HIV/AIDS: Past, Present and Future

Eric Michael Rhodes  

Welcome to History Talk, the podcast that brings together experts to discuss current events in historical perspective. My name is Eric Michael Rhodes and I'm here with my co-host, Lauren Henry. Together with you, our listeners will be exploring how the past informs the present this year.

 

Lauren Henry 

That's right, Eric. December is AIDS Awareness Month, and we'll be using this month's episode to look at the history of HIV AIDS from a scientific and a social perspective. We'll explore where the disease came from, how it spread around the world, and how governments, public health institutions, and advocacy organizations have worked to control treat and prevent it.

 

Eric Michael Rhodes  

In the West. Most of us think of HIV AIDS as a phenomenon that began in the 1980s when news first broke of a mysterious and highly deadly disease that was affecting certain subsets of the population, gay men, people who inject drugs, and Haitian immigrants. In reality, however, the history of HIV AIDS stretches back more than a century. We'll trace that history today and show how the rise of this disease has coincided with the most important trends of the 20th century from European colonialism in Africa to the Proxy Wars fought between the allies of the United States and the Soviet Union during the Cold War to the forces of globalization and economic neoliberalism that have shaped the global economy in the 21st century.

 

Lauren Henry 

To help us make sense of this all we're very fortunate to be joined by three esteemed scholars today. Up first is Dr. Thomas McDow of the Ohio State University, known to friends and colleagues as Dodie. He is Associate Professor of History and the director of the Goldberg Center for Excellence in Teaching. Dodie writes about Africa and the Indian Ocean world and is the author of this month's feature article in our publication, Origins.

 

Dr. Thomas McDow 

Great to be here.

 

Eric Michael Rhodes  

Next we have Dr. Kathy Lancaster. She's an Assistant Professor at the College of Public Health at The Ohio State University. An epidemiologist, Kathy studies, the treatment and prevention of human immunodeficiency virus or HIV. Thank you for being here, Kathy.

 

Dr. Kathy Lancaster  

Thanks for having me.

 

Lauren Henry 

And finally, Dr. Jesse Kwiek is here with us in the studio. Jesse is Associate Professor of microbiology at The Ohio State University. He researches the biology, pharmacology and public health impacts of HIV. Thanks for coming, Jesse.

 

Dr. Jesse Kwiek 

Happy to be here.

 

Eric Michael Rhodes  

Let's start from the very basics. What is HIV and how is it different than AIDS?

 

Dr. Jesse Kwiek 

I'll take that one. So infectious diseases can be caused by bacteria, fungus, parasites and viruses and HIV, which stands for ”human immunodeficiency virus” is a virus as the name implies that infects human immune cells and causes the disease aids or Acquired Immuno Deficiency Syndrome. We know a lot about the transmission of HIV and that it can be transmitted when certain body fluids blood, semen, rectal fluids, vaginal fluids, and breast milk come in contact with mucosal membranes or if HIV infected blood is directly injected into somebody, that is a very efficient way to transmit HIV. Now contrary to what your great uncle might have said, or what you might have read on the internet, HIV cannot be transmitted by air, water, saliva, sweat, tears, urine, closed mouth kissing, insects, especially mosquitoes, cannot transmit it, toilet seats, or by sharing food or drink. Following HIV infection, we know that HIV replicates in the body and ultimately what it does is it destroys our immune cells and makes us susceptible to many different diseases which normally our immune system fights off. These include a special form of pneumonia called Pneumocystis pneumonia, which was originally what keyed us off to HIV, makes us susceptible to certain viral induced cancers such as Kaposi Sarcoma, and to bacterial infections, the respiratory infections, such as tuberculosis.

 

Dr. Thomas McDow 

I mean, my thoughts on that, I think that's a great description, and hopefully useful to people who might not know about these things. But that's also what we understand now. And one of the things as a historian that I'm interested in is how we've come to understand those and the scientific story, I think of HIV deserves some attention as well.

 

Lauren Henry 

When did HIV first appear in humans as far as we can tell?

