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Forty years ago last week, the Centers for Disease Control and Prevention reported five cases of a rare pneumonia in Los Angeles that it described as “unusual”: The patients were all young, previously healthy “active homosexuals” whose immune systems had inexplicably stopped working. Two had died by the time of the report’s publication, and the other three died soon after.
It was, unbeknown to the C.D.C., the first official U.S. recognition of the disease now called AIDS: one of the worst pandemics in human history that has since killed nearly 35 million people, including over 700,000 Americans.
Although H.I.V. and AIDS may feel to some like “yesterday’s news,” as the Canadian journalist André Picard writes, they are anything but: Last year, while the world trained its epidemiological attention on the coronavirus, H.I.V. infected 1.5 million people and killed 690,000. What lessons do the two viruses teach us about pandemics and how to fight them? Here’s what people are saying.
State negligence can be deadly
In both pandemics, slow responses from national governments resulted in needless death — though the cause and timeline of the delays were quite different. In the case of AIDS, very little was known about the disease for many years, and the vacuum was filled by stigma, misinformation and apathy:
AIDS wouldn’t land on the front page of The New York Times until 1983, by which point it had killed 558 Americans.
At White House press briefings, questions about deaths from the “gay plague” routinely elicited peals of laughter from reporters and from President Ronald Reagan’s press secretary.
President Reagan himself did not publicly mention the word “AIDS” until 1985, by which time about 12,000 Americans had been infected and 6,000 had died.
“The silence of the Reagan administration was palpable, especially when compared to the attention given to the limited number of people who had become sick and died of Legionnaires’ disease or toxic shock syndrome, two other public epidemics from the 1980s,” wrote Kenneth H. Mayer, who was an infectious disease fellow at Harvard Medical School when AIDS emerged. “The implicit message from the administration was that because AIDS seemed to be confined to groups of individuals who didn’t matter to society, the less said, the better.”
In the case of Covid, the delay was due more to the economic and political costs of recognizing the viral threat.
When the first U.S. case of Covid-19 was identified in January 2020, White House advisers sounded the alarm about the need to take aggressive action, but President Donald Trump refused to do so, as Times journalists reported. By the time he did in March, the U.S. outbreak was well underway.
A February report from The Lancet estimated that 40 percent of U.S. Covid deaths could have been avoided if the Trump administration’s response had been more competent and the American health care system more equitable.
The dysfunction was not limited to the federal government. In New York, for example, Gov. Andrew Cuomo and Mayor Bill de Blasio sparred for control over New York City’s pandemic response plan well into March, weeks after the first case was detected. Dr. Thomas R. Frieden, the former head of the C.D.C. and former commissioner of the city’s Health Department, estimated that 50 to 80 percent of the city’s deaths could have been avoided if restrictions had been put in place just one to two weeks earlier.
Medical advances can be marvelous — and political
Just as neglect dictates how some lives are ended by disease, attention and investment shape how others are saved from it: Like the antiretroviral therapies that transformed AIDS from a death sentence into a manageable and preventable illness, the mRNA vaccines forcing the U.S. coronavirus outbreak into retreat owe their creation to government-funded research discoveries. But while the vaccines gained approval from the Food and Drug Administration in a record-breaking 11 months, it took six years for the first H.I.V. drug to do so and another nine for the triple-drug therapy that is now the standard of care.
There are scientific reasons for the discrepancy. H.I.V. is an exceedingly wily pathogen — unlike with the coronavirus, the immune system can almost never clear an H.I.V. infection on its own — and gene sequencing technology now moves at a pace that would have been difficult to imagine in the 1980s.
But many top government scientists also wanted nothing to do with AIDS because of whom it was killing, as Molly Roberts wrote for The Washington Post last year. That changed only when the confrontational activist organization Act Up turned its sights on the director of the National Institute of Allergy and Infectious Diseases, a young Anthony Fauci. After a disruptive protest at the National Institutes of Health in 1988, Fauci invited the activists into his lab. In 1990, he endorsed Act Up’s demand to give AIDS patients access to experimental drugs, a pivotal policy change that to this day influences how clinical trials are conducted.
