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.
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,
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.
But recently it had been much quieter. And regulars weren't just customers in a place like this.
They were friends. A community that stuck together in society was giving you a hard time about who you were.
You could come to Dan's cafe and be who you wanted to be, at least for a couple of hours.
But he was missing a few people. He hadn't seen some dear friends in what felt like forever.
He'd heard rumours, though court mentions on the TV in the corner of the cafe, whispers from conversations at the tables.
Welcome to the 1980s, a time many of us remember well.
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.
I well recall the emerging concern that later grew into a media panic around HIV and the disease it leads to AIDS.
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.
Shortly, we'll speak to Dr. Harold Jaffe, now visiting professor in Oxford's Nuffield Department of Population Health,
who back in 1981 joined the original task force of the CDC.
That's the Centres for Disease Control and Prevention, assigned to study the disease that would soon become known as AIDS.
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.
I asked John to begin by describing the virus for us.
So the HIV or the human immunodeficiency virus probably crossed over from animals, chimpanzees most likely at the turn of the last century.
So they probably be with us for over 100 years. And they were in Africa for a long time until the early 80s,
when it first became apparent that young gay men on the West Coast of America started to suffer with an infection called pneumocystis pneumonia,
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.
And there's a whole cluster of these young men on this on the West Coast. And it didn't make sense.
And so people started to question whether there was something else going on or some new infection that could explain it.
And so that was when in the early 80s, this new virus was discovered, which didn't have a name at the time,
obviously, but immuno human immunodeficiency virus that explains what it does and who it affects.
And really, from then on, it became a global pandemic, spreading very quickly to all countries associated with a lot of illness,
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.
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.
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,
was killing people all around the world and producing conditions that we didn't really know how to manage to
later on in the 90s when we could actually give a tablet for this and keep people well to where we are today,
where I can treat in my clinic someone who's living with HIV with one tablet that they take once a day.
And we now expect a life expectancy that is normal compared to anyone else.
And for them not to have to suffer with these other infections and conditions, which we would otherwise call AIDS.
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.
So first, what HIV is the virus? It's just it's the organism, if that's what you wanna call it.
Viruses are organisms and it is it is the bug that causes the trouble.
And you can be infected with HIV without having AIDS.
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.
And AIDS stands for acquired immunodeficiency syndrome.
And really what AIDS is, is a mixture of infections and cancers that the person who has HIV will.
Develop if their immune system breaks down too much. So once the immune system does to fail those infections that normally can keep control
of and the cancer is in your body that might take off your immune system stops them.
They can then start to take hold on that person and cause them to become ill.
And that is why we start seeing these conditions associated with HIV. So it's not HIV that actually kills you.
It's the cancers or the other infections that your immune system lets in when it becomes too weak.
And that's what AIDS is. So it's different from HIV and a lot of people get confused about that.
So that's the disease. But how is it spread?
I checked back in with one of our main guides throughout this series, Lúcio Giftee, on how the HIV virus is transmitted.
HIV can be transmitted via exchange and variety bodily fluids from infected people such splodge breast milk,
semen, vaginal secretions can also be transmitted from mother to child during pregnancy and delivery.
The symptoms feature think vary depending on the stage of infection.
So all the way from the beginning, people not feeling unwell or feeling kind of flu like symptoms.
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.
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.
And also, the infection then progressively weakens the immune system.
And then other signs and symptoms can come in like swollen lymph nodes, weight loss, fever, diarrhoea, cough, and then much later on.
And free depression without end and therapy.
Then you can develop more severe illnesses such as tuberculosis, cryptococcal meningitis, cancers, lymphomas,
Kaposi's sarcoma, more severe bacterial infections, maracay populations that tend to be infected.
Every country has a different kind of main transmission link.
Essentially,
key populations and their sexual partners accounted for about 60 percent of all new HIV infections globally amongst people 50 to 49 years.
And this was data from last year.
So your key populations are men who have sex with men, people who inject drugs, prisoners or other people in close settings.
We also have sex workers and their clients. Transgender people sometimes also social circumstances can make people become to populations such
as adolescent girls and young women in southern Africa and Eastern Africa indigenous populations.
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.
The risk factors are unprotected anal jonell, sex sharing, contaminated needles, syringes and such.
Having sexually transmitted infections such as syphilis and herpes also receiving unsafe injections and blood transfusions.
And then for healthcare workers and other important, transmission's accidentally needlestick injuries.