 

Eric Michael Rhodes  

So we want to think about the viral history of HIV, the evolution of the virus that ends up causing aids scientists looking at the viral clock of HIV have found samples in human tissue that were taken in the 19- late 1950s and early 1960s, which using phylogenetic trees have enabled them to reconstruct the virus or the crossover point from non-human primates and again, there's a window of when that happened with genetic dating, but it could have been as early as the late 19th century or the first decades of the 20th century. And where exactly do we think that it first appeared?

 

Dr. Thomas McDow 

Well, working from the work of Beatrice Han and her team to work with the Simian virus to figure out where that happens. They've really narrowed it down to the southeastern corner of Cameroon and the Sangha River Basin. So this is in Equatorial Africa and riverine networks that are part of the broader Congo River network. But maybe Jesse maybe you could say something more about the techniques.

 

Dr. Jesse Kwiek 

Yeah, sure. So you know, it's right around the mid-2000s, when molecular biology was really up and running, and again, as Dodie mentioned, Beatrice Han and her colleagues, they had noticed that chimpanzees and other non-human primates living either in captivity or in the wild, were infected with a close relative to HIV called SIV or simian immunodeficiency virus and so what Beatrice Han and colleagues did is they went out all across Central Africa, and they actually collected the feces and the urine from wild chimpanzees and then using modern molecular biology techniques, you can isolate parts of the viral genome out of there, then you can use some computational biology techniques to sort of rebuild a phylogeny, which is really a family tree of the different viruses and when you stack up HIV with viruses from other non-human primates, turns out it's most closely related to HIV from chimpanzees and so that is really, gave us the first clue as to where it might have been coming from.

 

Lauren Henry 

So we have this very clear idea of where the disease originates in this very specific region in Cameroon. And then we have the sort of public awareness of it, which happens across the world, and several decades later. And I wondered if you could fill us in on what happens in between what sort of forces propelled the spread of HIV, especially before it becomes something that is part of the scientific or public consciousness.

 

Dr. Thomas McDow 

And I think this is one of the most interesting points of connection between a scientific understanding and historical understanding, because once we take this information that Beatrice Han and her colleagues have been able to put together and match it with the findings of Michael Woroby, and the phylogenetic trees that they've done, that then helps us put it in a time and a place which connects it to a story of Africa, Equatorial Africa during the colonial period and this is a period in which colonial interest in Equatorial Africa grew tremendously and so that networks of exchange which were long standing, with the coming of European colonialism, however, we see it increase in scale and scope of connections and so again, putting these things within the riverine network, we see the way that steamships both lead to the exploitation of natural resources in the region, but also moved people around in a greater degree. So it sort of solid clues that we haven't put in this history together, are against samples that were taken in 1959, and 1960 and what's now Kinshasa, but had been the Belgian colonial capital of Leopoldville, which is further down the Congo River from where the Sangha river connects to it and across the river from Brazzaville of the French Congo. So these are two large cities that exploded in growth during the colonial period and so we can hypothesize that after people talk about the spillover, there's an zoonotic transfer that happened in the early decades of the 20th century, an individual infected with HIV, that earliest HIV transmitted the disease some way or maybe he or she moved down the river and so if we think about increasing pace of connection, and mobility, we then can begin to understand how the conurbation around Brazzaville and Leopoldville would have been the place where the virus would have intensified.

 

Eric Michael Rhodes  

Do you agree with that, Kathy?

 

Dr. Kathy Lancaster  

Correct. I mean, it's really idea of, as Jesse mentioned, the potential aspects of transmission and one of them being sex and exposure to vaginal and female fluid is part of human nature and so globalization, the more people you get together, the more mixing there is, the more potential for that sexual transmission occurs and so that's, I think, really what Dodie is getting at with that period of extreme growth within the region.

 

Eric Michael Rhodes  

So these samples were taken in the late ‘50s and early ‘60s that have enabled us to reconstruct the genealogy of the disease Doty, could you speak a little bit about the Cold War context and how that might have affected the spread of HIV?

