As a young doctor in June 1981, I noted the first report in Morbidity and Mortality Weekly of some cases of opportunistic pneumonias and malignancies in men who have sex with men in New York and California. By that point in time, I had completed my residency and was working at Fenway Health, a community-based clinic that served the local population, but also had a commitment to the health care needs of gay men and lesbians. The first report was curious, but within a month there was a second report. By the fall, we started seeing many men coming in with hard-to-treat infections and tumors that were normally only seen in patients who had gotten aggressive chemotherapy for cancer or had to have their immune system suppressed because of transplants. Within six months, we really were in the middle of "the plague years."
In the earliest days, we were in sheer terror of the disease, primarily out of ignorance. We had little clue how the virus was transmitted, nor did we know what caused it. From 1981 until 1985, rumors abounded, misinformation spread throughout the medical community, and mistrust grew. However, by 1985. HIV was shown to be the cause of AIDS. Careful epidemiologic studies established that the virus was not easily transmitted other than through blood contact or through intimate sexual contact.
Now, with the advent of the International AIDS Conference returning to the United States after more than 20 years, it is time for reflection on how far we've come since those early, horrific days. The first major turning point in the epidemic was in the mid-1990s, when researchers began to realize that combinations of different individual antiretroviral medications together could arrest the virus in its tracks. These drugs have made HIV a manageable illness today for many, rather than a death sentence.
The next corner that was turned was in 2000, when that year's International AIDS Conference was held in Durban, South Africa. By that point in time, the cocktail of medications patients had to take had been simplified, with fewer pills necessary, but the cost of the medication was still more than $15,000 per year. Along with several of my colleagues, we walked to and from our hotel to the convention center in Durban, and looked around thinking that every third or fourth person we saw was likely to be infected, and that he or she faced a death sentence because the medications needed to treat them were literally all but impossible to afford to anyone making even the median income in the region. We saw a need for action for to make AIDS medications more accessible, and we successfully demanded it, Through the importation of the generic medications, initially manufactured in India, the cost of treating HIV/AIDS fell more than 100-fold within a few years. In 2003, President George W. Bush established the President's Emergency Plan for AIDS Relief, PEPFAR, the only positive accomplishment I can think of from that administration. The influx of funding -- $15 billion over five years -- helped to drive down the cost of medications even further.
So where are we today? Over the past two years, research has given us the the definitive proof as to just how much antiretroviral medications can decrease HIV incidence. The study known as HPTN 052 that suggested that early initiation of antiretroviral therapy decrease the likelihood of transmission in serodiscordant couples -- where only one partner is HIV-positive -- by 96 percent. The availability of these drugs is nothing short of a public health imperative.
At the XIX International AIDS Conference coming up this week in Washington D.C., the main question will be this: Do we have the political will to finally make antiretroviral drugs available to all who need them? For there are now only eight million people on treatment across the world, yet 34 million people are living with the virus; where infection rates are highest, many are not even aware they are infected. This mobilization will require massive scaling up of HIV testing, providing people with care, and developing support systems that give them crucial incentives to remain in care. Complimentary programs that help at risk people develop the skills to decrease their risk are also necessary, coupled with the judicious use of antiretroviral pre-exposure prophylaxis (PrEP) in some populations who are at particularly high risk for becoming infected.
In addition to the economic issues around access to HIV medications, this week's conference will address a host of other social and structural factors that are potentiating the global AIDS epidemic. In many developing countries, women are unable to know if their partners are infected, nor do their societies grant them the freedom to request that their partners use protection; micro-financing is one of many interventions we are discussing.
Injection drugs are another common vector for transmission of HIV, yet many countries impose punitive sentences on their users in lieu of proven "harm reduction" measures such as needle exchange programs. Finally, another major discussion will be taking place regarding the homophobia that pervades many countries where HIV is most prevalent; it is all but impossible to effectively reduce unsafe sex practices when men who have sex with other men are afraid for their lives.
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