1 00:00:08,240 --> 00:00:16,760 Daniel loved evenings and Castro. Surely there was nowhere in the world like San Francisco where the sun seemed to hang in the sky forever. 2 00:00:16,760 --> 00:00:26,420 It's like dancing on the street, cars outside as he turned the open sign on the door to close that twilight globe or to smile to his face, 3 00:00:26,420 --> 00:00:34,370 one that had been missing for a while. Years past, he would have had to ease the last of his regulars out into the night air at closing time. 4 00:00:34,370 --> 00:00:41,540 But recently it had been much quieter. And regulars weren't just customers in a place like this. 5 00:00:41,540 --> 00:00:48,380 They were friends. A community that stuck together in society was giving you a hard time about who you were. 6 00:00:48,380 --> 00:00:55,250 You could come to Dan's cafe and be who you wanted to be, at least for a couple of hours. 7 00:00:55,250 --> 00:01:01,190 But he was missing a few people. He hadn't seen some dear friends in what felt like forever. 8 00:01:01,190 --> 00:01:10,880 He'd heard rumours, though court mentions on the TV in the corner of the cafe, whispers from conversations at the tables. 9 00:01:10,880 --> 00:01:15,920 Welcome to the 1980s, a time many of us remember well. 10 00:01:15,920 --> 00:01:28,010 The night episode of our history of pandemic season sees us leave the perils of influenza behind, only to discover an entirely new virus HIV. 11 00:01:28,010 --> 00:01:38,960 I well recall the emerging concern that later grew into a media panic around HIV and the disease it leads to AIDS. 12 00:01:38,960 --> 00:01:48,050 But today we'll follow the story from the beginning with medical experts who've worked on the frontline of this pandemic since the early days. 13 00:01:48,050 --> 00:01:56,570 Shortly, we'll speak to Dr. Harold Jaffe, now visiting professor in Oxford's Nuffield Department of Population Health, 14 00:01:56,570 --> 00:02:01,790 who back in 1981 joined the original task force of the CDC. 15 00:02:01,790 --> 00:02:11,000 That's the Centres for Disease Control and Prevention, assigned to study the disease that would soon become known as AIDS. 16 00:02:11,000 --> 00:02:22,370 First, though, we'll hear from Professor John Frater, also now part of the Nuffield Department who started working with HIV patients in the mid 1990s. 17 00:02:22,370 --> 00:02:26,510 I asked John to begin by describing the virus for us. 18 00:02:26,510 --> 00:02:37,940 So the HIV or the human immunodeficiency virus probably crossed over from animals, chimpanzees most likely at the turn of the last century. 19 00:02:37,940 --> 00:02:46,010 So they probably be with us for over 100 years. And they were in Africa for a long time until the early 80s, 20 00:02:46,010 --> 00:02:54,860 when it first became apparent that young gay men on the West Coast of America started to suffer with an infection called pneumocystis pneumonia, 21 00:02:54,860 --> 00:03:03,510 which you normally would only see in people who had immune systems that weren't working very well or did had chemotherapy or something else like that. 22 00:03:03,510 --> 00:03:08,090 And there's a whole cluster of these young men on this on the West Coast. And it didn't make sense. 23 00:03:08,090 --> 00:03:14,060 And so people started to question whether there was something else going on or some new infection that could explain it. 24 00:03:14,060 --> 00:03:19,880 And so that was when in the early 80s, this new virus was discovered, which didn't have a name at the time, 25 00:03:19,880 --> 00:03:27,730 obviously, but immuno human immunodeficiency virus that explains what it does and who it affects. 26 00:03:27,730 --> 00:03:35,420 And really, from then on, it became a global pandemic, spreading very quickly to all countries associated with a lot of illness, 27 00:03:35,420 --> 00:03:44,510 a lot of stigma, a lot of huge impacts on economies and sort of social development and really kind of went into all corners of people's lives. 28 00:03:44,510 --> 00:03:50,990 And it was it was only in the mid 90s that we began to have some treatment for this and treatment that was really effective. 29 00:03:50,990 --> 00:04:00,050 And so really, one chapter closed, if you like, in the mid 90s, a condition that we didn't know how to treat was killing young people, 30 00:04:00,050 --> 00:04:05,330 was killing people all around the world and producing conditions that we didn't really know how to manage to 31 00:04:05,330 --> 00:04:11,570 later on in the 90s when we could actually give a tablet for this and keep people well to where we are today, 32 00:04:11,570 --> 00:04:17,180 where I can treat in my clinic someone who's living with HIV with one tablet that they take once a day. 33 00:04:17,180 --> 00:04:21,830 And we now expect a life expectancy that is normal compared to anyone else. 34 00:04:21,830 --> 00:04:27,050 And for them not to have to suffer with these other infections and conditions, which we would otherwise call AIDS. 35 00:04:27,050 --> 00:04:35,870 You asked what AIDS was. And I think one of the things that people get a bit confused about is the difference between HIV and AIDS. 36 00:04:35,870 --> 00:04:40,180 So first, what HIV is the virus? It's just it's the organism, if that's what you wanna call it. 37 00:04:40,180 --> 00:04:44,600 Viruses are organisms and it is it is the bug that causes the trouble. 38 00:04:44,600 --> 00:04:47,750 And you can be infected with HIV without having AIDS. 39 00:04:47,750 --> 00:04:55,430 In fact, on average, it takes about eight years, give or take a few for for on average to go from infection to developing AIDS. 40 00:04:55,430 --> 00:05:00,200 And AIDS stands for acquired immunodeficiency syndrome. 41 00:05:00,200 --> 00:05:07,470 And really what AIDS is, is a mixture of infections and cancers that the person who has HIV will. 42 00:05:07,470 --> 00:05:16,920 Develop if their immune system breaks down too much. So once the immune system does to fail those infections that normally can keep control 43 00:05:16,920 --> 00:05:21,600 of and the cancer is in your body that might take off your immune system stops them. 44 00:05:21,600 --> 00:05:26,160 They can then start to take hold on that person and cause them to become ill. 45 00:05:26,160 --> 00:05:31,680 And that is why we start seeing these conditions associated with HIV. So it's not HIV that actually kills you. 46 00:05:31,680 --> 00:05:36,720 It's the cancers or the other infections that your immune system lets in when it becomes too weak. 47 00:05:36,720 --> 00:05:40,680 And that's what AIDS is. So it's different from HIV and a lot of people get confused about that. 48 00:05:40,680 --> 00:05:44,160 So that's the disease. But how is it spread? 49 00:05:44,160 --> 00:05:52,560 I checked back in with one of our main guides throughout this series, Lúcio Giftee, on how the HIV virus is transmitted. 50 00:05:52,560 --> 00:05:59,700 HIV can be transmitted via exchange and variety bodily fluids from infected people such splodge breast milk, 51 00:05:59,700 --> 00:06:07,360 semen, vaginal secretions can also be transmitted from mother to child during pregnancy and delivery. 52 00:06:07,360 --> 00:06:11,580 The symptoms feature think vary depending on the stage of infection. 53 00:06:11,580 --> 00:06:19,980 So all the way from the beginning, people not feeling unwell or feeling kind of flu like symptoms. 54 00:06:19,980 --> 00:06:26,160 And this is at the beginning in the first two weeks after being infected, when actually they can be their most infectious during this time. 55 00:06:26,160 --> 00:06:32,270 And this is when quite a lot of transmission happens, when people are unaware of their status and they have quite a high bar load. 56 00:06:32,270 --> 00:06:36,330 And also, the infection then progressively weakens the immune system. 57 00:06:36,330 --> 00:06:46,680 And then other signs and symptoms can come in like swollen lymph nodes, weight loss, fever, diarrhoea, cough, and then much later on. 58 00:06:46,680 --> 00:06:50,160 And free depression without end and therapy. 