HIV/AIDS in 1990 and 2012: from San Francisco to Washington, DC.

IN 1990, THE INTERNATIONAL AIDS CONFERENCE WAS LAST held in the United States. The US Food and Drug Administration had approved only 1 antiretroviral drug to treat human immunodeficiency virus (HIV) infection (zidovudine, approved in 1987 [FIGURE]). Highly active antiretroviral therapy, which has made it possible to reduce the risk of HIV transmission and for infected individuals to live longer and healthier, was still 5 years in the future. The AIDS epidemic remained very much out of control in the United States and around the world. Each year brought many more infections and deaths, and the expanding pandemic threatened to overwhelm the capacity for an effective response. This month, the International AIDS Conference returns to the United States. The conference has been absent for more than 2 decades because from 1987 to 2010 the United States restricted entry of people living with HIV. These restrictions could have led to the cancellation of the 1990 San Francisco conference; there were fears that large numbers of people with HIV infection might be arrested on their way to the meeting. However, the 1992 conference, originally planned for Boston, was moved to Amsterdam as a protest against the continuing restrictions. The International AIDS Society, which convenes the conference, adopted a policy that prohibited the society from holding meetings in countries that restricted the short-term entry of people living with HIV and AIDS. HIV-specific travel and residence restrictions have never served a public health purpose. In January 2010, the United States formally lifted its travel and immigration restrictions regarding people with HIV. Yet as of 2011, the 30th year of the epidemic, about 50 countries still had some form of restriction on the entry, stay, and residence of people living with HIV based on their HIV status. As the ongoing controversy illustrates, the AIDS epidemic has always been about human rights, not simply a virus and its effects on the immune system. Social and political systems struggle to come to grips with discriminatory and punitive attitudes and practices directed at infected individuals, while scrambling to find sufficient resources for treatment and prevention. The AIDS epidemic is usually dated from June 5, 1981, when the Morbidity and Mortality Weekly Report published a report of Pneumocystis carinii pneumonia in 5 previously healthy young men in Los Angeles, 2 of whom had died. The first International AIDS Conference was held in Atlanta in 1985, the third in Washington, DC, in 1987, and the sixth in San Francisco in 1990. In 1990, I worked as a medical writer for the Los Angeles Times and covered the San Francisco conference. Through a scientific lens, the conference, as I wrote at the time, was the first such gathering “where the promise of eventual success [against AIDS] loomed large, if only the political, economic and social will can be found to implement the key research advances.” Dozens of new AIDS drugs were in various stages of development. Anthony S. Fauci, then and now the director of the National Institute of Allergy and Infectious Diseases, set the goal for the 1990s as “a lofty one, namely the ability to completely and indefinitely suppress HIV in infected individuals.” The politics of AIDS, however, were quite unsettled. On the second-to-last day of the meeting, scientists and activists marched side by side through downtown San Francisco in a symbolic show of unity that was reported around the world. The message was, “We’re all in this together. Action equals life.” Yet in an equally striking tableau at the conference’s closing ceremony, jeering activists, frustrated over the response to the epidemic by the US government, drowned out remarks by Louis W. Sullivan, then the Secretary of Health and Human Services, as he stoically called for tolerance and unity in the fight against AIDS. During the last 2 decades, scientists, public health officials, and AIDS activists have not always agreed, but they have often listened to one another and worked toward common goals. Some of the United Nations’ current targets and commitments for elimination of HIV/AIDS might be considered primarily about public health (for example, reducing sexual transmission of HIV, preventing HIV among drug users, eliminating new HIV infections among children, increasing to 15 million the number of people accessing HIV treatment, and avoiding tuberculosis deaths), and some might be considered primarily about human rights (for example, eliminating gender inequalities, stigma and discrimination, and travel restrictions).