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What Can the HIV/AIDS Pandemic Teach Us About COVID-19?

We must reduce stigma, understand transmission, and improve access to testing.

I recently had the opportunity to talk about assessing risk and making sensible decisions about COVID-19 on the BBC World Service radio program The Real Story. Host Ritula Shah posed some challenging questions to me and my co-panelists, Lenore Manderson, Professor of Medical Anthropology at the University of Witwatersrand in South Africa; Frank Furedi, Professor Emeritus of Sociology at the University of Kent in the UK; and Gabor Mate, a well-known addiction medicine physician from Vancouver. I’d been invited to discuss my last blog post, in which I discussed how we can use harm reduction to navigate the uncertain and changing path out of the COVID-19 pandemic.

When we think of 20th-century pandemics, AIDS quickly comes to mind. My colleague at UC San Francisco, Paul Volberding, was a key player in the early days of HIV/AIDS in San Francisco. An oncologist by training, Volberding helped to found the first HIV outpatient AIDS clinic in the United States and the first inpatient ward at San Francisco General Hospital. I’ve listened to his analysis of the current pandemic with great interest, hoping to learn how the AIDS crisis can teach us ways to sensibly navigate the path forward out of COVID-19. Here’s what I’ve learned:

We are way ahead with COVID compared to HIV/AIDS. Unusual opportunistic infections, including Kaposi’s sarcoma in gay men, were first noted in October 1980. A series of six cases of unusual infections in gay men were reported in the CDC’s Morbidity and Mortality Weekly Report in June 1981. At that time, it was unclear what was causing these illnesses. There were a number of speculations that turned out to be wrong, including the use of amyl nitrate (“poppers”).

However, it was not until two years later that a virus, originally named HTLV-3 and later HIV, was identified as the cause of the immunological compromise that was decimating the immune system of many of those who were infected, which allowed for opportunistic infections. Endemic homophobia and the discomfort in discussing the sexual practices in which HIV could be spread combined with a lack of leadership around the disease, notably Ronald Reagan’s unwillingness to even mention the burgeoning crisis until September 1985, greatly contributed to its spread.

In the case of the respiratory illness known as COVID-19, the causative virus, SARS-CoV2, was identified within days of the first cluster of patients with a unique pneumonia being identified in Wuhan, China in December 2019 and rapid communication allowed for a quick, albeit sometimes disorganized, international response.

Without understanding what causes the illness, it’s a lot harder to advise how to prevent it, and in the absence of information, fear reigns. One of the largest fears in the early days of HIV was, "Can this be spread by casual contact?” The fear that an HIV-positive waiter could infect a restaurant patron, or an HIV-positive nurse could infect a patient, fueled fear, and because the disease at that time largely impacted gay men, it also fueled homophobia and panic.

With COVID-19, what we know about the disease has changed over time and become clearer in the ensuing months. While we once thought that only symptomatic patients could spread the disease, it’s become clear that the role of pre-symptomatic carriers (and to a lesser extent, asymptomatic carriers) accounts for a significant proportion of transmission, which led to physical distancing and mask use requirements. The role of transmission via surface contact, leading people to wipe down their groceries with disinfectant once home from the store, once feared as a significant means of transmission, may turn out to be less of a risk.

Despite challenges with access to COVID19 testing, a test was available quickly and helps to prevent spread. The first HIV antibody test (ELISA) was not discovered until 1984 and not available until 1985, over three years into the epidemic. This first HIV test was largely used for testing blood supplies, and it was not until 1987, when the Western Blot test became available, that HIV testing started to be widely available. Even then, there were a number of barriers that prevented people from getting tested (results took two weeks, and many people, fearful of losing insurance or jobs understandably declined testing which contributed to the stigma of HIV).

COVID-19 screening looks for the active virus, not antibodies, to tell if someone is actively infectious. As COVID-19 viral testing becomes more widely available, it will be important for people to get regularly tested, just as sexually active people should know their HIV status, to protect the people around them (and with HIV, to begin treatment if they are infected).

Like the early days of AIDS, COVID-19 is a novel disease without a specific treatment. AZT, the first drug for HIV/AIDS was not approved by the FDA until 1987, some seven years after the first cases were reported. Until that date, all that could be done for AIDS patients with opportunistic infections was to try to bolster the immune system with antibiotics, antivirals, or chemotherapy, and to treat symptoms. There was no specific treatment for the disease for many years, and even then, early drug treatment was often intolerable and only marginally effective. Similarly, treatment of COVID-19 depends largely on supportive care such as mechanical ventilation for the sickest patients.

While HIV in the early days was most often a terminal diagnosis, the time between infection and death was longer than the rapid onset and death seen in some cases of COVID-19. It took a decade into the HIV pandemic before the death toll in the United States hit 100,000. This sober milestone was met by COVID19 in just a little over two months. However, in the days before effective treatments, HIV was almost uniformly fatal, killing most of the people who became infected. COVID-19’s case fatality rate, made difficult to calculate by limited access to testing, is probably in the low single-digit percentage rate.

Learning from HIV/AIDS: The path forward with COVID-19

Past pandemics can be important teachers for controlling new threats. In my next post, I’ll talk about how we can use harm reduction as a viable strategy for reducing the risk of transmitting COVID-19.