AIDS at 20

The Plague That's Killed 22 Million Isn't Done With Us Yet. While We Hunt For A Vaccine, People Continue To Die - From AIDS Or The Drugs Intended To Treat It.

On June 5, 1981, the federal Centers for Disease Control issued its weekly newsletter on outbreaks of illness and unusual deaths in the United States. Two tourists returning from the French West Indies had come down with dengue fever, reported one story. An additional 6,707 children were diagnosed with lead poisoning. And in a 553-word article, doctors reported that a rare parasitic lung infection, Pneumocystis carinii pneumonia, had shown up in Los Angeles. It had struck "5 young men, all active homosexuals." Three out of three tested had an inexplicable depression of their immune function.

And so it began.

How do you mark 20 years of AIDS? With mourning, surely, for the 22 million lives from San Francisco to Nairobi that acquired immune deficiency syndrome has stolen: Ryan White, Rock Hudson, Arthur Ashe, Alvin Ailey, Rudolf Nureyev, Randy Shilts, Elizabeth Glaser, Keith Haring, Liberace and all the emaciated, sunken-eyed nameless victims. And you mark it, too, with horror that last year 5.3 million people worldwide--14,500 a day--were newly infected. In the developed world, you probably also mark 20 years of AIDS with a sense of hope that the carnage of the early plague years may be behind us, thanks to drugs that have turned AIDS into a chronic disease that you live with rather than die of, at least for a while: after all, advertisements for the medications show young, buff HIV-positive men climbing mountains. And maybe you also commemorate June 5 with a trace of smugness. We closed bathhouses, sent every U.S. household a pamphlet called "Understanding AIDS" and preached safe sex, with the result that, in the United States, new HIV infections peaked at 150,000 a year in the mid-1980s and then plunged to 40,000 in every year of the 1990s. When 1997 brought the first report of a decline in AIDS deaths in America... well, we thought the worst was over.

We had no idea. Throughout the world 36 million people--more than the population of Australia--are HIV-positive, including 800,000 to 900,000 in the United States (of whom an estimated 300,000 don't know it). AIDS is now the fourth leading cause of death globally, and the leading cause of death in Africa. There it has stolen a generation and imperiled the future: it robs economies of their workers, families of their support and children of their parents. In seven African countries, more than 20 percent of the 15- to 49-year-old population is infected with HIV: 20 percent in South Africa, and a mind-numbing 36 percent in Botswana. Zambia cannot train teachers fast enough to replace those killed by AIDS. Within 10 years, there will be 40 million AIDS orphans in Africa.

Asia remains comparatively untouched. Only Cambodia, Thailand and Burma have infection rates above 1 percent. But the pandemic may be like a typhoon gathering strength off an unsuspecting coast. India's HIV rate of "only" 0.7 percent translates to 3.7 million infectious people. China predicts 5 million to 6 million HIV-positives by 2005. "With the current resources," says Dr. Peter Piot of UNAIDS, "it is not going to be possible to contain this epidemic."

Drugs won't do it. At upwards of $15,000 a year, the regimen that has helped thousands of HIV-positive people in the United States and Europe is out of reach for most Africans and Asians. Even international pressure to make the meds available at cost is only a first step: without a public-health infrastructure, poor countries can't distribute the drugs and track the patients. But even in the United States, "drugs cannot be seen as the ultimate solution," says Dr. Michael Merson, director of the Center for Interdisciplinary Research on AIDS at Yale University. Already the meds are being foiled by HIV's quick-change artistry. Susceptible strains mutate into drug-resistant strains. And there is another problem. "People who take the drugs feel better," says Merson. "They see a decrease in their viral load, become confident the drugs work and then become more sexually active. When that happens, they may not practice safe sex."

Safe sex. Although in 1986 William F. Buckley Jr. called for people with AIDS to be tattooed on their forearms and buttocks, public-health authorities had a less hysterical response: avoid infection by not sharing needles and by wearing a condom during sex. To an astonishing extent, people did. Being bombarded with the message that AIDS equals death "was a very strong motivator for people to change their behavior," says James Nguyen of the San Francisco-based STOP AIDS Project.