Still thinking about the relationship between HIV and AIDS.
I want you to cheque whether the medical community had discovered both at the same time or as I seem to remember,
that AIDS had become apparent long before the virus was identified. So effectively, yes, because you have to have a clinical condition first.
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,
causing problems in North America over on the West Coast. And so clearly, there must have been people getting ill.
But whatever the infrastructure was, it wasn't picking up the fact that this was sort of out of the ordinary.
It was only when these new conditions appeared. So, yes.
So people were getting this infection called pneumocystis pneumonia.
They were getting cancelled. One in particular called Kaposi's sarcoma.
And once you have those, you are officially, if you like, diagnosed with AIDS, AIDS.
AIDS is a collection of different conditions. And if you have one of those conditions, then you have an AIDS diagnosis.
So, yes, AIDS came first and AIDS was the trigger, if you like the flag for saying what is causing this?
Now, at the time, we didn't know it was AIDS because I hadn't been invented yet.
It was just an odd collection of cancers and infections that we didn't understand,
but seemed to be clustering around, you know, certain groups of people.
And so that caused the epidemiologists in the same way that, you know, we're worrying about Koven.
Now, where did this come from?
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,
well, where has this come from and how do we make sensible that this. And that is when.
Virus. Virus was found and in fact, finding that virus that to the awarded the Nobel prise to the people who did it,
it was such a huge event to a huge achievement, if you like.
So, yes, it's absolutely the critical condition came first. And that is, in a way, sometimes classic epidemiology.
You know, we have conditions we don't understand. I would have been one of them. Now, people suddenly had coughs and and headaches.
We didn't know why. And we had to find an explanation. And it turned out to be a coronavirus.
And the story of HIV back in the beginning is just the same.
Let's hear now from one of the people right at the heart of that work in those early days.
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,
called me resistance in young homosexual men in Los Angeles.
The reason this was unusual is because this infection pneumocystis normally occurred only in people with cancer,
chemotherapy or something to suppress your immune system. These individuals were not healthy, were healthy before and hadn't had these conditions.
So while they were developing these serious infections with misery time, we now know they were infected with HIV.
The story of HIV became much clearer. A lot of work, it appears, since this is a virus that originated in 19 primates,
particularly in chimpanzees and gorillas, perhaps it probably passed or in humans about 100 years ago related to humans,
which means animals for meat virus infecting animals with a related virus called SIOP, which is simian immunodeficiency virus.
It took a while to adapt to human. Houseman's did so, of course.
Probably about 75 years and started causing disease in humans, probably in the early 1970s,
late 1970s in Africa, spread a Caribbean and then the United States.
I asked where he was working at that time while I was working as a medical epidemiologist
and a neuro disease physician at CDC in Atlanta when these cases came to us.
We didn't know what to do with them. They didn't fit into the obvious CS category that we knew about.
So we assembled a task force of people with various disciplines, including virology,
immunology, neuro diseases, cancer, everything analogy and said we'll take a crack at this.
That happened in June 1981. We really did know where the disease was coming.
We just said these case reports from the cities. So we needed to find out where it was occurring.
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.
And the first thing you need for us as a nation, what are you looking for?
The disease didn't have a name. We call it Tarsa Alive. Kaposi's sarcoma and opportunistic infections.
So we published a case definition and started asking people will look for the disease in their
major metropolitan areas and discovered that the disease was just limited in San Francisco,
Los Angeles and New York was occurring throughout the country at the time, only gay men.
We started out investigating individual cases. So we sent people out, including myself, to interview cases.
I know how they were living with their possible risk factors were we needed to do a more definitive study
to find out how the disease was being transmitted so that we did what's called a case control study.
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.
So we did this in homosexual men in four cities in San Francisco, Los Angeles, Atlanta, New York.
We interviewed 50 patients in great deaths concerning their sexual behaviour, drug use and so on.
We had one hundred and twenty apparently healthy homosexual men as they control patients.
Big differences in their histories of sexual activity. The cases were much more sexually active.
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.
It took a while to do that.
But over the course of a year, to appreciate this with sexually transmitted disease, that was before the virus was actually isolated in 1983.
Why we continue and colleague to Paris.
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.
So that's been good. It's hard to figure out who the controls should be.
So ideally, it would be a random sample of gay men, but nobody knew how to do that.
So we tried various approaches. We ended up using came in seeing the private practises in physicians in these cities
and also recruited gay men from public SDD or GM clinics using the controls.
