The Forgotten Epidemic: AIDS in the 21st Century

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I would like to express my appreciation to all of the participants of this HIV Workshop and especially to each participant who took the time to write a review for this special issue of AJRI. I think people who have devoted their lives to the study of AIDS are a very special breed, and I am very happy to be among you, and somewhat embarrassed to say some of the things I will say, because you know more about individual parts of this big puzzle than I do. I am going to speak to you as the oldest person you are going to meet; I will be saying things about history that you know but I will speak from a different perspective.

In early 1981 when I was designated Surgeon General I had never heard about AIDS, no one had ever heard about AIDS, and the handful of scientists who knew about immunodeficiency did not even know what to call it, much less what it was really all about. AIDS entered the consciousness of the Public Health Service quite gradually and without fanfare. In June 1981, the Center for Disease Control published its first report on what was to become the AIDS epidemic. It concerned five previously healthy homosexuals who were admitted to Los Angeles Hospitals with a very rare form of pneumonia caused by Pneumocystis carinii. By the time the report had been published, two of the men had died and the other three died shortly thereafter. Five cases were not many but this lethal disease was so rare that a handful of cases in a single year in any one place was like an epidemic. Soon the reports trickled in on cases occurring in other cities as well. Then a month later, the Public Health Service published a report that 26 young previously healthy homosexual men had been diagnosed with Kaposi’s sarcoma, an uncommonly reported cancerous condition usually found, if at all, among elderly men. It took years for our government to concede that this illness was unique and serious. In 1987, I was finally given the authority to publicly confront the disease. This was accomplished by sending information regarding AIDS to every US household. This still serves as the distinction of being the largest public mail distribution in US history.

  • image(C. Everett Koop)

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If we skip forward 30 years, the face of AIDS has clearly changed. On a worldwide level, this epidemic is no longer a homosexual disease; rather, it is one that has killed 25 million men, women, and children. Today, more than 33 million people are infected with HIV worldwide, with an estimated 2.7 million new infections in 2008. Worldwide, the majority of infections are heterosexually transmitted, with adolescents and women bearing a disproportionate burden. Nevertheless, because of the outstanding success of antiretrovirals, HIV/AIDS has become the ‘Forgotten Epidemic’. I would like you to consider the following about HIV: (i) HIV is a chronic disease only in the developed world; (ii) the primary means of HIV transmission is heterosexual sex; and (iii) culture, social behavior, and economics, more than demography, play a bigger role in HIV transmission and disease course.

This conference is the first of its kind to offer insight into the biology of sexual transmission, both men to women and women to men. We have come so far, but still have a long way to go to understand the complexity of this disease. I commend all participants for their willingness to share a goal that emphasizes the importance of mucosal immunity in the male and female reproductive tracts for the transmission of HIV and to identify the means whereby the mucosal immune system can be optimized to achieve protection against HIV acquisition. The articles in this special issue will ensure that the important messages shared at this Workshop at Dartmouth Medical School in Hanover, NH, will reach an ever-growing audience and shorten the time until HIV is no longer the ‘Forgotten Epidemic’ but rather the ‘Past Epidemic’.

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