59 00:06:50,160 --> 00:06:58,650 Then you can develop more severe illnesses such as tuberculosis, cryptococcal meningitis, cancers, lymphomas, 60 00:06:58,650 --> 00:07:06,480 Kaposi's sarcoma, more severe bacterial infections, maracay populations that tend to be infected. 61 00:07:06,480 --> 00:07:12,330 Every country has a different kind of main transmission link. 62 00:07:12,330 --> 00:07:13,370 Essentially, 63 00:07:13,370 --> 00:07:23,860 key populations and their sexual partners accounted for about 60 percent of all new HIV infections globally amongst people 50 to 49 years. 64 00:07:23,860 --> 00:07:26,310 And this was data from last year. 65 00:07:26,310 --> 00:07:35,620 So your key populations are men who have sex with men, people who inject drugs, prisoners or other people in close settings. 66 00:07:35,620 --> 00:07:46,950 We also have sex workers and their clients. Transgender people sometimes also social circumstances can make people become to populations such 67 00:07:46,950 --> 00:07:53,250 as adolescent girls and young women in southern Africa and Eastern Africa indigenous populations. 68 00:07:53,250 --> 00:08:02,100 They don't have many rights and they can be victims of a lot of sexual violence and they can become two populations in that way. 69 00:08:02,100 --> 00:08:11,250 The risk factors are unprotected anal jonell, sex sharing, contaminated needles, syringes and such. 70 00:08:11,250 --> 00:08:20,280 Having sexually transmitted infections such as syphilis and herpes also receiving unsafe injections and blood transfusions. 71 00:08:20,280 --> 00:08:26,160 And then for healthcare workers and other important, transmission's accidentally needlestick injuries. 72 00:08:26,160 --> 00:08:30,090 Still thinking about the relationship between HIV and AIDS. 73 00:08:30,090 --> 00:08:37,470 I want you to cheque whether the medical community had discovered both at the same time or as I seem to remember, 74 00:08:37,470 --> 00:08:47,100 that AIDS had become apparent long before the virus was identified. So effectively, yes, because you have to have a clinical condition first. 75 00:08:47,100 --> 00:08:57,630 So one of the great mysteries about this is that HIV Hidemi been affecting people in Africa for probably nearly a century before it was discovered, 76 00:08:57,630 --> 00:09:03,630 causing problems in North America over on the West Coast. And so clearly, there must have been people getting ill. 77 00:09:03,630 --> 00:09:10,410 But whatever the infrastructure was, it wasn't picking up the fact that this was sort of out of the ordinary. 78 00:09:10,410 --> 00:09:14,400 It was only when these new conditions appeared. So, yes. 79 00:09:14,400 --> 00:09:18,270 So people were getting this infection called pneumocystis pneumonia. 80 00:09:18,270 --> 00:09:22,290 They were getting cancelled. One in particular called Kaposi's sarcoma. 81 00:09:22,290 --> 00:09:27,780 And once you have those, you are officially, if you like, diagnosed with AIDS, AIDS. 82 00:09:27,780 --> 00:09:33,630 AIDS is a collection of different conditions. And if you have one of those conditions, then you have an AIDS diagnosis. 83 00:09:33,630 --> 00:09:40,430 So, yes, AIDS came first and AIDS was the trigger, if you like the flag for saying what is causing this? 84 00:09:40,430 --> 00:09:44,010 Now, at the time, we didn't know it was AIDS because I hadn't been invented yet. 85 00:09:44,010 --> 00:09:48,090 It was just an odd collection of cancers and infections that we didn't understand, 86 00:09:48,090 --> 00:09:52,830 but seemed to be clustering around, you know, certain groups of people. 87 00:09:52,830 --> 00:09:56,840 And so that caused the epidemiologists in the same way that, you know, we're worrying about Koven. 88 00:09:56,840 --> 00:09:57,930 Now, where did this come from? 89 00:09:57,930 --> 00:10:03,990 How can you track that down in the early days of bats in the same way in the early days of HIV and the group of people had to say, 90 00:10:03,990 --> 00:10:07,540 well, where has this come from and how do we make sensible that this. And that is when. 91 00:10:07,540 --> 00:10:13,210 Virus. Virus was found and in fact, finding that virus that to the awarded the Nobel prise to the people who did it, 92 00:10:13,210 --> 00:10:17,620 it was such a huge event to a huge achievement, if you like. 93 00:10:17,620 --> 00:10:23,590 So, yes, it's absolutely the critical condition came first. And that is, in a way, sometimes classic epidemiology. 94 00:10:23,590 --> 00:10:29,320 You know, we have conditions we don't understand. I would have been one of them. Now, people suddenly had coughs and and headaches. 95 00:10:29,320 --> 00:10:33,580 We didn't know why. And we had to find an explanation. And it turned out to be a coronavirus. 96 00:10:33,580 --> 00:10:36,550 And the story of HIV back in the beginning is just the same. 97 00:10:36,550 --> 00:10:40,930 Let's hear now from one of the people right at the heart of that work in those early days. 98 00:10:40,930 --> 00:10:49,150 Dr. Harold Jaffe. Well, first, anybody knew about it was actually 1981 when we received a report from CDC about some cases of unusual infection, 99 00:10:49,150 --> 00:10:53,640 called me resistance in young homosexual men in Los Angeles. 100 00:10:53,640 --> 00:10:58,330 The reason this was unusual is because this infection pneumocystis normally occurred only in people with cancer, 101 00:10:58,330 --> 00:11:06,010 chemotherapy or something to suppress your immune system. These individuals were not healthy, were healthy before and hadn't had these conditions. 102 00:11:06,010 --> 00:11:12,310 So while they were developing these serious infections with misery time, we now know they were infected with HIV. 103 00:11:12,310 --> 00:11:19,180 The story of HIV became much clearer. A lot of work, it appears, since this is a virus that originated in 19 primates, 104 00:11:19,180 --> 00:11:28,360 particularly in chimpanzees and gorillas, perhaps it probably passed or in humans about 100 years ago related to humans, 105 00:11:28,360 --> 00:11:36,190 which means animals for meat virus infecting animals with a related virus called SIOP, which is simian immunodeficiency virus. 106 00:11:36,190 --> 00:11:40,030 It took a while to adapt to human. Houseman's did so, of course. 107 00:11:40,030 --> 00:11:46,420 Probably about 75 years and started causing disease in humans, probably in the early 1970s, 108 00:11:46,420 --> 00:11:52,300 late 1970s in Africa, spread a Caribbean and then the United States. 109 00:11:52,300 --> 00:11:57,430 I asked where he was working at that time while I was working as a medical epidemiologist 110 00:11:57,430 --> 00:12:01,060 and a neuro disease physician at CDC in Atlanta when these cases came to us. 111 00:12:01,060 --> 00:12:05,920 We didn't know what to do with them. They didn't fit into the obvious CS category that we knew about. 112 00:12:05,920 --> 00:12:10,660 So we assembled a task force of people with various disciplines, including virology, 113 00:12:10,660 --> 00:12:17,170 immunology, neuro diseases, cancer, everything analogy and said we'll take a crack at this. 114 00:12:17,170 --> 00:12:20,830 That happened in June 1981. We really did know where the disease was coming. 115 00:12:20,830 --> 00:12:25,330 We just said these case reports from the cities. So we needed to find out where it was occurring. 116 00:12:25,330 --> 00:12:32,280 Where it was occurring was only in came in or other populations. So to do that, we needed a surveillance system, which we didn't have. 117 00:12:32,280 --> 00:12:36,850 And the first thing you need for us as a nation, what are you looking for? 118 00:12:36,850 --> 00:12:42,520 The disease didn't have a name. We call it Tarsa Alive. Kaposi's sarcoma and opportunistic infections. 119 00:12:42,520 --> 00:12:46,600 So we published a case definition and started asking people will look for the disease in their 120 00:12:46,600 --> 00:12:50,800 major metropolitan areas and discovered that the disease was just limited in San Francisco, 121 00:12:50,800 --> 00:12:55,690 Los Angeles and New York was occurring throughout the country at the time, only gay men. 122 00:12:55,690 --> 00:13:02,380 We started out investigating individual cases. So we sent people out, including myself, to interview cases. 