the first MMWR publication. The U.S. National Institutes of Health are, by far, the biggest funders of AIDS research in the world.
The closest thing HIV has to a vaccine is antiretrovirals, cocktails of drugs that are used to keep the virus from replicating. That suppression makes it virtually impossible to transmit the virus and unlikely that infected people will fall sick.
It is a major improvement from the early days of the pandemic: Treatments have gone from non-existent, to complex and brutal, to incredibly effective. Some people now take only a single pill daily to control HIV. Given the aging demographic of those infected, and the damage caused by long-time treatments, however, many take a myriad of pills for conditions such as heart disease and diabetes.
Despite the lack of vaccines, both HIV infections, which peaked at 3.3 million in 1997, and AIDS deaths, which hit almost two million in 2006, have come down tremendously over the years. In 2019, there were “only” 1.7 million people newly infected with HIV, and 690,000 AIDS deaths. Treatment as prevention (TAsP), an approach developed in Canada, has contributed to the steep decline in cases. The concept is illustrated in the slogan U = U (undetectable = untransmittable).
In wealthy countries, HIV cases have largely disappeared outside of marginalized groups such as intravenous drug users and sex workers. The vast majority now occur in southern Africa.
This illustrates one of the many parallels Dr. Fauci sees between the pandemics, both in the scientific and political response. Infectious diseases always prey on vulnerable populations, and there are always groups who are harder hit, whether it’s gay men for AIDS or elders for COVID-19.
Dr. Fauci said on the podcast his greatest fear is that, as with AIDS, Western countries will control the initial surge and then move on, leaving the developing world to cope with the burden of COVID-19 for years to come.
In the 2020s, just as in the 1980s, it is well-off countries and individuals who are benefiting disproportionately from both new prevention programs and treatments.
As effective as HIV treatments are, it remains a struggle to get them to those who can most benefit. Of the 37.6 million people in the world living with HIV, 27.4 million have access to antiretrovirals, a vast improvement over the 7.8 million a decade ago, but still leaving many to suffer and die. Even in wealthy countries such as Canada, ARVs can be too costly, and are not covered by public-health plans in all provinces.
A similarly cruel pandemic math is playing out with COVID-19. Countries such as India and Nepal are experiencing deadly shortages of basic medical supplies, including oxygen.
Of the almost two billion vaccine doses administered worldwide, only a tiny fraction of shots have gone to those living in the developing world. The recovery is being enjoyed by the haves, not the have-nots.
Ron Rosenes, a long-time AIDS activist, was diagnosed with HIV in 1987, but is sure he was infected in the late 1970s when, like many of his generation, he revelled in the sexual liberation movement and was a frequent visitor to some of the over-the-top discos of New York.
Today, he says: “I’m a survivor, witness and pioneer – among the first generation to age with HIV.”
Echoing Dr. Fauci, Mr. Rosenes said his greatest frustration with COVID-19 is seeing the same prejudices and inequities surface 40 years after the advent of AIDS.
The scapegoating language, from “gay plague” to “China virus,” is similar. The tendency to blame “others” for the spreading of disease remains strong. With AIDS, it was gay men, and even individuals such as Gaétan Dugas. (The Canadian flight attendant was long described as Patient Zero, or the first case, when in fact he was patient O, the letter, for “out of California.”) Now, the COVID-19 finger-pointing is aimed at workers like those at the Wuhan seafood market (or, more recently, at a Wuhan microbiology lab).
The political unwillingness to invest adequately to protect those at greatest risk of newly emerging viruses – whether it’s gay men and hemophiliacs, or essential workers and elders – remains problematic. So too does the eagerness to move on when it’s only the marginalized who are still suffering.
Mr. Rosenes, at 73, was among the first to get the COVID-19 vaccine, and he hopes to see another world-changing scientific breakthrough. “I’m cautiously optimistic that I will still be around to see an HIV vaccine.”
He is only slightly less optimistic that he will be a witness to both the beginning, and beginning of the end, of two of the worst pandemics in history.
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