 

Dr. Thomas McDow 

Yes, I would be happy to do that because I think that one of the things that is really interesting, again, sort of mapping this disease along a human experience, we see that the decolonization in the Congo, which is where Leopoldville was helps us understand the story of HIV. That is a relatively well-known case, when the Congo became independent very quickly in 1960, the first prime minister was a man named Patrice Lumumba. This was in a Cold War context, and the Congo's wealth in the Katanga region was very important in a Cold War setting, right. That's where uranium used and one of the atomic bombs dropped in Japan had come from and so guarding and keeping that uranium safe was a strong interest of the US and their allies, but Patrice Lumumba did not seem interested in American allies, and there was fear that he would reach out and make connections with the Soviet Union and so with CIA help, he was abducted and eventually assassinated by Congolese people and this led to a five year struggle sometimes called the Congo crisis. Which called the UN in, and the Secretary General of the UN died when trying to go visit in a mysterious plane crash and lots of Belgian troops that came in American troops that came in the incomplete or the disastrous decolonization of the Congo also meant that many expatriates and other professionals have left the country. And so as the country stabilized in the late 1960s, there was an attempt to fill in the professional ranks and so French speaking people were valued and so there were many Belgians who came back or stayed, but also many Haitians were hired and so I think the number by the late 1960s, they were more than 4000 Haitians living and working in the Congo, and part of living is having sex and so it's likely that sexual transmission of the disease happened and that one or more Haitian expatriate workers who again also were escaping from their own Cold War dictator, but it went in going home with took the disease back with them and again, using the same processes and Michael Woroby has done the same work on the phylogenetic trees to show that the origin of the US epidemic has links to Haiti.

 

Dr. Kathy Lancaster  

So I have to say, from a public health standpoint, the influence of the cold war on the HIV epidemic is one that's not talked about as much. And so Dodie, I feel like you put this really nice addition to the history of HIV, but at least from you know, is not as discussed widely within a public health setting, which is pretty neat.

 

Eric Michael Rhodes  

Well, I mean, there's other strands of, that is from how, so we're talking about one island, the Caribbean, for Haiti. But you know, the Cuban epidemic also has a Cold War linkage as well, in the sense that the number of Cubans that came to West Southern Africa to Angola as volunteers, teachers, development workers, but also as military, to support the liberation of Angola during the Angolan Civil War, to support Augustine and NATO's socialist movement was great and so again, in a Cold War setting, the Cuban soldiers coming to fight, actually fighting South Africans who were serving as kind of proxies for the US in southern Africa and again, the end of that conflict, when the Cubans and Angolans defeated the South Africans set off a chain of events that, again, are very widely known, but maybe not linked in this way, but the independence of South West Africa, which became Namibia in 1989 and then eventually the South Africans having to realize that the gig was up and releasing Nelson Mandela from prison.

 

Lauren Henry 

So we've gotten now out of this very small corner into the beginning of the kind of sense of this as a global phenomenon and I was hoping we could turn to the 1980s in the United States.

 

Dr. Jesse Kwiek 

Yeah, sure. So we first recognized HIV in humans in the early 1980s. Lots of clinicians around the country noticed that healthy young men were coming down with basically lung infections that they hadn't seen and they initially put it together and realized that something was causing a disease amongst otherwise healthy men.

 

Lauren Henry 

What are some of the either social or public health conditions that allowed this disease to first take hold in certain parts of the country or among certain communities in the 1980s?

 

Dr. Kathy Lancaster  

I mean, a lot of it is in some ways the sexual revolution, and I'm not the historian. So I could be wrong, if that's the right term for that time period, but I think it also really kind of became this liberalization as well, in terms of the availability of bathhouses in terms of encouraging or at least providing opportunities for potential transmission drug use in the 70s, as well an increase of injection drug use, that was occurring among individuals also provided another route of transmission around that time period. And so it really just created this perfect storm.

 

Dr. Jesse Kwiek 

And in something about the biology of the virus also really permitted its spread. And what that is, is that essentially, when someone is first infected with HIV, they really have mild flu like symptoms, but it really is not until five or 10 years later, that if they're untreated, they will actually start to begin to develop AIDS and the Acquired Immuno Deficiency Syndrome. So oftentimes, early in the 80s, you know, the first HIV diagnostic really didn't come around until 1985 and so there was no way to tell who was actually living with HIV, that coupled with the fact that there's a very long latency period between infection and when symptoms develop really meant that this epidemic was growing and we were without the ability to diagnose it and it really didn't make people sick until they've been living with for a long time and, you know, likely were unaware that they should perhaps change the way they were doing things.