123 00:13:02,380 --> 00:13:08,110 I know how they were living with their possible risk factors were we needed to do a more definitive study 124 00:13:08,110 --> 00:13:13,360 to find out how the disease was being transmitted so that we did what's called a case control study. 125 00:13:13,360 --> 00:13:19,360 We take cases where people have the disease and compare them to healthy people who don't have the disease and try to find a difference. 126 00:13:19,360 --> 00:13:25,330 So we did this in homosexual men in four cities in San Francisco, Los Angeles, Atlanta, New York. 127 00:13:25,330 --> 00:13:31,810 We interviewed 50 patients in great deaths concerning their sexual behaviour, drug use and so on. 128 00:13:31,810 --> 00:13:36,280 We had one hundred and twenty apparently healthy homosexual men as they control patients. 129 00:13:36,280 --> 00:13:41,780 Big differences in their histories of sexual activity. The cases were much more sexually active. 130 00:13:41,780 --> 00:13:48,520 They also used a lot of drugs as well. So we thought that this was a sexually transmitted infection, but we couldn't rule out the role of drugs. 131 00:13:48,520 --> 00:13:50,110 It took a while to do that. 132 00:13:50,110 --> 00:13:57,410 But over the course of a year, to appreciate this with sexually transmitted disease, that was before the virus was actually isolated in 1983. 133 00:13:57,410 --> 00:13:59,750 Why we continue and colleague to Paris. 134 00:13:59,750 --> 00:14:04,510 I think at the time we did the study, there were only 70 known cases in the United States where a liberal, 50 of them. 135 00:14:04,510 --> 00:14:08,020 So that's been good. It's hard to figure out who the controls should be. 136 00:14:08,020 --> 00:14:11,890 So ideally, it would be a random sample of gay men, but nobody knew how to do that. 137 00:14:11,890 --> 00:14:17,730 So we tried various approaches. We ended up using came in seeing the private practises in physicians in these cities 138 00:14:17,730 --> 00:14:22,690 and also recruited gay men from public SDD or GM clinics using the controls. 139 00:14:22,690 --> 00:14:26,240 I think we realised that the epidemic was limited to gay men. 140 00:14:26,240 --> 00:14:29,740 We realise how bad it was going to be. I mean, well, we thought it was only a gay man. 141 00:14:29,740 --> 00:14:32,320 We thought, well, this is a bad problem, that it won't spread. 142 00:14:32,320 --> 00:14:37,390 Once we realised it was sexually transmitted, then the blood supply, we realised it was gonna be a big problem throughout the world. 143 00:14:37,390 --> 00:14:45,340 And it was. However, as Harold recalls, it took a while for the mainstream media to latch on to this emerging threat. 144 00:14:45,340 --> 00:14:47,550 Mainstream media, mostly ignored, is the beginning. 145 00:14:47,550 --> 00:14:52,780 They treated it as sort of a medical odyssey, caffeinated game and didn't pay much attention to it. 146 00:14:52,780 --> 00:14:57,390 Now, the gay press, in contrast, paid a lot of attention to it to try to be so earnest, the gay community. 147 00:14:57,390 --> 00:15:04,750 But the mainstream press didn't really get engaged. We started seeing cases in transfusion recipients, children, people with haemophilia. 148 00:15:04,750 --> 00:15:12,510 That took a couple of years before that happened. I remember. We published the first cases of cases in transfusion recipients, cases in children. 149 00:15:12,510 --> 00:15:16,410 Media certainly paid attention. I had, I think, three news crews in the sun. 150 00:15:16,410 --> 00:15:20,520 We asked CDC, this is great, we're getting some attention to this epidemic. 151 00:15:20,520 --> 00:15:27,790 There were really a year and a half ago. So we put out a lot of public information in adverts in other media and scientific papers. 152 00:15:27,790 --> 00:15:34,070 A landmark event was mainly know the surgeon general's report on AIDS to every American household, maybe seven. 153 00:15:34,070 --> 00:15:36,900 That I think had a big effect come in public. 154 00:15:36,900 --> 00:15:45,180 And by the time John Freyja started working in this field, the public awareness and medical impact of the disease had grown hugely. 155 00:15:45,180 --> 00:15:50,100 So I first got involved looking after people living with HIV back in. 156 00:15:50,100 --> 00:15:56,670 I'm just I think that mid 90s and it was by chance, I actually at that time, I wasn't really sure what I was going to do. 157 00:15:56,670 --> 00:16:02,520 I mean, I'd only been qualified in medicine about two or three years, and I was sort of flirting with lots of different specialities. 158 00:16:02,520 --> 00:16:09,190 None of them really got me interested. And then just by chance, I was working at St. Mary's Hospital in London, 159 00:16:09,190 --> 00:16:14,610 in Paddington, which was one of the key centres back then for people living with HIV. 160 00:16:14,610 --> 00:16:20,990 And, you know, there were two dedicated wards, you know, over 20 beds each that were full all the time. 161 00:16:20,990 --> 00:16:27,120 The patients coming through the doors were all young men, predominantly, predominantly young men, and they're my age. 162 00:16:27,120 --> 00:16:33,510 And so I think it was an immediate sort of sense, you know, of of integration with what was going on. 163 00:16:33,510 --> 00:16:37,320 You felt as a doctor like that. This was new. And it was different. 164 00:16:37,320 --> 00:16:41,460 We weren't quite sure what we were doing. We were getting some people better and sending them home. 165 00:16:41,460 --> 00:16:46,590 But some people were dying in their beds on the wards. And, you know, this shouldn't be happening in the mid 90s. 166 00:16:46,590 --> 00:16:52,810 And so it was from there that I got very interested in what this was all about and what was happening. 167 00:16:52,810 --> 00:17:00,010 And on the back of that, just as the drugs were coming out, it was just at the time when the drugs were being launched, these triple cocktail. 168 00:17:00,010 --> 00:17:05,550 There was the opportunity to do some work to to find out if these drugs really were going to be effective on people. 169 00:17:05,550 --> 00:17:10,640 And so I was able to sort of take a take a peek at Imperial College then to look at these drugs. 170 00:17:10,640 --> 00:17:16,890 Then once I started work on HIV, I never really looked back, really. And it's been sort of a sort of a rollercoaster since then. 171 00:17:16,890 --> 00:17:24,550 Part of that rollercoaster experience was the appreciation of just how far this disease had spread. 172 00:17:24,550 --> 00:17:35,280 I asked First Herald and then John to tell us more about the experience of HIV and AIDS outside the United States and particularly in Africa. 173 00:17:35,280 --> 00:17:42,580 Let's beginning. We weren't aware of places anyplace other states was until 1983 when we saw it in reports from Africa, 174 00:17:42,580 --> 00:17:45,400 actually, about Africans seeking care in Europe, 175 00:17:45,400 --> 00:17:51,620 in Belgium and France and the UK, people who could afford to travel to get medical care coming from Central Africa. 176 00:17:51,620 --> 00:17:56,190 That's when we realised the epidemic wasn't just in the United States was becoming a global problem. 177 00:17:56,190 --> 00:18:02,050 And we were giving a talk in the U.K., I think it was in March 1983 when the cases in the UK. 178 00:18:02,050 --> 00:18:08,900 Maybe about 10 or 12 physician came up to me afterwards and said, that's a terrible problem you have in the United States. 179 00:18:08,900 --> 00:18:12,810 And I thought you might just just be us. You might have it, too. 180 00:18:12,810 --> 00:18:20,470 I think that first question about why it was early picked up, you know, in North America, on the West Coast, in San Francisco, 181 00:18:20,470 --> 00:18:28,390 when the sort of a small group of young gay men became unwell with this very rare chest infection is a really good one. 182 00:18:28,390 --> 00:18:32,160 Why wasn't it spotted earlier? And should we have spotted it earlier? 183 00:18:32,160 --> 00:18:35,470 What we know is that it came from West Africa. 184 00:18:35,470 --> 00:18:41,590 We know it travelled up through Haiti, into North America, and that those debates about how that happened. 