I think we realised that the epidemic was limited to gay men.
We realise how bad it was going to be. I mean, well, we thought it was only a gay man.
We thought, well, this is a bad problem, that it won't spread.
Once we realised it was sexually transmitted, then the blood supply, we realised it was gonna be a big problem throughout the world.
And it was. However, as Harold recalls, it took a while for the mainstream media to latch on to this emerging threat.
Mainstream media, mostly ignored, is the beginning.
They treated it as sort of a medical odyssey, caffeinated game and didn't pay much attention to it.
Now, the gay press, in contrast, paid a lot of attention to it to try to be so earnest, the gay community.
But the mainstream press didn't really get engaged. We started seeing cases in transfusion recipients, children, people with haemophilia.
That took a couple of years before that happened. I remember. We published the first cases of cases in transfusion recipients, cases in children.
Media certainly paid attention. I had, I think, three news crews in the sun.
We asked CDC, this is great, we're getting some attention to this epidemic.
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.
A landmark event was mainly know the surgeon general's report on AIDS to every American household, maybe seven.
That I think had a big effect come in public.
And by the time John Freyja started working in this field, the public awareness and medical impact of the disease had grown hugely.
So I first got involved looking after people living with HIV back in.
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.
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.
None of them really got me interested. And then just by chance, I was working at St. Mary's Hospital in London,
in Paddington, which was one of the key centres back then for people living with HIV.
And, you know, there were two dedicated wards, you know, over 20 beds each that were full all the time.
The patients coming through the doors were all young men, predominantly, predominantly young men, and they're my age.
And so I think it was an immediate sort of sense, you know, of of integration with what was going on.
You felt as a doctor like that. This was new. And it was different.
We weren't quite sure what we were doing. We were getting some people better and sending them home.
But some people were dying in their beds on the wards. And, you know, this shouldn't be happening in the mid 90s.
And so it was from there that I got very interested in what this was all about and what was happening.
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.
There was the opportunity to do some work to to find out if these drugs really were going to be effective on people.
And so I was able to sort of take a take a peek at Imperial College then to look at these drugs.
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.
Part of that rollercoaster experience was the appreciation of just how far this disease had spread.
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.
Let's beginning. We weren't aware of places anyplace other states was until 1983 when we saw it in reports from Africa,
actually, about Africans seeking care in Europe,
in Belgium and France and the UK, people who could afford to travel to get medical care coming from Central Africa.
That's when we realised the epidemic wasn't just in the United States was becoming a global problem.
And we were giving a talk in the U.K., I think it was in March 1983 when the cases in the UK.
Maybe about 10 or 12 physician came up to me afterwards and said, that's a terrible problem you have in the United States.
And I thought you might just just be us. You might have it, too.
I think that first question about why it was early picked up, you know, in North America, on the West Coast, in San Francisco,
when the sort of a small group of young gay men became unwell with this very rare chest infection is a really good one.
Why wasn't it spotted earlier? And should we have spotted it earlier?
What we know is that it came from West Africa.
We know it travelled up through Haiti, into North America, and that those debates about how that happened.
But one of the main things was as immigration took off,
an economic sort of success was achieved in Africa and industrialisation and the railway lines grew.
And those the growth of the sex industry, which often goes hand-in-hand with industrialisation and with all of those things,
actually started to move out of probably quite a small area where it was.
So it may well have been quite contained before sort of big transport networks were set up.
And it may just have been that there was something going on.
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.
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.
And tuberculosis is often the cause of death with people who don't have treatment with HIV.
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?
So it's difficult. I think what was what was different on the West Coast is it was so unusual to see one
young person with pneumocystis would be a surprise to see a whole cluster of them.
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.
So what happened there was completely out of the ordinary. And so clearly raised a lot of red flags.
There was something going on. It was now time to bring in our third guest for the episode.
Professor Jemmy Whitworth from the London School of Hygiene and Tropical Medicine,
formerly team leader for the Medical Research Council programme on AIDS, based in Uganda.
I worked in Uganda from 1996 until 2004.
I was based in Entebbe at the Uganda Virus Research Institute, which is where the Medical Research Council had its headquarters.
Most of the work that I was doing was in villages in southwestern Uganda, particularly in Masaka district.
Now, these were the days before antiretroviral drugs were widely available.
So it was a very different era, perhaps true to what we have now.
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.
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.