 

Dr. Kathy Lancaster  

And we also entered this period where people were still living in a bit of denial and it was really advocacy groups or community empowerment that was occurring, especially within the gay male community, and that they were seeing their friends, their family members dying of, again, these conditions that they should not have been dying from and it really pushed the issue to the forefront and really forced some of the political leaders to start making recognition in terms of this is as public health issue that needs attention.

 

Eric Michael Rhodes  

So that dovetails really nicely. I just wanted to ask how these public health institutions and governments responded to the spread of HIV in the 1980s?

 

Dr. Thomas McDow 

I think the kind of popular characterization would be the government's did very little or that concern that the medical establishment didn't react quickly enough or ignored people who were suffering from AIDS and there is a truth to some parts of that, but I think that one of the stories of HIV that we could appreciate more is the scientific scramble to try to make sense of this disease and maybe Jesse might want to say more about that.

 

Dr. Jesse Kwiek 

Sure. So in the early 80s, again, people were coming down with these opportunistic infections and we really, the scientists were trying to figure out what was the causative agent and so HIV is what's known as a retrovirus and it was first described, or isolated by a French group, Luc Montagnier, and Francois Barré-Sinoussi, who are eventually Nobel laureates first made the discovery, which was sort of confirmed and the whole situation got very complicated when Robert Gallo, the US scientist entered into that, and there was all kinds of allegations of fraud and things like that, but nevertheless, really, around 1983 is when we first discovered that HIV was causing AIDS.

 

Dr. Thomas McDow 

So there was an immediate scientific interest in this and people wanting to figure it out. But at the same time, part of the longer history here is Kathy talked about the sexual revolution, and really a strain within that of gay liberation, but the other sort of coming from the other side of the picture, is the rise of American conservatism, right? By the 1980s, with the election of Ronald Reagan and his coalition, which included would have been old mainline conservatives along with the Christian religious right, we have a an outspoken concern about men with men, but also that AIDS would for that, for some of those people were an abomination and so they were working against or did not want the government to be involved and Ronald Reagan himself was very, very slow to acknowledge AIDS, even though people that he had been close to and reconnected with from his Hollywood career, were both affected and infected. And so in that way, the death of Rock Hudson and I believe is 1985 was kind of a signal moment in terms of making people more aware of the disease and also of the government's inaction.

 

Eric Michael Rhodes  

So we've talked about the concentrated epidemic within the United States, among primarily gay men is that

 

Dr. Jesse Kwiek 

Certainly, in the United States, the epidemic is concentrated

 

Eric Michael Rhodes  

—is concentrated

 

Dr. Jesse Kwiek 

—among men who have sex with men, but worldwide, roughly 50% of the people living with HIV are women today.

 

Dr. Kathy Lancaster  

—today.

 

Eric Michael Rhodes  

So I wondered if we could look at the global context again, and talk about how policies in the global arena contributed to the rise of a generalized epidemic in a place like Africa.

 

Dr. Thomas McDow 

Right, again, Jesse got to make the public service announcements about HIV, I will get to say that Africa is not a country, so that our viewers don't think they were thinking of it as a solitary place. But when we look at the explosion of the epidemic, from the first measurable moments of it in the Great Lakes region of Eastern Africa, and then growing over the 1980s, and early 1990s, to Southern Africa, we want to understand what contributed that spread and so when we think about the rise of conservatism in the US and Britain, both of those had certain effects on government and government spending and government interest but also, it fed a broader global phenomenon in the wake of a debt crisis in the 1970s and early 1980s, but it meant that many African countries were in a position where they were greatly in debt, and were having trouble repaying that debt and so what became fashionable from the IMF and the World Bank were a set of conditions that countries had to meet in order to qualify for debt relief, or new loans, sometimes called structural adjustment, where debt relief could come but with governments having to meet certain requirements, and among those requirements are liberalism in the economy, and scaling back the public sector. So having people pay for their own health care, rather than giving health care, having people pay user fees for like health care and education. So this is happening in the 1980s, and into the 1990s and so this was pressure put on African countries. So at the very moment when their health systems needed to be the most at the ready, they were being encouraged by international donor community to scale back.

