25 years of AIDS

Anthony S Fauci, one of the world's leading experts on HIV/AIDS, summarises the first quarter century of the pandemic

In June 1981 the first cases of what is now known as acquired immunodeficiency syndrome (AIDS) were reported in the Morbidity and Mortality Weekly Report. Many researchers speculated that the profound immunodeficiency in these patients was because of some environmental factor, perhaps even recreational drug misuse. Initially an infectious agent seemed unlikely to be the cause of this syndrome-otherwise why had it not been seen before? The idea that the problem could be resolved quickly was early optimism.

UNAIDS/O'HANLON
Global treatment-not beyond reach

Soon it became clear that hopes for an easy solution were unfounded. Cases of AIDS were soon reported in diverse populations of men and women and in children born to women with AIDS or women who had a history of drug misuse. Accumulating epidemiological data showed soon that a virulent micro-organism was to blame, and by 1983 a likely culprit-a previously unknown retrovirus-had been identified. Now it is known as the human immunodeficiency virus (HIV). In 1984 HIV was shown to cause AIDS.

Twenty five years after the first reports, HIV/AIDS has grown into a global pandemic that affects men, women, and children in almost every country in the world. By the end of 2005, the virus had infected more than 65 million people worldwide, of whom 25 million had died, according to estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS). More than 90% of infections and related deaths have been in poor countries, which are also burdened by food insecurity and endemic infections, such as tuberculosis, malaria, and a range of parasitic diseases. In these countries, the virus threatens not only human welfare, but also social, political, and economic stability.

Considerable progress has been made in the fight against HIV/AIDS. Researchers have delineated many of the complex pathogenic mechanisms of HIV related disease. And they have developed tests to diagnose infection and assays to track the course of infection in individual patients. Potent treatments have been developed for HIV related disease and associated infections and cancers, substantially decreasing HIV related disease and deaths wherever they have been used. In a growing number of rich and poor countries, prevention programmes have slowed the spread of infection.

But the pandemic continues to destroy lives, communities, and societies. And much remains to be accomplished both in terms of the scientific and medical challenges and in terms of the logistical and operational difficulties in making treatment and prevention services and other interventions available in poor countries. In poor and middle income countries only a quarter of people with HIV who need antiretroviral drugs (ARVs) have received them. And fewer than one in five people at risk of infection have access to basic prevention services. As a result, the pandemic continues to expand, and even countries that are considered success stories have unacceptable burdens of untreated patients and incident infections.

While we endeavour to deliver ARVs to the three quarters of people who lack access to these life saving drugs, we must develop a next generation of ARVs. These will have improved toxicity and resistance profiles and perhaps ultimately will drain the reservoirs of latent virus, which prevents eradication of the virus from infected people. As we deliver proved approaches to prevention (for example, education and behaviour modification, ARVs to prevent transmission from mother to child, condoms, and needle exchanges to reduce harm in injecting drug users), research must accelerate on new strategies. A top priority is the development of a topical microbicide to protect women against infection in settings where abstinence or using condoms are not tenable. Other priorities are the validation of circumcision and prophylactic antiretroviral therapy for prevention. A vaccine that prevents infection, or at least slows the progression of disease, is badly needed but still lacking and remains a critical goal of AIDS research.

Anthony S Fauci

As we enter the second quarter century of AIDS, we are at a pivotal juncture at which many infected people are dying and HIV infection is still spreading despite substantial scientific advances. Collectively we must do more to slow the spread of HIV/AIDS. As individuals we must eliminate stigma towards and discrimination against people with HIV. As clinicians we must use the most effective regimens available to treat people with HIV related disease. As friends and caregivers we must help people who have HIV/AIDS. As researchers we must further elucidate the pathogenesis of this complex disease and develop improved treatments and tools for prevention. And as public health workers, policymakers, and activists we must bring the benefits of advances in essential research to treatment and prevention to the people who need them most.