It's 1984. A 20-year-old homosexual man walks into the clinic complaining of swollen glands.
It could well be a death sentence.
It is only three years since the first handful of cases of what would come to be known as acquired immune deficiency syndrome (AIDS) were described. Little is known about it -- how it's transmitted, if it's transmitted, who's at risk -- all are questions still under discussion.
For doctors on the front lines, "you knew what they had, and it was terrible," says Dr. Philip Berger, now chief of family and community medicine at St. Michael's Hospital in Toronto.
In 1984, Berger was one of the first doctors in Toronto treating patients with the new syndrome. He couldn't test for HIV -- it had just been established as the cause of the syndrome and there were no tests. He had no drugs to cure or even slow the disease. He couldn't advise on precautions, because it still wasn't completely clear how the disease was transmitted. Indeed, some researchers still argued it wasn't an infectious disease at all, but a result of over-use of party drugs such as amyl nitrate.
The armamentarium, Berger says, was terribly limited:
"You could be available, and you could be kind."
But that was it. During that early period of what has now become a pandemic, it seemed nothing could halt the inevitable. Patients with AIDS died, usually within a few years of diagnosis.
The prognosis depended on the initial diagnosis, according to Dr. John Bartlett, chief of infectious diseases at Johns Hopkins University. A patient with one of the more advanced opportunistic illnesses -- Pneumocystis carinii pneumonia, say, or Kaposi's sarcoma -- would have a year or so.
"If they had swollen glands, it might be the acute antiretroviral syndrome, and then they would live a bit longer," Bartlett says. "But they would die."
And there was essentially nothing to be done. "It was all temporizing," Bartlett says.
Contrast that with 2009.
Today, if a young homosexual man walks into a clinic with swollen glands, he'll first be tested for HIV, possibly with a rapid test that delivers results within a few hours or even -- with the latest technology -- in a few minutes.
If the cause of the swollen glands is indeed HIV, further tests will establish the viral load and -- to measure the impact the virus has had on the immune system -- the CD4-positive T cell count.
Once those things have been established, the medical team will start to devise a therapeutic regimen, choosing three of more of 25 drugs in five classes.
The virus that the young man harbors will be tested for resistance to the drugs, so that the best combination can be chosen. And drug interactions -- with other drugs he may be taking and among the HIV drugs themselves -- will also be accounted for.
Choosing a regimen is now such a complicated process that Berger's team includes a pharmacist who does a custom analysis of each patient to match him or her with the right drugs.
But perhaps the most striking contrast, according to Bartlett, is life expectancy.