 

Dr. Jesse Kwiek 

I'll just add, I think another thing that really exacerbated the quote unquote, African HIV epidemic really has been the scarcity or the inaccessibility of most antiretroviral drugs. So we know in about 1987, when the FDA approved the first antiviral drug, AZT, but Africa and Sub Saharan Africa, in particular, have been at least 10 or 15 years behind in their ability to gain access to sort of the lifesaving drugs, and we know from some more recent studies, that people that our on HIV therapy are also less likely to transmit the virus. So the longer the people do not have access to the drugs, the more likely they are to transmit and so again, even though tests were often available back then there was this sense of feeling amongst many people in the world that why should I bother to get tested, I'm just going to die anyhow, right? And so now as drugs become available, and people have access to them, and they see the effects that drugs have on people and they’re, you know how much energy they have, and that they're starting to feel better, you know, I think, the rollout and the accessibility of drugs, much of which came from actions or activities of the Clinton Foundation of PEPFAR, which is the President's Emergency Plan for AIDS Relief, all of these things, which made antiviral drugs accessible, I think, has helped to slow the epidemic. But I think the opposite of that is also true that in the absence of antiretroviral drugs, that the virus spread rapidly.

 

Dr. Kathy Lancaster  

And I'll add the prevention setup that at least in terms of the 80s and 90s, you know, we really have the scientific developments to not only did we have treatment available, arguably how effective it was or how it ultimately became resistant to HIV, and how we needed new and better treatment options available. But in terms of prevention, we started identifying that, at least within the African continent, that the primary mode of transmission was sexual contact, predominantly heterosexual contact, but again, nonetheless, sexual contact and so there was a big movement where international donors were coming in with prevention messaging and so one of the predominant prevention messaging that was occurring within specifically Sub Saharan Africa was the "ABC" campaign, which was remain Abstinent, Be faithful, and Condom use, that really allowed an opportunity for some leaders, either religious leaders or political leaders within the region to start cherry picking some of the messaging, and so allowed an opportunity to really focus on perhaps more of the abstinence; remain abstinent. Well, we know evidence shows that that may not always be achievable for everyone and so it's important to think about that also the idea of being faithful, well what does that mean? That's a Western construct? What does it mean to be faithful a lot of times in the qualitative work that I've done within the region, you ask people what that means and they say, "Well, I trust my partner." It has nothing to do with who they have sex with and so there was a little bit of that loss in translation and then condoms are a very highly effective prevention method that people can use, but again, you know, we're bringing in a method that is generally not always acceptable within the United States, but bringing it to a context where it may not always be readily available for people to use, there's an unfamiliarity with it, what are condoms? How do you use it? How do you use it properly? And so there was a lot of resistance to that in the, early on in the epidemic as well, even though we had that preventative measure.

 

Dr. Thomas McDow 

And I think looking at the ABCs, we can see the way that the US epidemic and a Western epidemic shaped a global response and so that all of those, the ABC messages made sense for Western epidemic. Condoms particularly worked very well for gay men who felt like having come out of a closet, and that is a very sex positive and affirming to stop -- and some, what people said at the time -- stopping having sex is to go back in the closet, but with using condoms, effectively, you can continue to have sex but in in the global context where fertility may be part of the question, it doesn't work in the same way.

 

Lauren Henry 

Thinking about agency and terms of who the actors are in this conversation, I was wondering if you could talk to us about how people with HIV and their loved ones have influenced healthcare policy and public policy, either in the United States or around the world?

 