185 00:18:41,590 --> 00:18:45,070 But one of the main things was as immigration took off, 186 00:18:45,070 --> 00:18:51,430 an economic sort of success was achieved in Africa and industrialisation and the railway lines grew. 187 00:18:51,430 --> 00:18:57,730 And those the growth of the sex industry, which often goes hand-in-hand with industrialisation and with all of those things, 188 00:18:57,730 --> 00:19:01,240 actually started to move out of probably quite a small area where it was. 189 00:19:01,240 --> 00:19:06,570 So it may well have been quite contained before sort of big transport networks were set up. 190 00:19:06,570 --> 00:19:09,430 And it may just have been that there was something going on. 191 00:19:09,430 --> 00:19:19,410 But with everything else that people were putting up with, it just didn't quite stand out as to a cause of a new disease, May one. 192 00:19:19,410 --> 00:19:27,610 I'm just speculating what it might be. What we know in Africa is that many of the people who live with HIV also get tuberculosis. 193 00:19:27,610 --> 00:19:31,450 And tuberculosis is often the cause of death with people who don't have treatment with HIV. 194 00:19:31,450 --> 00:19:38,200 Well, we know TB was already in Africa, so it may be just there wasn't that trigger to say, well, is there another explanation for this? 195 00:19:38,200 --> 00:19:44,770 So it's difficult. I think what was what was different on the West Coast is it was so unusual to see one 196 00:19:44,770 --> 00:19:49,600 young person with pneumocystis would be a surprise to see a whole cluster of them. 197 00:19:49,600 --> 00:19:54,820 You know, no one is going to say this is normal. And so people are going to start looking very quickly for an explanation for that. 198 00:19:54,820 --> 00:20:00,610 So what happened there was completely out of the ordinary. And so clearly raised a lot of red flags. 199 00:20:00,610 --> 00:20:05,560 There was something going on. It was now time to bring in our third guest for the episode. 200 00:20:05,560 --> 00:20:10,360 Professor Jemmy Whitworth from the London School of Hygiene and Tropical Medicine, 201 00:20:10,360 --> 00:20:16,090 formerly team leader for the Medical Research Council programme on AIDS, based in Uganda. 202 00:20:16,090 --> 00:20:24,280 I worked in Uganda from 1996 until 2004. 203 00:20:24,280 --> 00:20:35,200 I was based in Entebbe at the Uganda Virus Research Institute, which is where the Medical Research Council had its headquarters. 204 00:20:35,200 --> 00:20:45,820 Most of the work that I was doing was in villages in southwestern Uganda, particularly in Masaka district. 205 00:20:45,820 --> 00:20:52,720 Now, these were the days before antiretroviral drugs were widely available. 206 00:20:52,720 --> 00:20:57,790 So it was a very different era, perhaps true to what we have now. 207 00:20:57,790 --> 00:21:12,490 I arrived after the epidemic had really taken hold in Uganda, and we were still in a situation where we didn't know a great deal about the disease. 208 00:21:12,490 --> 00:21:25,750 Most of the work that I was involved in, at least initially, was around describing what the impact of this was at the population level. 209 00:21:25,750 --> 00:21:34,060 How frequent was the disease? What type of people were most often affected by it? 210 00:21:34,060 --> 00:21:39,370 What was the natural history of how this infection progressed? 211 00:21:39,370 --> 00:21:45,730 What were the main causes of deaths and of infections that people had surprising? 212 00:21:45,730 --> 00:21:50,450 Perhaps, too, to think that that wasn't known at that time? 213 00:21:50,450 --> 00:22:00,460 If you think about the Corona virus now, within the first six months, we've known an awful lot about what the risk factors are. 214 00:22:00,460 --> 00:22:05,260 How frequently is the way in which it progresses? 215 00:22:05,260 --> 00:22:11,230 But things were much slower to be organised in in those days. 216 00:22:11,230 --> 00:22:22,990 And so even 10 years after the epidemic had taken hold, we were still learning quite a lot of basic epidemiological information about HIV. 217 00:22:22,990 --> 00:22:30,540 But what? We did discover was that it was throughout the population. 218 00:22:30,540 --> 00:22:33,930 It was what you might call a generalised epidemic. 219 00:22:33,930 --> 00:22:42,360 Initially, it had probably been in very high risk groups, but it had spilt out from those into the general population. 220 00:22:42,360 --> 00:22:51,180 The other main factor that came out from this was that it was actually a pretty long, drawn out illness. 221 00:22:51,180 --> 00:22:57,720 The initial impression from Africa had been that it was a very rapid, severe disease. 222 00:22:57,720 --> 00:23:04,140 But that's because we were only looking at people who were admitted into hospital when they were in extremeness. 223 00:23:04,140 --> 00:23:13,470 When we actually did studies in villages, we found that on average, people were living for about 10 years with this infection. 224 00:23:13,470 --> 00:23:20,730 But for the first six, seven, eight years of that time, they were actually relatively well, 225 00:23:20,730 --> 00:23:29,760 maybe they had more frequent chest infections or more frequent diarrhoea or skin rashes. 226 00:23:29,760 --> 00:23:32,790 But in general, they were pretty well for most of that time. 227 00:23:32,790 --> 00:23:39,030 And it was really only in the last year or two of their life that they were getting severely ill. 228 00:23:39,030 --> 00:23:48,510 As well as the epidemiology, we had studies which were looking at the more social aspect of the disease. 229 00:23:48,510 --> 00:23:59,160 And a lot of work about sexual activity, transactional sex, adolescent sexual behaviour and so on. 230 00:23:59,160 --> 00:24:04,560 And the way in which society reacted to this infection. 231 00:24:04,560 --> 00:24:14,250 One of the most interesting things I found in this part of Uganda was this cultural institution called a senga. 232 00:24:14,250 --> 00:24:19,250 And Sanger translates in Luganda into meaning. 233 00:24:19,250 --> 00:24:35,130 And and the the point here is that within the culture in this part of Uganda, it is not common for parents and children to discuss sex, 234 00:24:35,130 --> 00:24:44,870 but it is entirely permissible for children to talk to their aunt or the uncle about sexual matters. 235 00:24:44,870 --> 00:24:52,350 That was the way in in which traditionally this this was organised in in this society. 236 00:24:52,350 --> 00:25:02,640 And what we were able to do from knowing about about sangat was actually to try to to support this institution more. 237 00:25:02,640 --> 00:25:13,230 And the two ways in which we did this one was that particularly women who were of the right age and had nephews and nieces, 238 00:25:13,230 --> 00:25:18,840 we were able to to give them more information about HIV, 239 00:25:18,840 --> 00:25:29,280 what it was, how it was transmitted, how it could be prevented and so on, so that they were better able to perform their role as a singer as well. 240 00:25:29,280 --> 00:25:34,680 We also tried elements of developing what you might call professional singers. 241 00:25:34,680 --> 00:25:45,360 So people who, with this additional knowledge, could become confidants of adolescent girls particularly and give them that information, 242 00:25:45,360 --> 00:25:57,870 although they might not necessarily be blood relatives. And I think this points to a wider point about HIV and actually epidemics in general, 243 00:25:57,870 --> 00:26:08,550 and that is that you really need the population to be on side and contributing to controlling an epidemic. 244 00:26:08,550 --> 00:26:16,230 And in fact, if you don't have that, it's very difficult, if not impossible, to control an epidemic. 245 00:26:16,230 --> 00:26:26,310 It can't actually be done just by the authorities or by professional groups as a as a vertical activity. 246 00:26:26,310 --> 00:26:30,300 You can't impose that control on a population. 