Many of today's teens and twentysomethings lack that motivation. "Young people are not nearly as terrified of [HIV/AIDS]," says Sean O'Brien Strub, founder of the magazine Poz. In a new survey of six American cities, researchers find that among young (age 23 to 29) men who have sex with men, 4.4 percent become newly infected with HIV every year. Among African-American men who have sex with men, the rate is 14.7 percent. The new face of HIV is young and female, like Promise, now 20. She had nonconsensual sex with her 22-year-old boyfriend when she was 16. "What makes you think it couldn't happen to you?" she asks the high-school classes she visits for Health and Education for Youth. Among 13- to 19-year-olds, 64 percent of HIV-positives are female.

In San Francisco, public-health researchers see the foreshadowings of a new disaster. There have been "changes in behavior, more unsafe sex being advertised on the Internet and in chat rooms," says Tom Coates, director of the AIDS Research Institute at the University of California. Author Andrew Sullivan was recently outed as the HIV-positive gay man who posted his profile on an Internet site dedicated to barebacking, or condomless sex. "It is true that I posted an ad some time ago... [in order] to find and possibly meet other gay men who are HIV-positive," Sullivan wrote on his Web site. He was attacked for the apparent disconnect between his frequent calls for gays to disdain promiscuity and his own solicitation. But he is hardly alone. After a while, it becomes impossible to sustain the vigilance, and people rationalize away the risk, especially when they believe in pharmacological miracles. "We are a society that likes magic bullets, so... the tendency is to focus on treatment," says Helene Gayle of the CDC. "People have gotten complacent." In 2000, eight cents of every federal dollar spent on HIV/ AIDS in the United States went to prevention.

In the 20 years since the first reports of what we now know was AIDS, an entire generation has been born and come of age never knowing a world without the epidemic. The disease has changed the personal as well as the political--how we think and how we love, what we teach our children and what words we say in public. More than anything else, AIDS changed the way we view the threat of emerging diseases. "Until AIDS, most of us thought of catastrophic plagues, like the Black Death and the Spanish-flu epidemic of 1918, as things of the past," says Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. "We lost sight of the fact that every once in a while a new disease will emerge and knock the socks off the human population. It happened with HIV/ AIDS, and it can happen again."

AIDS also changed what it means to be a patient. People with AIDS stormed scientific conferences, banded together in ways no other patients ever had, helped revolutionize the process of testing experimental drugs and inspired others. "There is no question that breast-cancer activism started because of AIDS activism," says Fran Visco, president of the National Breast Cancer Coalition. "We saw its success and decided to emulate it," deploying thousands to lobby for increased research funding.

And AIDS changed what it means to be gay in America. "The images of gay men dying of this awful disease rendered them objects of sympathy and opened the doors to compassion," says Walter Armstrong, editor of Poz. In the eyes of straight America, death gave gay men a humanity they had long been denied. Homophobia, and attacks on gays, became a little less acceptable. Although some argue that AIDS divided gays--positives from negatives--it seems more likely that a united gay community was forged in the crucible of AIDS. "People facing mortality responded courageously and seized the chance to proclaim their identity," says Armstrong. "And it forced society's institutions"--from hospitals that barred gay men from seeing their dying lovers to employers that denied them bereavement leave--"to recognize gay relationships."

On June 25, the United Nations General Assembly will convene a session on HIV/AIDS, the first ever devoted to a public-health crisis. Delegates will try to agree on a global action plan, and grapple with how to fund it: $7 billion to $10 billion a year is needed to fight the spread of HIV. If we get lucky with prevention, treatment and a vaccine, by 2021 AIDS will be killing 5 million people a year. If we don't, the toll could be 12 million. AIDS is 20 years young. The worst plague in modern history is far from done with us.

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