The Eras of AIDS
Foreword to the Encyclopedia of AIDS

by James W. Curran, M.D., M.P.H.

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The greatest challenge in trying to develop a perspective on HIV/AIDS, especially for those of us who worked to investigate the "new" disease in the early days of the epidemic in the United States, is to get far enough away from it to allow objectivity. For all practical purposes, AIDS is still a "new disease" among humankind.

Keeping the perspective of newness is important, especially for those working to develop prevention interventions for a disease that cannot yet be controlled using traditional technological methods: vaccines are not yet available, treatments are limited, and a cure is still a vision for the future.

Our successes have been real but counted in small increments, with measurement difficult and skepticism abundant. The numbers present a formidable obstacle to our confidence in the effectiveness of prevention efforts. The first 100,000 AIDS cases in the United States were reported over a period of eight years, the second 100,000 cases in a period of only 26 months. By 1996, more than half a million AIDS cases were reported, and more than 300,000 people had died.

Although the number of cases reported each year is expected to level off in the United States, the toll of 60,000 to 80,000 annual new cases and more than 50,000 deaths each year represents by far the highest number and rate of cases in any industrialized country. Because millions of additional adolescents and young adults are potentially at risk each year, the challenge of reducing the number of youths infected with HIV (who will develop AIDS years hence) depends upon continued efforts to educate and provide skills and upon continued availability of resources for prevention.

It may provide perspective on the short history of AIDS since it was first reported in 1981 to examine these years more closely. The first five years of the epidemic can be called the era of discovery. Scientific advances were remarkably rapid – the first cases were identified and described, modes of transmission were documented, the etiologic agent was discovered, tests were developed for screening the blood supply, and AZT, the first antiviral agent for HIV, was licensed.

Only 22 months after the first cases were reported, this devastating syndrome was named and the likely cause and modes of transmission were recognized; as a result, recommendations for preventing AIDS from being transmitted through sexual contact, blood transfusions, and injecting drug use were published. The recommendations, based on carefully studied epidemiological patterns, were published in March 1983 when there were only 1,000 reported cases of AIDS in the entire United States and before the virus causing AIDS was isolated.

Discovery of the virus that caused AIDS led to the development of diagnostic tests. The isolation of the virus and licensing of the HIV antibody test in March 1985 were true prevention successes, with procedures to protect the blood supply in place in all U.S. blood banks just two months later. In addition, uses of the antibody tests in population surveys showed that the virus was much more common than the numbers of reported AIDS cases indicated. The visible AIDS epidemic had often been referred to as only "the tip of the iceberg," and the new data proved it to be a much more substantial public health threat.

Around 1986, we entered a new era – this was the beginning of what I call the era of growth. At a Public Health Service-wide planning meeting, it was projected that from 1986 through the end of 1991 about 270,000 AIDS cases would be reported. This prediction made people confront the future: AIDS was not going away. Thousands of people would become sick and die, and increasing services would be required to care for them.

These projections were accompanied by expressions of fear and uncertainty from the public as well as from professionals. AIDS was looked upon as "different" from other public health problems, and we were forced to confront the need for a comprehensive and imaginative response to disease prevention. The rapid growth in numbers of HIV-infected persons who were seriously ill was accompanied by fear, uncertainty, and recognition of the need to do more to prevent infection and treat HIV disease. During the mid-1980s, the international epidemic of HIV/AIDS was recognized. At the First International Conference on AIDS in Atlanta, Georgia, in 1985, prominent scientists who attended described the extent of AIDS in sub-Saharan Africa. Throughout the decade, HIV/AIDS spread explosively across the continent.

Fed by the rapid scientific discoveries of the early 1980s, optimism about "conquering AIDS" grew as well. There were promises from the scientific community that a vaccine would be developed shortly. The discovery of AZT made us believe that AIDS soon would become a manageable illness, like diabetes. Government AIDS research, prevention, and care budgets expanded, and the number of people working on the problem grew rapidly.