247 00:26:30,300 --> 00:26:37,640 The population needs to take ownership and need to recognise their role in being able to control it. 248 00:26:37,640 --> 00:26:48,540 So in in Uganda, one of the ways in which Uganda was was successful in actually being able to control the epidemic is that the 249 00:26:48,540 --> 00:26:57,270 population took control themselves once they understood that this illness was not a visitation from God, 250 00:26:57,270 --> 00:27:06,420 but was actually caused by a a virus and that was transmitted largely through sexual contact and that 251 00:27:06,420 --> 00:27:13,460 there were things you could do to protect yourself once they took control and took charge of that. 252 00:27:13,460 --> 00:27:20,220 Then the control of the HIV epidemic really started to take off. 253 00:27:20,220 --> 00:27:32,140 Our next guest was also working in Africa. Around that time. Dr Kevin de Cock, now director of the CDC, whose work in Kenya was from 2006 to 2009. 254 00:27:32,140 --> 00:27:37,180 Director of the World Health Organisation's Department of HIV AIDS. 255 00:27:37,180 --> 00:27:41,710 By the way, you might hear an alarm going off in Kevin's office in the background. 256 00:27:41,710 --> 00:27:51,310 I can assure you he was safe throughout the recording. CDC started working in Kenya back in 1979, and that was actually I wasn't involved, 257 00:27:51,310 --> 00:27:56,650 but I was actually working in Kenya teaching internal medicine at the university. 258 00:27:56,650 --> 00:28:08,500 The CDC got involved here to do malaria research. But in from about 2000 onwards, that mandate broadened to include HIV research. 259 00:28:08,500 --> 00:28:18,280 And then in 2003, President Bush announced the very large programme, the President's Emergency Plan for AIDS Relief, 260 00:28:18,280 --> 00:28:24,610 which was really the beginning of the AIDS, big AIDS money for treatment prevention. 261 00:28:24,610 --> 00:28:27,580 I mean, for a very comprehensive HIV approach. 262 00:28:27,580 --> 00:28:35,890 So in Kenya, we've been involved not only in working with other agencies such as USAID and the Department of Defence, 263 00:28:35,890 --> 00:28:44,140 but working with the government and the Ministry of Health on very broad HIV programme work, including treatment, treatment, scale up. 264 00:28:44,140 --> 00:28:50,380 But we've also been involved in HIV research here. So that's the HIV presence that we have here in Kenya. 265 00:28:50,380 --> 00:29:00,070 It's a very large programme. At its height, the budget was about four for the overall budget, not just CDC was about 500 million dollars a year. 266 00:29:00,070 --> 00:29:08,890 The huge investment in HIV has strengthened systems and that's had a spinoff effect on other areas. 267 00:29:08,890 --> 00:29:20,410 I mean, I think, for example, of laboratory public health, laboratory capacity in Kenya, enormous investment in HIV for HIV diagnosis, 268 00:29:20,410 --> 00:29:27,970 use of rapid tests, quality assurance and control, strengthening of the tuberculosis laboratory system. 269 00:29:27,970 --> 00:29:33,910 But the tax spin offs in terms of laboratory management, leadership, et cetera, et cetera. 270 00:29:33,910 --> 00:29:43,540 Another area where HIV money's been used, but other moneys as well has been in the workforce development, particularly epidemiology. 271 00:29:43,540 --> 00:29:49,900 I mean, I recall when we started the Field Epidemiology Training Programme, 272 00:29:49,900 --> 00:29:54,640 which is sort of a copy of that E.S. programme that I talked about at the beginning. 273 00:29:54,640 --> 00:30:02,410 CDC has invested in these field epidemiology programmes in many countries across the world, some more successful than others. 274 00:30:02,410 --> 00:30:10,600 Well, we started the one in Kenya back in 2004 and the capacity today to investigate outbreaks, 275 00:30:10,600 --> 00:30:15,280 including the ongoing coronavirus, Saar's coronavirus to situation. 276 00:30:15,280 --> 00:30:23,800 It's really very, very different from how it was at the beginning. So there's been in there has been major impact of the HIV programmes. 277 00:30:23,800 --> 00:30:31,570 And it's true that in those West African countries like Liberia, Sierra Leone and Guinea, there was little or no investment. 278 00:30:31,570 --> 00:30:33,960 And they don't mean their HIV situation. 279 00:30:33,960 --> 00:30:41,230 They do have HIV and it's a serious disease, but very low rates of infection compared to eastern southern Africa. 280 00:30:41,230 --> 00:30:46,570 But I think eastern southern Africa have been more developed in other areas as well. 281 00:30:46,570 --> 00:30:50,500 Of course, South Africa, which has a very severe HIV epidemic, I mean, 282 00:30:50,500 --> 00:30:56,080 that was the man has been for a long time the most advanced economy on the continent. 283 00:30:56,080 --> 00:31:03,580 So it's a it's a complex picture. I wanted to return to the timeline of this disease and how the medical profession 284 00:31:03,580 --> 00:31:09,640 developed their approach to taking on this devastating virus in the early days of HIV. 285 00:31:09,640 --> 00:31:14,830 And this was back in the days when, you know, if you have a virus, you just sort of take some paracetamol or go to bed. 286 00:31:14,830 --> 00:31:20,770 We didn't really have anything. You could treat a virus infection. You know, it's just you could treat bacteria with antibiotics, 287 00:31:20,770 --> 00:31:25,700 but viruses where you just sort of you just suck it up and wait to get it to get over here. 288 00:31:25,700 --> 00:31:29,290 Well, if your immune system to work and in the early days of HIV, really, 289 00:31:29,290 --> 00:31:34,660 there weren't any obvious medications around what one of the drug companies had an 290 00:31:34,660 --> 00:31:39,250 old cancer drug on the shelf that hadn't really worked out very well for cancer. 291 00:31:39,250 --> 00:31:46,360 But when they tested a lot of their drugs against HIV, this drug called AZT or as a dolphin, didn't happen to have some effect against death. 292 00:31:46,360 --> 00:31:51,560 And so this was the first time there was a tablet you could take which would inhibit HIV. 293 00:31:51,560 --> 00:31:55,020 And so there was a little bit of optimism back then. You know, we thought this will be sorted. 294 00:31:55,020 --> 00:32:02,530 We can give a tablet, we can cure HIV with our tablet and, you know, pandemic halted and we can kind of go back to normal reality. 295 00:32:02,530 --> 00:32:08,080 Unfortunately, what happened was, is that this tablet, AZT, was given to people with HIV. 296 00:32:08,080 --> 00:32:14,500 And for a short period of time, sometimes weeks, you could see that the virus level in their body would drop down, 297 00:32:14,500 --> 00:32:21,070 but then it would come back up again to where it was before, and then the person's disease would carry on as before. 298 00:32:21,070 --> 00:32:27,510 And so the effect of AZT was very short. And so this led to a lot of anxiety as to why that was. 299 00:32:27,510 --> 00:32:31,550 And then another drug came along, which you could pair up with AZT. 300 00:32:31,550 --> 00:32:35,040 And now we had dual therapy. He gave two tablets. So we call all. 301 00:32:35,040 --> 00:32:38,310 This is the answer we'll give to drugs now because one isn't good enough. 302 00:32:38,310 --> 00:32:45,660 And when you gave two drugs, the level of virus in the body dropped down lower than it had done before and for longer. 303 00:32:45,660 --> 00:32:50,340 But then it came back up again after a few months. And what we start to find is, 304 00:32:50,340 --> 00:32:55,200 and this is the one is really when science and clinical medicine properly started coming 305 00:32:55,200 --> 00:33:00,600 together is when you took the DNA sequence of the virus that was infecting those people. 306 00:33:00,600 --> 00:33:06,450 You could see that the virus had mutated and the virus had mutated in places where the drug was acting. 307 00:33:06,450 --> 00:33:10,560 And so it was very clear then HIV can mutate really quickly. 308 00:33:10,560 --> 00:33:17,010 And if you just have one or two drugs and you only need one or two mutations to become resistant, you become resistant straight away. 309 00:33:17,010 --> 00:33:23,040 However, the breakthrough was in 1996 when the new class of drugs called protease inhibitors. 