On June 5, 1981 — 35 years ago this Sunday — the Centers for Disease Control and Prevention published a report with an inauspicious title: “Pneumocystis Pneumonia — Los Angeles.” Nestled between pieces on dengue and measles, the article in the Morbidity and Mortality Weekly Report briefly described five patients, all young men from Los Angeles with cases of life-threatening pneumonia. While it didn’t immediately grab headlines, its publication represented a turning point in public health: the beginning of the AIDS era.
In another 35 years, will AIDS be a fading memory?
These patients’ pneumonia had been caused by a particular species of fungus, which back then was responsible for fewer than 100 pneumonia cases annually. Young, healthy people weren’t supposed to be vulnerable to this fungal infection, and the fact that men with no known risk factors were suddenly falling victim to it was a huge red flag that something strange was afoot.
The patients shared other characteristics as well, and at that point, scientists could only speculate what, if any, of these traits were associated with the strange new disease. All five patients were “active homosexuals,” were positive for cytomegalovirus (CMV), had yeast infections, ranged in age from 29 to 36, and used inhalant drugs (aka “poppers”). The CDC knew right away that this mysterious cluster of illnesses must have been caused by “a common exposure that predisposes individuals to opportunistic infections” — an observation that, in hindsight, was incredibly accurate, as HIV destroys the immune system and opens its host to normally rare infections. The editors posited that “some aspect of a homosexual lifestyle” might increase risk for this type of pneumonia — perhaps a sexually transmitted disease that somehow caused pneumonia.
In her memoir, Dr. Mary Guinan tells how, as the CDC’s resident herpes expert, she was considered the best qualified to vet the paper for publication, as the patients described by the authors all had CMV, which is a type of herpesvirus. She ended up abandoning her search for a herpes cure, and instead joined the task force formed to unravel the mysteries of this new disease. As part of a nationwide team tasked with uncovering risk factors, Guinan was stationed in San Francisco, where she interviewed gay men, some with the disease and others who showed no signs of it. (In fact, a needlestick accident that could have exposed Guinan to HIV ultimately resulted in the abrupt resignation of her secretary, who feared for her life.) Her team discovered that men with the mysterious disease had more than twice the number of lifetime male sexual partners than the control subjects.
In May 1982, the New York Times was reporting on a “new homosexual disorder” that was alternately called GRID (gay-related immunodeficiency) or AID (acquired immunodeficiency disease) — but whose cause was still unknown. By then, a total of 335 cases had been documented, and it was understood that, while gay men were disproportionately affected, the new disease could also strike heterosexuals. The disease was described as an “immunological time bomb” that suppressed the patient’s natural immunity, leading to opportunistic infections, such as pneumonia and thrush, or rare forms of cancer, like Kaposi’s sarcoma.
However, other aspects of the new disease were not understood. According to the New York Times, “most experts” believed that, if it were caused by an infectious agent, that single pathogen wouldn’t be sufficient to cause disease — rather, the pathogen’s deadly effects had to be activated by another factor, “perhaps a drug.” Inhalant drugs were thought to be a prime candidate, and gay men with the disease were found to be much more likely to report using them compared to those who did not show signs of the disease.
In June 1982, a year after the first MMWR report, another article on a cluster of Kaposi’s sarcoma cases in California went to print. By this time, evidence that this disease was sexually transmitted was gaining strength — but the hypothesis that the disease was caused by street drugs wasn’t completely off the table. But it was becoming apparent that the mysterious new disease wasn’t spread by “some aspect of a homosexual lifestyle” — it was spread by some aspect of a human lifestyle: sexual activity.
When investigators realized the virus could infect many different types of people in many different ways, the name GRID gave way to the more accurate AIDS (acquired immune deficiency syndrome), and in 1984, AIDS was confirmed to be caused by a virus, HIV, which was sufficient by itself to cause disease — no drugs required. We soon learned that, worldwide, HIV is transmitted sexually, primarily by anal and vaginal sex; by direct contact with blood, such as by blood transfusions and shared IV drug equipment; and from mother to child, such as during pregnancy, childbirth, and breastfeeding. It wasn’t a “gay disease.”
That first MMWR report was a landmark not only because it foreshadowed the epidemic that was to erupt in the coming months, but also because it was the first time the word homosexual was used in the CDC’s weekly publication. While the word was used in the text, Guinan wanted the word to be featured in the title, but editors stuck with “Pneumocystis Pneumonia — Los Angeles,” a plain reference to a disease and the geographical location in which it was found.
Skittishness surrounding stigmatized issues like homosexuality were not confined to the CDC — President Ronald Reagan came under intense criticism for his failure to mention AIDS during the first years of the epidemic. This November, we will probably be choosing between Hillary Clinton and Donald Trump in the presidential race. While Clinton has a comprehensive platform on HIV/AIDS (one strange comment about the Reagans notwithstanding), Trump’s campaign website is silent on the issue (some offensive language attributed to an endorser notwithstanding). It’s imperative that we choose leaders who can address taboo topics without flinching. Perhaps in another 35 years, AIDS will be confined to history books, thanks to leadership from compassionate legislators and brilliant scientists.