“This was the birth of the Fauci protocol,” Roberts wrote. “The diagnosis he drew from the activists: Science and politics aren’t independent; they’re inextricably intertwined.”
The billions of dollars that have poured into H.I.V. and AIDS research since paved the way for the Covid vaccines. As Fauci told The Wall Street Journal in December, “Everything we do with every other pathogen spins off of things we’ve learned with H.I.V.”
Researchers are hoping the debt might be repaid. In April, Moderna announced plans to conduct Phase 1 trials this year for two mRNA H.I.V. vaccines, which have shown promise in early tests.
Pandemics are global, but they don’t affect everyone equally
In the early months of the coronavirus outbreak, it was common to see the pandemic described as an “equalizer.” But the AIDS pandemic showed the opposite was true: “We learned early on that the human immunodeficiency virus disproportionately affects vulnerable populations such as gay men, sex workers, drug users, transgender people, young women, and incarcerated people,” Adeeba Kamarulzaman, president of the International AIDS Society, wrote in Stat. “Likewise, Covid-19 has hit vulnerable people particularly hard, such as older adults; people living with chronic diseases like diabetes, obesity, hypertension and cardiovascular disease; the working poor; migrants; and incarcerated people.”
And in both pandemics, lifesaving medicines have not made it to many of those who need them most. When antiretroviral therapies came to market, they were said to be the most expensive prescription drugs in history, at some $22,000 per patient per year. “A new reality quickly emerged,” Chris Beyrer, a professor of public health and human rights at Johns Hopkins, recalled in The Lancet. “Most of the H.I.V. patients on A.R.T. were in high-income countries. But most people living with H.I.V. were in low-income and middle-income countries (LMICs). This painful period, from 1996 to 2003, was the height of the loss of lives from AIDS.”
In 2001, after a yearslong legal battle between Nelson Mandela’s government in South Africa and pharmaceutical companies, developing countries won the right from the World Trade Organization to produce and import low-cost generic H.I.V. drugs. With the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002 and President George W. Bush’s Emergency Plan for AIDS Relief in 2003, drug prices plummeted and access expanded, saving tens of millions of lives.
Still, the end of the H.I.V. pandemic is a long way away. Infections have declined by 47 percent since their peak in 1998, but the United Nations effort to end AIDS as a public health threat by 2030 is badly off track — in part, researchers say, because of the coincidence of Covid-19. And both within and between countries, progress has been deeply unequal.
“Four decades on from the start of the AIDS crisis, the global H.I.V. response is teetering, caught in a perfect storm of waning political and public engagement, diminishing funds and the global shock of Covid-19,” Christine Stegling, the director of Frontline AIDS, said. “In many countries, the AIDS crisis never ended — the world just stopped talking about it.”
With the coronavirus pandemic, one can see a similar dynamic starting to take shape in vaccine-rich countries, where talk of “post-pandemic life” proliferates while the rest of the world waits for vaccines. Although the Biden administration endorsed waiving intellectual property rights for the vaccines, as was done for H.I.V. drugs, the proposal still faces opposition from the European Union.
“The science of Covid-19 vaccines has been spectacular,” Beyrer wrote, “but we will need that solidarity, and the passionate global advocacy that marked the H.I.V. response, if we are to reach global vaccine equity and access and defeat this next pandemic.”
Do you have a point of view we missed? Email us at [email protected]. Please note your name, age and location in your response, which may be included in the next newsletter.
“How ACT UP Changed America” [The New Yorker]
“Three lessons for the COVID-19 response from pandemic H.I.V.” [The Lancet]
“We got COVID-19 vaccines in record time. Why are H.I.V. vaccines taking so long?” [POZ]
“The Invisible Dead of Covid Colonialism” [New York]
“Forty years after first documented AIDS cases, survivors reckon with ‘dichotomy of feelings’” [NBC]
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