310 00:33:23,040 --> 00:33:25,920 And what was different here is you could then give three drugs. 311 00:33:25,920 --> 00:33:30,560 So a protease inhibitor on its own wouldn't do anything much more than the others would. 312 00:33:30,560 --> 00:33:38,100 But if you give three drugs, the virus has to work too hard to make three mutations against all three at the same time. 313 00:33:38,100 --> 00:33:46,500 And although we know it can produce many mutations really quickly and it's been calculated that in someone not on treatment, 314 00:33:46,500 --> 00:33:51,840 HIV makes every single possible mutation in its genome every day. 315 00:33:51,840 --> 00:33:58,200 So you're up against, you know, Darwin's ideal machine of how to make evolution and natural selection work. 316 00:33:58,200 --> 00:34:02,520 So you're up against a huge cliff here. But three drugs gets over it. 317 00:34:02,520 --> 00:34:05,610 Because even with that mutation rate, three drugs, 318 00:34:05,610 --> 00:34:10,490 one of them will be effective and then stop the virus mutating so it can't become resistant to the other. 319 00:34:10,490 --> 00:34:14,940 So that three drug moment was known as the triple cocktail. 320 00:34:14,940 --> 00:34:19,950 And this is when therapy started to work back in the 90s, in the mid 90s. 321 00:34:19,950 --> 00:34:23,700 The drugs were effective, but they were almost impossible to take. 322 00:34:23,700 --> 00:34:28,680 You know, you're taking, you know, 16, 20 tablets a day. You would take them three times a day. 323 00:34:28,680 --> 00:34:30,750 Some of them had to be kept in the fridge. 324 00:34:30,750 --> 00:34:36,370 So if you're going to work, you have to some of higer tablets in the work fridge and no one would notice you taking them at lunch time. 325 00:34:36,370 --> 00:34:40,380 Some of them had to be taken with certain things or couldn't be taken with grapefruit juice. 326 00:34:40,380 --> 00:34:41,340 It was, you know, 327 00:34:41,340 --> 00:34:50,010 almost impossible to ask people to successfully take these tablets for the rest of their lives and hope that it would work and be effective. 328 00:34:50,010 --> 00:34:55,770 And so we did start to see some resistance in some people. And so that created sort of potential problems. 329 00:34:55,770 --> 00:34:59,640 But actually, if those people you could get the drugs, it worked. 330 00:34:59,640 --> 00:35:06,570 And then what has happened over the last decade, I'd say a decade and a half, is that the drugs have become simpler, 331 00:35:06,570 --> 00:35:11,580 they become less toxic, fewer side effects, and they become much easier to take. 332 00:35:11,580 --> 00:35:15,180 And they've even been able to wrap the three drugs into one single tablet. 333 00:35:15,180 --> 00:35:24,550 So now you can take, as I said before, what you now you can take one tablet once a day and that will control your HIV in terms of what happens next. 334 00:35:24,550 --> 00:35:29,220 You know, what we'd ideally like to do is have a situation where you don't even have to take a tablet a day. 335 00:35:29,220 --> 00:35:32,460 And we're now coming up with what's called injectables. 336 00:35:32,460 --> 00:35:37,980 So in this sort of thing, you have long acting drugs and you can give them and it's what's called a depo forms. 337 00:35:37,980 --> 00:35:43,350 You have an injection and that injection will give you enough drug to last you for three months at the moment. 338 00:35:43,350 --> 00:35:47,790 And so the future for therapy is people just come to clinic three or four times a year, 339 00:35:47,790 --> 00:35:55,560 have their injection, and they don't need to take tablets anymore. And the implications for that are enormous for people who are hard to reach, 340 00:35:55,560 --> 00:35:59,880 for young people who struggle sometimes to take tablets for some of the areas 341 00:35:59,880 --> 00:36:03,270 of the world where sort of healthcare isn't as well-developed as it could be. 342 00:36:03,270 --> 00:36:07,440 Are you not getting tablets out of the pharmacies is sometimes difficult just because of the supply network. 343 00:36:07,440 --> 00:36:14,910 So there are changes still afoot to make things better. But I think what we can say now is that the therapy that we have is effective 344 00:36:14,910 --> 00:36:19,270 and that we expect lifespans of people living with HIV to be healthy and long, 345 00:36:19,270 --> 00:36:30,630 a normal evolution in treatment of this disease became even more exciting when in 2008, the first person was effectively cured of HIV. 346 00:36:30,630 --> 00:36:36,750 Timothy Ray Brown was known more widely as the Berlin patient. 347 00:36:36,750 --> 00:36:45,160 Very sadly, just months after I talked to John, Timothy passed away after a battle with resurgent leukaemia. 348 00:36:45,160 --> 00:36:48,930 And we'd like to both recognise his huge contributions to the fight against 349 00:36:48,930 --> 00:36:56,110 AIDS and to dedicate this episode of the history of pandemics to his memory. 350 00:36:56,110 --> 00:36:59,980 We can treat HIV, but that doesn't get rid of it from the body. 351 00:36:59,980 --> 00:37:04,120 And one of the issues around living with HIV is still in there. You know, there are thirty seven million people. 352 00:37:04,120 --> 00:37:10,090 I still think living with this virus is that there is a burden of having to take that tablet every day. 353 00:37:10,090 --> 00:37:18,130 There are still some side effects. We know that. And just having the virus on board probably does other things to you rather than AIDS. 354 00:37:18,130 --> 00:37:24,210 So living with a virus may people people describe it as a sort of an increased frailty score. 355 00:37:24,210 --> 00:37:27,850 It is a new age quicker. You have a higher risk of dementia. 356 00:37:27,850 --> 00:37:33,550 You have a higher risk of heart disease. You have a high risk of sort of other problems around your kidneys or your liver. 357 00:37:33,550 --> 00:37:42,130 So although most people do extremely well, it's not perfect. And so the hope for the future is to get a cure for HIV. 358 00:37:42,130 --> 00:37:49,390 The problem with that is that as part of its lifecycle, the virus buries itself into your DNA. 359 00:37:49,390 --> 00:37:55,330 In fact, it buries itself so deeply into your DNA that your body thinks it is part of you. 360 00:37:55,330 --> 00:38:02,530 And so it ignores it. And once it's there, integrated into your own chromosomes, the drugs can't touch it. 361 00:38:02,530 --> 00:38:07,300 And it just sits there fast asleep. And when it wants to wake up, it just chooses to do that. 362 00:38:07,300 --> 00:38:12,180 And that's why you have to take the drugs for life. There's actually that virus is buried in your DNA. 363 00:38:12,180 --> 00:38:16,990 Might wake up tomorrow or it might wake up in five years time and you don't know when that's going to be. 364 00:38:16,990 --> 00:38:22,780 And so you have to take a tablet every day just in case. That's the day the virus chooses to wake up. 365 00:38:22,780 --> 00:38:30,370 Now, in order to get round that, there's a there's there's a hope that we might be able to attack that that virus hidden in the DNA. 366 00:38:30,370 --> 00:38:35,050 And the initial clues to that came from a population of people living up in Scandinavia, 367 00:38:35,050 --> 00:38:40,150 predominantly, who have a certain mutation in one of their immune genes. 368 00:38:40,150 --> 00:38:44,560 And this mutation has the name CCR five, Delta 32, for what it's worth. 369 00:38:44,560 --> 00:38:51,340 But the only reason you don't know the name, but the main thing about that mutation is if you have it, the virus can't infect you. 370 00:38:51,340 --> 00:38:56,920 And we know there are a number of people in Europe as well who have this is much more rare in Asia and Africa. 371 00:38:56,920 --> 00:39:01,820 So it's sort of it's sort of predominately in northern Europe and sort of gets rarer and rare from there outwards. 372 00:39:01,820 --> 00:39:08,890 But it is certainly there. And if you have enough copies of this mutated gene, you can't get infected with HIV. 373 00:39:08,890 --> 00:39:14,230 And so the individual, the Berlin patient who's who's released, his name is Timothy Ray Brown. 