How frequent was the disease? What type of people were most often affected by it?
What was the natural history of how this infection progressed?
What were the main causes of deaths and of infections that people had surprising?
Perhaps, too, to think that that wasn't known at that time?
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.
How frequently is the way in which it progresses?
But things were much slower to be organised in in those days.
And so even 10 years after the epidemic had taken hold, we were still learning quite a lot of basic epidemiological information about HIV.
But what? We did discover was that it was throughout the population.
It was what you might call a generalised epidemic.
Initially, it had probably been in very high risk groups, but it had spilt out from those into the general population.
The other main factor that came out from this was that it was actually a pretty long, drawn out illness.
The initial impression from Africa had been that it was a very rapid, severe disease.
But that's because we were only looking at people who were admitted into hospital when they were in extremeness.
When we actually did studies in villages, we found that on average, people were living for about 10 years with this infection.
But for the first six, seven, eight years of that time, they were actually relatively well,
maybe they had more frequent chest infections or more frequent diarrhoea or skin rashes.
But in general, they were pretty well for most of that time.
And it was really only in the last year or two of their life that they were getting severely ill.
As well as the epidemiology, we had studies which were looking at the more social aspect of the disease.
And a lot of work about sexual activity, transactional sex, adolescent sexual behaviour and so on.
And the way in which society reacted to this infection.
One of the most interesting things I found in this part of Uganda was this cultural institution called a senga.
And Sanger translates in Luganda into meaning.
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,
but it is entirely permissible for children to talk to their aunt or the uncle about sexual matters.
That was the way in in which traditionally this this was organised in in this society.
And what we were able to do from knowing about about sangat was actually to try to to support this institution more.
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,
we were able to to give them more information about HIV,
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.
We also tried elements of developing what you might call professional singers.
So people who, with this additional knowledge, could become confidants of adolescent girls particularly and give them that information,
although they might not necessarily be blood relatives. And I think this points to a wider point about HIV and actually epidemics in general,
and that is that you really need the population to be on side and contributing to controlling an epidemic.
And in fact, if you don't have that, it's very difficult, if not impossible, to control an epidemic.
It can't actually be done just by the authorities or by professional groups as a as a vertical activity.
You can't impose that control on a population.
The population needs to take ownership and need to recognise their role in being able to control it.
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
population took control themselves once they understood that this illness was not a visitation from God,
but was actually caused by a a virus and that was transmitted largely through sexual contact and that
there were things you could do to protect yourself once they took control and took charge of that.
Then the control of the HIV epidemic really started to take off.
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.
Director of the World Health Organisation's Department of HIV AIDS.
By the way, you might hear an alarm going off in Kevin's office in the background.
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,
but I was actually working in Kenya teaching internal medicine at the university.
The CDC got involved here to do malaria research. But in from about 2000 onwards, that mandate broadened to include HIV research.
And then in 2003, President Bush announced the very large programme, the President's Emergency Plan for AIDS Relief,
which was really the beginning of the AIDS, big AIDS money for treatment prevention.
I mean, for a very comprehensive HIV approach.
So in Kenya, we've been involved not only in working with other agencies such as USAID and the Department of Defence,
but working with the government and the Ministry of Health on very broad HIV programme work, including treatment, treatment, scale up.
But we've also been involved in HIV research here. So that's the HIV presence that we have here in Kenya.
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.
The huge investment in HIV has strengthened systems and that's had a spinoff effect on other areas.
I mean, I think, for example, of laboratory public health, laboratory capacity in Kenya, enormous investment in HIV for HIV diagnosis,
use of rapid tests, quality assurance and control, strengthening of the tuberculosis laboratory system.
But the tax spin offs in terms of laboratory management, leadership, et cetera, et cetera.
Another area where HIV money's been used, but other moneys as well has been in the workforce development, particularly epidemiology.
I mean, I recall when we started the Field Epidemiology Training Programme,
which is sort of a copy of that E.S. programme that I talked about at the beginning.
CDC has invested in these field epidemiology programmes in many countries across the world, some more successful than others.
Well, we started the one in Kenya back in 2004 and the capacity today to investigate outbreaks,
including the ongoing coronavirus, Saar's coronavirus to situation.
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.
And it's true that in those West African countries like Liberia, Sierra Leone and Guinea, there was little or no investment.
And they don't mean their HIV situation.
They do have HIV and it's a serious disease, but very low rates of infection compared to eastern southern Africa.