Dr. Thomas McDow 

Certainly, I think that if we were to imagine that something like as traumatic and devastating as HIV AIDS could have been, that government policies would have turned to address these without any action from infected and affected people, we make a very big mistake. So, you know, I think the earliest story of AIDS in the US is one of gay men coming together to the Gay Men's Health crisis was formed very early on, to help take care of people, and so the pulling in of individuals and taking care of them was vital to that. But also in the face of what was perceived as government inaction and unwillingness, the AIDS coalition to unleash power, right, ACT Up, was a vital voice of protest in the United States to call out the Reagan administration and to, and the actions they took taking over the New York Stock Exchange, kind of non-violent protest and civil disobedience to draw attention to the inequalities and the ways that their friends were dying of a disease that they thought was not getting the attention it needed, is a, is a vital part of the story and leads to a great deal of change and awareness, although their methods were uncomfortable to many, and so picking apart the history of protest movements and change in the United States is very interesting and so when there is a, finally an act of Congress to help pay for treatment, it's named for Ryan White, who was a young boy from Indiana who had AIDS but had contracted it through hemophilia and was a very telegenic and loving kid who appealed to many people. And so he as kind of a poster boy for AIDS was much more palatable from the federal government point of view than the protesters who had been willing to put their lives on the line to try to bring attention to this. There's a long story in that in the you know, the movie, how does it survive a plague tells a lot of that story and in a great way with and a companion book by David French does that. And I think that that you can look, in Sub Saharan Africa, the most closest cognate to that is the treatment action campaign in South Africa, which was pushing for access to antiretroviral drugs as soon as they were available. And again, using mass action, and ironically using some of the same techniques that the anti-apartheid movement had used. But in this case, using it against the ANC government to try to draw attention to this.

 

Dr. Jesse Kwiek 

I'll just add that another great thing that came out of the HIV epidemic, if there was anything great that came out of it, was groups like ACT UP really put a lot of pressure on the Food and Drug Administration, to cause them to think differently about how drugs were approved and the process that goes through, who gets to comment on how those trials are run, who gets that input. And so HIV was first described in about '83, or it was identified, but it wasn't until '87 when AZT came around, and so what ACT UP and others did is they really wanted a way to fast track the human subjects research, right, like all new molecules that want to become drugs have to go through human clinical trials, and so what ACT UP really did again, is they pushed the timeframe of that to try to speed it up. But they also said that we want to have a voice on how these studies are set up, we want to have input about that. We want to make sure that you're developing things that we want, that we need access to and so they really were the first group to promote having community members serve on the review panels that review how human subjects research takes place. So that's a, really a fantastic addition to drug discovery and drug development and drug approval that came out of this epidemic.

 

Eric Michael Rhodes  

And that is not just for HIV drugs, right? That's now that's common practice?

 

Dr. Jesse Kwiek 

Correct. Absolutely.

 

Eric Michael Rhodes  

In other words, it's been patient-centered care that's come out of that. The film that Dodie mentioned, "How to Survive a Plague" ends around 1995, what had changed by 1995, with the drugs, specifically, what came out of the ACT UP actions?

 

Dr. Jesse Kwiek 

So the first thing that came out was, you know, AZT was the first drug that came out. And it turns out that just using a single drug, as a therapy for a person living with HIV is not effective for a very long time. HIV evolves approximately a million times faster than we do, and if you put a single drug into a person living with HIV, within three weeks that virus will essentially have evolved resistance to that drug then so you know, as the 90s, progressed on new classes of antiretrovirals called protease inhibitors came out protease inhibitors allowed clinicians to basically use multiple drugs of different classes, which enabled us to more effectively suppress viral replication, and thus prolong the life of people living with HIV. Since then, you know, I think there are about more than 30 different antiviral drugs that have been approved. These include things called protease inhibitors, integrase inhibitors, and now we've also (since the mid '90s) thought of different ways to use them, right? And so much like if you travel to a country in the world that has malaria, you take malaria prophylaxis, before you have malaria. We now have something called prep, which is "pre-exposure prophylaxis," so people that are either labeled as high risk or perceived to be at a high risk of acquiring HIV can take antiviral drugs prior to having HIV, and that's called pre exposure prophylaxis. We also have something called post exposure prophylaxis, meaning that needle sticks and healthcare workers, perhaps sexual assault, if there is a known or highly likely to be known HIV exposure, we know that taking antiviral drugs within 72 hours post that exposure does a fantastic job of reducing HIV transmission and then I'll just add one other thing, which I think is another huge success story of this HIV epidemic is we know that women living with HIV who become pregnant about one third of the time, if they're not on therapy, one third of the time, they will transmit their HIV to their newborn infant, and through, initially through AZT, but now through combination therapy, we know that if a pregnant woman living with HIV is on therapy, and her viral load is suppressed, and she doesn't breastfeed, that we can be basically reduce to near zero, the probability of her transmitting HIV to her child and in my mind, that's one of the real public health successes of this HIV epidemic. We can nearly eliminate mother to child transmission of HIV and in fact, one country in the world, Cuba in 2015, has been certified as basically the first country to have eliminated mother to child transmission of HIV and so I think what that tells us is, it's not just the drugs, but it's the healthcare infrastructure and the systems and the access to that health care that people have as well.