374 00:39:14,230 --> 00:39:22,150 He was living with HIV and then he developed a blood cancer, leukaemia, and he had some treatments for that which weren't successful. 375 00:39:22,150 --> 00:39:25,930 And eventually was decided he needed a stem cell transplant, 376 00:39:25,930 --> 00:39:34,570 which is basically getting bone marrow cells from other people and having them injected into you so that they can replace your cancer cells. 377 00:39:34,570 --> 00:39:39,070 So the idea is your cancer cells get wiped out with with mixed is a very toxic therapy. 378 00:39:39,070 --> 00:39:45,610 And then you get a new a new immune system delivered from this other person who's donated their immune cells. 379 00:39:45,610 --> 00:39:49,690 And that is a very commonly used treatment for leukaemia and other blood cancers. 380 00:39:49,690 --> 00:39:56,230 Now, the physician who is looking after Timothy Ray Brown, the Berlin patient, said, well, Robert, just give this guy a stem cell transplant. 381 00:39:56,230 --> 00:40:05,350 Why don't we try and give him a stem cell transplant from someone who is already resistant to HIV, someone with this Delta 32 mutation? 382 00:40:05,350 --> 00:40:09,340 And actually on the donor register, there were some people who could do this. 383 00:40:09,340 --> 00:40:14,170 And so he identified someone who gave a donation of bone marrow donation of these stem cells. 384 00:40:14,170 --> 00:40:18,640 And these were the stem cells that were used to treat Timothy Ray Brown's leukaemia. 385 00:40:18,640 --> 00:40:25,060 And they took and they worked. And his leukaemia was cured. But at the same time, he was given an immune. 386 00:40:25,060 --> 00:40:32,950 A new immune system that was resistant to HIV. And he is now the first of many, many millions, hopefully, to be cured one day. 387 00:40:32,950 --> 00:40:41,290 But it's a remarkable event and has now been followed on by another patient in London for the London patient who's had the same treatment. 388 00:40:41,290 --> 00:40:47,140 And it looks, again, to have been effective. He's been off therapy for, I think, over two years now and is doing well. 389 00:40:47,140 --> 00:40:55,930 So this shows a proof of principle that if you can do something as spectacular as a stem cell transplant with a mutated group of cells, 390 00:40:55,930 --> 00:40:59,860 you can cure HIV. So it's a proof of principle. 391 00:40:59,860 --> 00:41:05,080 It's to people. It is not something you're going to scale out to a pandemic, 392 00:41:05,080 --> 00:41:12,130 but it shows you that HIV can be cured and suggests that it is worth exploring strategies 393 00:41:12,130 --> 00:41:16,030 and ways that are scalable that might be able to produce the same sort of effect. 394 00:41:16,030 --> 00:41:20,830 As we reflect on the progress humanity has made in tackling this pandemic, 395 00:41:20,830 --> 00:41:29,200 something we must acknowledge is the terrible stigma that some parts of society have always associated with the disease. 396 00:41:29,200 --> 00:41:33,790 I asked Harold and John to reflect on the stigma past and present. 397 00:41:33,790 --> 00:41:35,800 Siegel The gay community was a real issue. 398 00:41:35,800 --> 00:41:42,030 I mean, about the AIDS epidemic, a stigma against scheme in the United States and probably throughout the world. 399 00:41:42,030 --> 00:41:45,780 But having this traditional new disease linked to them certainly increased the stigma. 400 00:41:45,780 --> 00:41:55,450 And it's, I think, a soon today. I think what's so interesting about HIV and I think the reason that really hit the public in. 401 00:41:55,450 --> 00:41:59,440 I using the word interest softly that because that there was a lot of different opinions, 402 00:41:59,440 --> 00:42:05,590 especially in the 90s and still, you know, you know, it was it was affecting gay men. 403 00:42:05,590 --> 00:42:11,860 It was affecting it was sexually transmitted. It was transmitted through drug use. 404 00:42:11,860 --> 00:42:17,560 You know, it was there were a lot of people who found all of those things abhorrent, you know. 405 00:42:17,560 --> 00:42:27,160 And so there were a lot of really strongly held appalling opinions in my mind about, you know, people who are suffering with a dreadful illness. 406 00:42:27,160 --> 00:42:32,890 And at the same time having to put up with that stigma. And I think that stigma persists today. 407 00:42:32,890 --> 00:42:36,940 And there's still a lot of ignorance around it. It's not just infection, it's how you catch it. 408 00:42:36,940 --> 00:42:41,680 You know, I wasn't talking that long ago with people and they still weren't sure, you know, how you catch HIV. 409 00:42:41,680 --> 00:42:44,890 I was. I was that I was giving a lecture. I'm not that long ago. 410 00:42:44,890 --> 00:42:51,490 And a doctor in the audience asked me, this is a doctor in the audience, asked me if HIV had been created by the CIA. 411 00:42:51,490 --> 00:42:56,710 You know, I mean, this there is so much craziness still. I don't know why people think these things, but they do. 412 00:42:56,710 --> 00:43:00,490 You know, so you're battling all these opinions at the same time. 413 00:43:00,490 --> 00:43:01,030 And, you know, 414 00:43:01,030 --> 00:43:10,150 I think the press didn't help to start with and trying to kind of ease the passage of people living with this and coming to terms with it. 415 00:43:10,150 --> 00:43:17,080 I think things are better now. And the way it's probably dropped out of the headlines, people don't really see HIV as a problem so much anymore. 416 00:43:17,080 --> 00:43:21,670 People know it's around, but I think they still a lot of ignorance. But people aren't really frightened of it. 417 00:43:21,670 --> 00:43:29,440 And I think, Mark, my personal feeling is as younger generations come through and they're more tolerant and they're more accepting of other people, 418 00:43:29,440 --> 00:43:33,790 you know, than sort of the groups who are affected by HIV don't have to put up with the same sort of stigma. 419 00:43:33,790 --> 00:43:37,840 I think we are seeing that, you know, as people come through. And I think that's good. 420 00:43:37,840 --> 00:43:40,930 There's a lot of hope in that sort of side of things. And perhaps my reflection. 421 00:43:40,930 --> 00:43:46,550 I think it was probably an era of people, of certain opinions driving a lot of the sort of the press and things like that. 422 00:43:46,550 --> 00:43:53,350 Hopefully that has now changed. But, yeah, back then there were some crazy ideas. Hopefully that goes back on a friend of mine it up really nicely. 423 00:43:53,350 --> 00:43:57,280 You said if you tell someone you've got cancer, I'll give you a hug if you telling me about HIV. 424 00:43:57,280 --> 00:44:01,920 They take a step back and you know, and that's still true today. 425 00:44:01,920 --> 00:44:03,200 You know. 426 00:44:03,200 --> 00:44:10,660 I have patients who are still hiding that diagnoses, who hide their tablets from their family, moms who hide their tablets from their children. 427 00:44:10,660 --> 00:44:16,060 So they don't know about it. I know I've got patients who won't even hug their grandchildren because they're scared they might. 428 00:44:16,060 --> 00:44:22,360 In fact, them, you know, so it does go into all parts of life and that often gets forgotten. 429 00:44:22,360 --> 00:44:29,620 So what do the case numbers look like today? I asked Harold for a summary of the current situation. 430 00:44:29,620 --> 00:44:36,880 Well, it's estimated now that about 38 million people worldwide with Asian HIV or AIDS, 20 million have died. 431 00:44:36,880 --> 00:44:43,570 Really advances made in the last 20 years was the availability of highly active treatment for HIV, 432 00:44:43,570 --> 00:44:50,170 which was first rolled out in Europe, in the United States in the late 1990s. At the time, people said, you can't use this in Africa. 433 00:44:50,170 --> 00:44:56,430 It's too expensive. It's too complicated. There's not a treatment infrastructure to be employed in Africa. 434 00:44:56,430 --> 00:45:01,240 Unfortunately, those predictions proved wrong with bilateral contributions. 