But I think eastern southern Africa have been more developed in other areas as well.
Of course, South Africa, which has a very severe HIV epidemic, I mean,
that was the man has been for a long time the most advanced economy on the continent.
So it's a it's a complex picture. I wanted to return to the timeline of this disease and how the medical profession
developed their approach to taking on this devastating virus in the early days of HIV.
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.
We didn't really have anything. You could treat a virus infection. You know, it's just you could treat bacteria with antibiotics,
but viruses where you just sort of you just suck it up and wait to get it to get over here.
Well, if your immune system to work and in the early days of HIV, really,
there weren't any obvious medications around what one of the drug companies had an
old cancer drug on the shelf that hadn't really worked out very well for cancer.
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.
And so this was the first time there was a tablet you could take which would inhibit HIV.
And so there was a little bit of optimism back then. You know, we thought this will be sorted.
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.
Unfortunately, what happened was, is that this tablet, AZT, was given to people with HIV.
And for a short period of time, sometimes weeks, you could see that the virus level in their body would drop down,
but then it would come back up again to where it was before, and then the person's disease would carry on as before.
And so the effect of AZT was very short. And so this led to a lot of anxiety as to why that was.
And then another drug came along, which you could pair up with AZT.
And now we had dual therapy. He gave two tablets. So we call all.
This is the answer we'll give to drugs now because one isn't good enough.
And when you gave two drugs, the level of virus in the body dropped down lower than it had done before and for longer.
But then it came back up again after a few months. And what we start to find is,
and this is the one is really when science and clinical medicine properly started coming
together is when you took the DNA sequence of the virus that was infecting those people.
You could see that the virus had mutated and the virus had mutated in places where the drug was acting.
And so it was very clear then HIV can mutate really quickly.
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.
However, the breakthrough was in 1996 when the new class of drugs called protease inhibitors.
And what was different here is you could then give three drugs.
So a protease inhibitor on its own wouldn't do anything much more than the others would.
But if you give three drugs, the virus has to work too hard to make three mutations against all three at the same time.
And although we know it can produce many mutations really quickly and it's been calculated that in someone not on treatment,
HIV makes every single possible mutation in its genome every day.
So you're up against, you know, Darwin's ideal machine of how to make evolution and natural selection work.
So you're up against a huge cliff here. But three drugs gets over it.
Because even with that mutation rate, three drugs,
one of them will be effective and then stop the virus mutating so it can't become resistant to the other.
So that three drug moment was known as the triple cocktail.
And this is when therapy started to work back in the 90s, in the mid 90s.
The drugs were effective, but they were almost impossible to take.
You know, you're taking, you know, 16, 20 tablets a day. You would take them three times a day.
Some of them had to be kept in the fridge.
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.
Some of them had to be taken with certain things or couldn't be taken with grapefruit juice.
It was, you know,
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.
And so we did start to see some resistance in some people. And so that created sort of potential problems.
But actually, if those people you could get the drugs, it worked.
And then what has happened over the last decade, I'd say a decade and a half, is that the drugs have become simpler,
they become less toxic, fewer side effects, and they become much easier to take.
And they've even been able to wrap the three drugs into one single tablet.
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.
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.
And we're now coming up with what's called injectables.
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.
You have an injection and that injection will give you enough drug to last you for three months at the moment.
And so the future for therapy is people just come to clinic three or four times a year,
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,
for young people who struggle sometimes to take tablets for some of the areas
of the world where sort of healthcare isn't as well-developed as it could be.
Are you not getting tablets out of the pharmacies is sometimes difficult just because of the supply network.
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
and that we expect lifespans of people living with HIV to be healthy and long,
a normal evolution in treatment of this disease became even more exciting when in 2008, the first person was effectively cured of HIV.
Timothy Ray Brown was known more widely as the Berlin patient.
Very sadly, just months after I talked to John, Timothy passed away after a battle with resurgent leukaemia.
And we'd like to both recognise his huge contributions to the fight against
AIDS and to dedicate this episode of the history of pandemics to his memory.
We can treat HIV, but that doesn't get rid of it from the body.
And one of the issues around living with HIV is still in there. You know, there are thirty seven million people.
I still think living with this virus is that there is a burden of having to take that tablet every day.
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.
So living with a virus may people people describe it as a sort of an increased frailty score.
It is a new age quicker. You have a higher risk of dementia.
You have a higher risk of heart disease. You have a high risk of sort of other problems around your kidneys or your liver.
