25 Years in HIV/AIDS: Much Progress, but No Cure

"That's amazing," Bartlett says. "You're going to have trouble finding another disease where there's been that kind of progress in that time span. It is clearly the best success story in medicine since H. influenzae vaccine or even eradication of smallpox."

Mark W. Kline, MD, of Baylor College of Medicine and Texas Children's Hospital in Houston has a 17-year-old patient who was one of the first children given HAART therapy in 1996. She'd been diagnosed with HIV when an infant. "Her adoptive parents were told not to expect her to survive to school age," he said in an e-mail. "Today, she's a high school varsity cheerleader."

The next challenge, Bartlett says, is to find a cure.

That seems likely to be a serious hurdle, and no one is predicting it will be cleared any time soon. When it comes to HIV/AIDS, optimism has repeatedly foundered on the hard rock of reality.

Finding the Cause, Slowing the Progress

It's worth noting that 25 years ago researchers were just starting to pin down the pathogen that would become known as HIV. In labs in Paris and Bethesda, Dr. Luc Montagnier and Dr. Robert Gallo were identifying the virus and showing that it caused AIDS.

The findings generated immense optimism.

In 1984, then Health and Human Services Secretary Margaret Heckler said Gallo's work would soon lead to a commercially available test. And, she added, "We hope to have a vaccine ready for testing in about two years."

That prediction was woefully off-base. It was only this year that researchers finally found a vaccine against HIV that had any effect whatsoever -- about a 30 percent benefit.

Heckler concluded in that speech that "yet another terrible disease is about to yield to patience, persistence, and outright genius."

Wrong again. HIV/AIDS remains terrible, although no longer an outright death sentence for those lucky enough to live in the developed world.

But it has not yet yielded, despite all the patience, persistence, and outright genius in the world at large.

That said, a major turning point came in 1996, when researchers showed that a combination of three antiretroviral drugs -- attacking the virus from different angles -- could slow or stop viral replication and restore immune function.

Today, says Dr. Joel Gallant, director of Johns Hopkins' Moore Clinic for HIV Care, if our hypothetical young man walked in "I would assure him that he will not die of AIDS if he remains under medical care by an HIV expert and takes his medications as prescribed."

"Overnight," Bartlett says, his AIDS clinic at Hopkins "became a clinic where people were going to live. It was pretty amazing."

It seemed possible, even, that the virus might be eradicated by such an approach, but that, too, turned out to be an overoptimistic mirage. HIV was too wily and had too many hiding places.

Attention turned to making more and better drugs, reducing side effects, and finding ways to overcome or prevent resistance. And by any measure, those efforts have paid off.

Today, a Tale of Two Worlds

In the developed world, patients on many current regimens need take only a single pill once a day, a far cry from the late 1990s, when the rule was several dozen, taken at various times, with and without food depending on the drug.

Adverse effects still occur but they are more easily managed.

And resistance is constantly monitored, so that medications can be switched if it develops. And there are many more drugs, so that switching is possible.

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