435 00:45:01,240 --> 00:45:08,240 The Global Fund, the president's initiative regionally, the United States President's Council on Drug Companies, who is possible? 436 00:45:08,240 --> 00:45:13,760 The treatment infrastructure that efficiently developed delivery attributed to the poorest countries in the world. 437 00:45:13,760 --> 00:45:20,830 That's had a massive effect on the epidemic. Given that HIV AIDS is still an epidemic in some parts of the world, 438 00:45:20,830 --> 00:45:29,440 I wondered off to Harold's long career in this field what he thought the prospects were for getting this disease fully under control. 439 00:45:29,440 --> 00:45:35,590 Well, I think there are three main strategies for dealing with the epidemic right now, and one of them is treatment and treatment for prevention. 440 00:45:35,590 --> 00:45:40,720 We know that people take their drugs suppressing amount of virus in their general secretions in blood. 441 00:45:40,720 --> 00:45:47,350 They become uninfected. So there is a big push to treat people not just for their own health, but to prevent transmission others. 442 00:45:47,350 --> 00:45:51,910 That's been highly successful. That's the basis of my sort of strategy right now. 443 00:45:51,910 --> 00:45:55,660 U.S. secretary of health in the 1980s predicted we'd have a vaccine in two years. 444 00:45:55,660 --> 00:46:00,730 We still haven't. People are still trying, but it's been very difficult to produce an effective vaccine. 445 00:46:00,730 --> 00:46:04,480 We don't have one, if you will, for the foreseeable future. 446 00:46:04,480 --> 00:46:11,010 There's also been a so-called cure agenda, trying to figure out ways percent of the body for good so you don't need these drugs. 447 00:46:11,010 --> 00:46:15,490 And there've been a few small steps forward in this, but it's something reprogramme very successful. 448 00:46:15,490 --> 00:46:23,350 So right now, our strategy for prevention is retreatment. It's not the public's mind is a big problem right now because treatment in public, 449 00:46:23,350 --> 00:46:28,810 I think in the sense of in Saigon, which it isn't, but things fade in our memories and our priorities change. 450 00:46:28,810 --> 00:46:32,230 What we think is important today, maybe not so important tomorrow, but it's important. 451 00:46:32,230 --> 00:46:36,550 Remember the epidemic in. So we're going to go away and it won't for a long time. 452 00:46:36,550 --> 00:46:41,860 Bottom line message is she will change behaviour, which is sort the Squiggy message, but I think it's true. 453 00:46:41,860 --> 00:46:46,160 So engagement became scared to change your behaviour. They stopped having unprotected sex. 454 00:46:46,160 --> 00:46:51,010 Rates of battery and syphilis dropped dramatically in the game population when treatment became available. 455 00:46:51,010 --> 00:46:57,220 That's kind of reversed. And people said, well, why get it so? We treated nubby fine and they weren't scared anymore. 456 00:46:57,220 --> 00:47:02,050 I think the same thing is true coronavirus. We have to keep that behavioural message going when we have a vaccine. 457 00:47:02,050 --> 00:47:10,210 Right. With that in mind, I wondered what our other guests thought were the lessons we could learn from the HIV AIDS pandemic, 458 00:47:10,210 --> 00:47:14,410 particularly in reflecting on our experience with Kovik today. 459 00:47:14,410 --> 00:47:27,100 Jemmy summarised like this. I think once there are measures that are seen as largely effective, then there often is a perception that this disease, 460 00:47:27,100 --> 00:47:33,400 this infection is somehow less of a serious effect than it used to be. 461 00:47:33,400 --> 00:47:46,470 Certainly we've seen that with with HIV. And it is true this has changed from being an infection, which was essentially a death sentence, 462 00:47:46,470 --> 00:47:55,900 and that people would be dead certainly within 10 years from having a diagnosis of HIV to this being a chronic, 463 00:47:55,900 --> 00:48:03,790 manageable condition with close to a normal life expectancy on effective treatment. 464 00:48:03,790 --> 00:48:09,220 And that does change the way that people behave about a disease. 465 00:48:09,220 --> 00:48:19,300 If you consider, for example, how people respond to a disease like diabetes and you compare that to how people think about corona virus, 466 00:48:19,300 --> 00:48:29,440 then very different attitude to those two diseases, largely because diabetes, we have good measures to be able to control that. 467 00:48:29,440 --> 00:48:34,720 And if you follow those, you will have a close to a normal life expectancy. 468 00:48:34,720 --> 00:48:37,990 So I think this is pretty inevitable. 469 00:48:37,990 --> 00:48:47,020 And sometimes that's a shame and it's a frustration for for for public health professionals that the basics get ignored. 470 00:48:47,020 --> 00:48:57,340 Things like washing your hands. Social distancing and perhaps masks in the future might be things that people start to forget 471 00:48:57,340 --> 00:49:03,670 about if they know that there are treatments available or that they have been vaccinated. 472 00:49:03,670 --> 00:49:09,670 And John was very pleased that we'd included HIV AIDS in our series of 10 pandemics. 473 00:49:09,670 --> 00:49:14,470 I don't think if you only had 10 and you haven't included, I'd make you have 11. 474 00:49:14,470 --> 00:49:19,330 You know, it's been really important and changing. It's changed science. 475 00:49:19,330 --> 00:49:23,530 It's changed how we use science and the practise of medicine. 476 00:49:23,530 --> 00:49:27,940 I will sit with the genetic code of the virus infecting my patient in front of me, 477 00:49:27,940 --> 00:49:31,390 and I will choose the drugs I give that patient based on that genetic code. 478 00:49:31,390 --> 00:49:36,370 I mean, that's lab breaking. It has changed people's opinions. It has tackled stigma. 479 00:49:36,370 --> 00:49:40,660 It's brought people together. Yeah, it's it's it's not just a virus. 480 00:49:40,660 --> 00:49:46,450 It is it is much bigger. And a lot of a lot of really good things have come out of that in the way that people have responded. 481 00:49:46,450 --> 00:49:50,980 And it's brought people together. I mean, fundamentally, it's a dreadful disease that needs treating and needs curing. 482 00:49:50,980 --> 00:49:55,450 But on the back of that, you know, the human response has been amazing. 483 00:49:55,450 --> 00:50:02,550 I think, you know, as a species, we are different because of it. 484 00:50:02,550 --> 00:50:10,830 Next time on Future Makers, we conclude our history of pandemic's season with a disease that is not only still with us today, 485 00:50:10,830 --> 00:50:18,870 but whose major outbreak happened only a few years ago. Ebola first discovered in 1976. 486 00:50:18,870 --> 00:50:30,330 Ebola erupted into West Africa in 2014, devastating populations in Guinea, Liberia and Sierra Leone before spreading further afield. 487 00:50:30,330 --> 00:50:34,200 This disease might be indelibly linked with one continent. 488 00:50:34,200 --> 00:50:40,920 It was an outbreak near the Ebola River in the Democratic Republic of Congo that gave it its name. 489 00:50:40,920 --> 00:50:48,030 But our experience of it provides lessons for the whole world, not least in pandemic preparedness. 490 00:50:48,030 --> 00:50:55,440 Many of which we may still need to learn today. Join me in discovering what those lessons are. 491 00:50:55,440 --> 00:51:09,110 In the concluding episode of Our History of Pandemics season, I'm Peter Milliken and you've been listening to Future Makers. 492 00:51:09,110 --> 00:51:18,440 Future Makers was created in-house at the University of Oxford and presented by Professor Peter Milliken from Hartford College. 493 00:51:18,440 --> 00:51:27,100 A voice actor today was Mike McDonald, and the series has written and produced by Ben Harwood and Steve Preciado. 494 00:51:27,100 --> 00:51:30,800 The school for the series was designed and created by me. 495 00:51:30,800 --> 00:51:39,348 Richard Walk's thank you on behalf of the whole team for listening to the history of Pandemic's.