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.
The problem with that is that as part of its lifecycle, the virus buries itself into your DNA.
In fact, it buries itself so deeply into your DNA that your body thinks it is part of you.
And so it ignores it. And once it's there, integrated into your own chromosomes, the drugs can't touch it.
And it just sits there fast asleep. And when it wants to wake up, it just chooses to do that.
And that's why you have to take the drugs for life. There's actually that virus is buried in your DNA.
Might wake up tomorrow or it might wake up in five years time and you don't know when that's going to be.
And so you have to take a tablet every day just in case. That's the day the virus chooses to wake up.
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.
And the initial clues to that came from a population of people living up in Scandinavia,
predominantly, who have a certain mutation in one of their immune genes.
And this mutation has the name CCR five, Delta 32, for what it's worth.
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.
And we know there are a number of people in Europe as well who have this is much more rare in Asia and Africa.
So it's sort of it's sort of predominately in northern Europe and sort of gets rarer and rare from there outwards.
But it is certainly there. And if you have enough copies of this mutated gene, you can't get infected with HIV.
And so the individual, the Berlin patient who's who's released, his name is Timothy Ray Brown.
He was living with HIV and then he developed a blood cancer, leukaemia, and he had some treatments for that which weren't successful.
And eventually was decided he needed a stem cell transplant,
which is basically getting bone marrow cells from other people and having them injected into you so that they can replace your cancer cells.
So the idea is your cancer cells get wiped out with with mixed is a very toxic therapy.
And then you get a new a new immune system delivered from this other person who's donated their immune cells.
And that is a very commonly used treatment for leukaemia and other blood cancers.
Now, the physician who is looking after Timothy Ray Brown, the Berlin patient, said, well, Robert, just give this guy a stem cell transplant.
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?
And actually on the donor register, there were some people who could do this.
And so he identified someone who gave a donation of bone marrow donation of these stem cells.
And these were the stem cells that were used to treat Timothy Ray Brown's leukaemia.
And they took and they worked. And his leukaemia was cured. But at the same time, he was given an immune.
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.
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.
And it looks, again, to have been effective. He's been off therapy for, I think, over two years now and is doing well.
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,
you can cure HIV. So it's a proof of principle.
It's to people. It is not something you're going to scale out to a pandemic,
but it shows you that HIV can be cured and suggests that it is worth exploring strategies
and ways that are scalable that might be able to produce the same sort of effect.
As we reflect on the progress humanity has made in tackling this pandemic,
something we must acknowledge is the terrible stigma that some parts of society have always associated with the disease.
I asked Harold and John to reflect on the stigma past and present.
Siegel The gay community was a real issue.
I mean, about the AIDS epidemic, a stigma against scheme in the United States and probably throughout the world.
But having this traditional new disease linked to them certainly increased the stigma.
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.
I using the word interest softly that because that there was a lot of different opinions,
especially in the 90s and still, you know, you know, it was it was affecting gay men.
It was affecting it was sexually transmitted. It was transmitted through drug use.
You know, it was there were a lot of people who found all of those things abhorrent, you know.
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.
And at the same time having to put up with that stigma. And I think that stigma persists today.
And there's still a lot of ignorance around it. It's not just infection, it's how you catch it.
You know, I wasn't talking that long ago with people and they still weren't sure, you know, how you catch HIV.
I was. I was that I was giving a lecture. I'm not that long ago.
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.
You know, I mean, this there is so much craziness still. I don't know why people think these things, but they do.
You know, so you're battling all these opinions at the same time.
And, you know,
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.
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.
People know it's around, but I think they still a lot of ignorance. But people aren't really frightened of it.
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,
you know, than sort of the groups who are affected by HIV don't have to put up with the same sort of stigma.
I think we are seeing that, you know, as people come through. And I think that's good.
There's a lot of hope in that sort of side of things. And perhaps my reflection.
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.
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.
You said if you tell someone you've got cancer, I'll give you a hug if you telling me about HIV.
They take a step back and you know, and that's still true today.
You know.
I have patients who are still hiding that diagnoses, who hide their tablets from their family, moms who hide their tablets from their children.
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.
In fact, them, you know, so it does go into all parts of life and that often gets forgotten.
So what do the case numbers look like today? I asked Harold for a summary of the current situation.
Well, it's estimated now that about 38 million people worldwide with Asian HIV or AIDS, 20 million have died.