 

Dr. Thomas McDow 

And I guess I would add about looking at things from the 1990s and going forward is the fact that now people everywhere in the world have access to this combination therapy, antiretrovirals, and so the fight for that, again, we mentioned what happened in South Africa, and which ended up eventually, with the pharmaceutical industry, the global pharmaceutical industry, and the US lobbying arm suing the government of South Africa for trying to break patents, which again, we can see this in terms of globalization, and the way that the neoliberal global order had tried to protect intellectual property in such a way that things like pharmaceutical companies could continue to make the profits that they wanted to. But it tells you something about this case, that when pharma tried to sue the government of South Africa, the governments of South Africa had an amicus curiae brief from the treatment action campaign so they, they were able to be on the same page to try to get this and this, the failure of that suit and the settlement afterwards, opened the gates for the spread of these drugs and so I think Kathy has a lot of experience working in Malawi, and can talk about perhaps the availability of antiretroviral drugs there and how it changed the face the epidemic.

 

Dr. Kathy Lancaster  

So the availability of drugs is really Malawi was one of the global leaders to provide ART to pregnant women in terms of lifelong treatment. So previously, as Jesse mentioned, there was this opportunity that obviously, that HIV is highly transmissible vertically, so from the mother to the child, and so initially, the treatment was to treat women with ART during their pregnancy, during a short period afterwards, and then depending on how their immune system was, they could then be removed off of ART, and then continue to live until they hit an appropriate threshold of their immune system starting to fail and getting back on treatment. And so as a way to counteract that, we started learning through a lot of different studies that the earlier you put people on ART, the more likely they are going to survive and live longer. So we had the opportunity to put them on treatment before their immune system really started to take a hit from the disease and be overrun by a virus. And so the first step that Malawi took was they provided what's called Option B+ where they put women on ART when they were pregnant, and then continued them on ART for their life and then in about 2014 is when Malawi actually again, was one of the first countries that initiated  treatment for all. So meaning, the moment that you find out that you are infected or living with HIV, you have the opportunity to immediately start treatment before you start seeing any of the severe side effects of HIV and the high viral loads really taking a toll and then you can continue living on ART for life and so Malawi has truly been one of the pioneers within the region in terms of ensuring access to all at any stage within the disease.

 

Lauren Henry 

So just to finish up, our motto is always "current events in historical perspective," but I would like to ask our esteemed panel, what does HIV look like in the future? And where do you think the disease, the challenges of the disease, or the treatment is going either in the United States or throughout the world?

 

Dr. Kathy Lancaster  

Really, at almost a golden age of the epidemic in terms of various modalities for prevention and treatment for HIV. So since 2005, we've essentially cut the number of deaths of people dying from HIV in half. So a lot of that was the availability of treatment that Dodie and Jesse had mentioned. But it's also been early diagnosis, availability of testing, so one of the scientific developments that we've had more recently is the idea of HIV self-testing. So at least now within the United States, you can go to a pharmacy and pick up an HIV test, removing that barrier of going to a clinic. Removing the potential anticipated or experienced stigma of receiving an HIV test and finding out the results, but being able to do it within the comfort wherever you choose. So that made the testing become more available.

 

Dr. Jesse Kwiek 

You could actually go on Amazon for about $35 and buy HIV tests and have them delivered to your house.

 

Dr. Kathy Lancaster  

Perfect. Yeah, so even Amazon's getting involved.

 

Eric Michael Rhodes  

--and maybe by drones in enough.

 

Dr. Kathy Lancaster  

The other exciting thing that we've really seen over the last decade is this idea of treatment as prevention. So treatment as prevention allows the opportunity for individuals who are living with HIV take treatment achieve what we call viral suppression or obtain a viral level that is technically undetectable and therefore if it is undetectable, it's untransmissible or transmittable and so the CDC and NIH and lots of other global organizations has kicked off the U Equals U campaign, meaning if you are undetectable, it's untransmittable and so they have the opportunity to take the drugs achieve a level of viral suppression to not put others at risk for transmitting and that was really at the idea of HPTN052, which was the HIV prevention trials network, which found that treatment was so highly effective at reducing the viral load that individuals would, if they're successful on their treatment, are unable to transmit.

