In the early 1980s, the emergence of a previously unknown and fatal disease, raised concern amongst medical professions and fear in the general population. Those suffering from this new disease presented with a range of opportunistic infections, including rare forms of pneumonia and cancer – suggesting the cause was a failing immune system.
Thirty years on, we now refer to this disease (or more correctly syndrome) as AIDS (Acquired Immune Deficiency Syndrome) and understand it is caused by HIV (the Human Immunodeficiency Virus).
Much has changed over those thirty years – socially, politically and scientifically. Here, I will focus on the latter describing how fight to combat AIDS and HIV has resulted some of the most brilliant science, and also some of the most appalling pseudoscience.
Fighting a disease requires learning as much as you can about it, in particular being able to isolate the cause. In 1984, this piece of the puzzle was solved by two teams, one in the US and one in France – the cause of this new disease was a retrovirus; named the Lymphadenopathy Associated Virus (LAV) by Luc Montagnier’s team at the Pasteur Institute in France, and HTLV –III by Robert Gallo’s team at the National Cancer Institute, the virus would eventually be known as HIV. On both sides of the Atlantic there were often bitter debates about whose contribution to the discovery of HIV was greatest, which was exacerbated in 2008, when Montagnier, but not Gallo, was awarded the 2008 Nobel prize in physiology and medicine.
The identification of the cause of AIDS, opened the door to a number of research opportunities including the development of a test to detect HIV, drugs to combat HIV and vaccines. One of these was achieved within a year, another required over a decade of research before significant progress was made, and the third has yet to be achieved.
By 1985, a blood test to detect for HIV antibodies was developed and immediately used to screen blood banks. The ability to test patients for HIV also allowed medical professionals to gather more data of the disease, however, without appropriate treatments or a vaccine the death rate from AIDS related conditions continued to climb.
In 1987, the first antiretroviral drug, AZT, was approved by the Federal Drug Administration (FDA) for use in the treatment of HIV infection and AIDS. A fairly blunt weapon in the treatment of HIV and AIDS, many of those given AZT experienced severe side effects, a fact which was later twisted by proponents of pseudoscience to suggest that these treatments actually “caused” AIDS. 1987 also saw the political group ACT UP successfully lobby the FDA to speed up drug approvals.
Over time, modification of AZT dosage lead to improved treatments and in 1990 it was approved for treatment in pediatric AIDS. However, the effects were not great and in 1990 the median time to death after diagnosis of AIDS was one year. It was not until 1995 and the development of the first HIV protease inhibitor, saquinavir, that more effective treatments of HIV began to emerge.
The development of HIV protease inhibitors proved to be a significant turning point in the war of AIDS. By effectively “jamming” the protease enzyme in its’ production of the proteins required for HIV to replicate it slowed the ability of HIV to infect new cells. Saquinavir, was quickly followed by other protease inhibitors and in 1996, nevirapine the first of another family of drugs, the Non Nucleoside Reverse Transcriptase Inhibitors (NNRTI) emerged. NNRTI’s, like AZT, interfere with the copying (or transcription) of viral genetic material into the host cells DNA, however, unlike AZT their structure is not based on the naturally occurring nucleotides in DNA.
Now having a range of drugs with which to treat HIV, doctors experimented with varying combinations and HAART (Highly Active Anti-Retroviral Therapy) became the standard treatment whereby patients were treated with several drugs simultaneously. As these treatments were perfected into the 21st century, deaths from AIDS began to decrease, and life expectancy of those with HIV began to lengthen.
The benefits of having multiple drugs to treat HIV are two-fold. Different types of drugs target different pathways that the virus uses to reproduce in the body. The more pathways that can be disrupted the less chance the virus has to reproduce. Also, HIV has the ability to mutate allowing it to become resistant to a specific drug – should this occur, the ability to switch to a new combination of drugs means that HIV replication can still be suppressed.
The effectiveness of the drugs developed in the 1990s lead to somewhat of a reduction in interest by drug companies to develop new drugs to treat HIV moving into the 21st century, however, some notable achievements included the development of fusion and integrase inhibitors. The first fusion inhibitor, Enfuvirtide, was approved by the FDA in 2003 and works by blocking the ability of HIV to fuse with cells and infect them. Raltegravir, the first integrase inhibitor was approved for use in 2007, and works by blocking the enzyme which integrates viral material into the host cells DNA. Incorporation of these drugs into the armamentarium available to today’s medical professional has further improved the outcome for those infected with HIV, with life expectancies expanding beyond several decades.
Although modern treatments of HIV have extended life expectancy and can reduce viral load to undetectable levels, this should not be accompanied by complacency. HIV still requires careful management – any break from the daily drug regimen can allow the virus the opportunity to develop resistance. Even after 30 years there is no cure, just careful management HIV’s replication. The old adage that prevention is better than cure an appropriate one.
AIDS related Pseudoscience
Like many other areas of science, HIV research has attracted its’ fair share of pseudoscientific beliefs. One of the most prominent are claims that AIDS is not caused by HIV. One of the key proponents of this argument is Peter Duesberg whose book “Inventing the AIDS Virus” claims that HIV is not the causative agent. Instead, his claims tend to be based on the suggestion that it is a “lifestyle” disease caused by a range of factors such as drug use (including anti-retrovirals), poor nutrition and poor sanitation. Such claims have been widely dispelled by the scientific community as they do not match the evidence. Indeed my impression of Duesberg’s book is that it has a moralistic rather than scientific undertone.
Based on the claims of Dueberg and other opponents of retroviral therapies, President Mbeki of South Africa delayed the use of these therapies in South Africa, in favour of traditional “remedies” no doubt resulting in hundreds of thousands of unnecessary infections and deaths.
Over the past 30 years homeopaths have also made regular claims that they hold the answer to curing AIDS, however, no evidence has been presented. Similarly claims that HIV can be treated or cured through nutrition have never been proven. And where such alternative treatments are used to replace conventional treatments, the typical consequences are a much shorter lifespan.
Conspiracy “theories” occasionally arise around the origin of HIV, including the suggestion that it was engineered to kill off one section of the population, for example African Americans or homosexuals. Given the nascent state of the sciences that would have been required to do this in the 1980s’ such ideas would be almost laughable if they weren’t so disturbing.