Really advances made in the last 20 years was the availability of highly active treatment for HIV,
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.
It's too expensive. It's too complicated. There's not a treatment infrastructure to be employed in Africa.
Unfortunately, those predictions proved wrong with bilateral contributions.
The Global Fund, the president's initiative regionally, the United States President's Council on Drug Companies, who is possible?
The treatment infrastructure that efficiently developed delivery attributed to the poorest countries in the world.
That's had a massive effect on the epidemic. Given that HIV AIDS is still an epidemic in some parts of the world,
I wondered off to Harold's long career in this field what he thought the prospects were for getting this disease fully under control.
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.
We know that people take their drugs suppressing amount of virus in their general secretions in blood.
They become uninfected. So there is a big push to treat people not just for their own health, but to prevent transmission others.
That's been highly successful. That's the basis of my sort of strategy right now.
U.S. secretary of health in the 1980s predicted we'd have a vaccine in two years.
We still haven't. People are still trying, but it's been very difficult to produce an effective vaccine.
We don't have one, if you will, for the foreseeable future.
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.
And there've been a few small steps forward in this, but it's something reprogramme very successful.
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,
I think in the sense of in Saigon, which it isn't, but things fade in our memories and our priorities change.
What we think is important today, maybe not so important tomorrow, but it's important.
Remember the epidemic in. So we're going to go away and it won't for a long time.
Bottom line message is she will change behaviour, which is sort the Squiggy message, but I think it's true.
So engagement became scared to change your behaviour. They stopped having unprotected sex.
Rates of battery and syphilis dropped dramatically in the game population when treatment became available.
That's kind of reversed. And people said, well, why get it so? We treated nubby fine and they weren't scared anymore.
I think the same thing is true coronavirus. We have to keep that behavioural message going when we have a vaccine.
Right. With that in mind, I wondered what our other guests thought were the lessons we could learn from the HIV AIDS pandemic,
particularly in reflecting on our experience with Kovik today.
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,
this infection is somehow less of a serious effect than it used to be.
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,
and that people would be dead certainly within 10 years from having a diagnosis of HIV to this being a chronic,
manageable condition with close to a normal life expectancy on effective treatment.
And that does change the way that people behave about a disease.
If you consider, for example, how people respond to a disease like diabetes and you compare that to how people think about corona virus,
then very different attitude to those two diseases, largely because diabetes, we have good measures to be able to control that.
And if you follow those, you will have a close to a normal life expectancy.
So I think this is pretty inevitable.
And sometimes that's a shame and it's a frustration for for for public health professionals that the basics get ignored.
Things like washing your hands. Social distancing and perhaps masks in the future might be things that people start to forget
about if they know that there are treatments available or that they have been vaccinated.
And John was very pleased that we'd included HIV AIDS in our series of 10 pandemics.
I don't think if you only had 10 and you haven't included, I'd make you have 11.
You know, it's been really important and changing. It's changed science.
It's changed how we use science and the practise of medicine.
I will sit with the genetic code of the virus infecting my patient in front of me,
and I will choose the drugs I give that patient based on that genetic code.
I mean, that's lab breaking. It has changed people's opinions. It has tackled stigma.
It's brought people together. Yeah, it's it's it's not just a virus.
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.
And it's brought people together. I mean, fundamentally, it's a dreadful disease that needs treating and needs curing.
But on the back of that, you know, the human response has been amazing.
I think, you know, as a species, we are different because of it.
Next time on Future Makers, we conclude our history of pandemic's season with a disease that is not only still with us today,
but whose major outbreak happened only a few years ago. Ebola first discovered in 1976.
Ebola erupted into West Africa in 2014, devastating populations in Guinea, Liberia and Sierra Leone before spreading further afield.
This disease might be indelibly linked with one continent.
It was an outbreak near the Ebola River in the Democratic Republic of Congo that gave it its name.
But our experience of it provides lessons for the whole world, not least in pandemic preparedness.
Many of which we may still need to learn today. Join me in discovering what those lessons are.
In the concluding episode of Our History of Pandemics season, I'm Peter Milliken and you've been listening to Future Makers.
Future Makers was created in-house at the University of Oxford and presented by Professor Peter Milliken from Hartford College.
A voice actor today was Mike McDonald, and the series has written and produced by Ben Harwood and Steve Preciado.
The school for the series was designed and created by me.
Richard Walk's thank you on behalf of the whole team for listening to the history of Pandemic's.