 

Dr. Thomas McDow 

But I guess as the historian, I have to play the role of the cynic here and that I know that my colleagues in public health and in science can imagine the way that things work perfectly, but when I think about the human condition, we realize that they don't always and so I think the Kathy's has introduced a very promising future, but which really strongly depends on people entering the cascade of care, as they call it. So once you're tested, and you're in a place where there are drugs available, the future is very bright and HIV has become essentially a lifetime disease that you can live with, like diabetes, but who is left out of that cascade of care? Where are the cases of HIV expanding, right? So a few years ago, I was in Scott County, Indiana, which had the fastest growing HIV rate in the country, which was a combination of the opioid crisis and injecting drug users exchanging sex and reusing needles written on top of a state that had outlawed needle exchange. I think also, when we look at the United States and see who was falling outside of this cascade of care, we talked about injecting drug users. But we also see extremely high rates among trans people of color and even more broadly, people of color, and especially African Americans are affected by HIV at much higher rates. So again, I think HIV helps us pinpoint inequalities in the world and so while I'm hopeful about the future, in terms of the drugs that are available, the systems that are in place, and the stigma, and social relations that shape our world, continue to also shape the epidemic.

 

Dr. Jesse Kwiek 

I'll just go ahead and add to say that it's pretty much now we have many of the tools that we need to end the HIV epidemic. But to date, there is only one person who has ever been cured of HIV and really, it's not a widely accessible modality and so there really is no cure for people living with HIV. Again, we know that antiretroviral therapies are incredibly effective, both at prolonging the life of people living with HIV, and at blocking HIV transmission, but again, you have to be able to have access to the healthcare infrastructure, you have to have the money and the funds to afford those drugs. And so really, a lot of effort, several billion dollars have been put into our efforts to discover or create an anti-HIV vaccine and to date, that vaccine does not exist. But one of the reasons there is so much continued excitement and enthusiasm to discover this vaccine is it really takes sort of adherence in a lot of parts of the human condition out of that in that ideally, it would be a shot that would prevent HIV transmission, whether or not we ever get there, I'm not sure, but nevertheless, right now, it is an infrastructure, healthcare access, and in my opinion, an economics hurdle that stands between us and really, I don't know if I'd say eradication, but basically further prevention of acquisition of new HIV infections.

 

Dr. Kathy Lancaster  

And I'll add in the meantime, until there potentially is a vaccine available, they're also testing currently, there are clinical studies going on that are testing other long-term modalities of treatments. So currently, people are taking either a single pill or multiple pills every single day in terms of their treatment for HIV, and they are now testing the opportunity of using long acting injectable treatment and so people can receive an injection of ART, perhaps lasting a month to maybe up to three months and so therefore, it wouldn't require them to come back and receive prescriptions or receive the pills from a clinician or a pharmacy but then also reduces that daily burden, of perhaps taking the pills.

 

Dr. Jesse Kwiek 

And that would be analogous to birth control.

 

Dr. Kathy Lancaster  

Exactly.

 

Eric Michael Rhodes  

We'll wrap it up on that note. Thank you to our three guests, doctors Thomas McDow, Jesse Kwiek and Kathy Lancaster.

 

Lauren Henry 

This episode of History Talk podcast was brought to you by Origins: Current Events in Historical Perspective, an online publication of the public history initiative and the Goldberg Center and the history department at The Ohio State University in Columbus and Miami University in Oxford, Ohio. Our main editors are David Steigerwald, Steven Conn and Nicholas Breyfogle. Our executive producer is David Staley, our audio and technical advisor is Paul Kotheimer, our audio producers and hosts are me Lauren Henry and Eric Michael Rhoades. Song and band information can be found on our website, and you can find our podcast and more on our website origins.osu.edu on iTunes, Stitcher and on SoundCloud, as well as everywhere else you get your podcasts and as always, you can find us on Twitter @OriginsOSU and at HistoryTalkPod. Thanks for listening and we'll see you next month.