1981: the AIDS epidemic begins: since AIDS first made headlines 25 years ago this summer, 25 million people have died, and the toll is still rising.

When I was a doctor at Bellevue Hospital in New York in the late 1970s, my colleagues and I were baffled by a small number of patients who suffered strange, inexplicable ailments. Some had come down with uncommon infections; others had contracted unusual forms of more common infections. And still others had developed a rare cancer.

We did not know at the time that these were our first AIDS patients.

Twenty-five years ago this summer, my first article about these illnesses appeared in The New York Times. (In addition to being a physician, I'm also a Times reporter.) The article, on July 3, 1981, ran inside the paper, a single column of about 900 words. The headline read, "Rare Cancer Seen in 41 Homosexuals."

The article noted ominously that these cancer patients had severe deficiencies in their immune systems that could not be explained. "The cause of the outbreak is unknown," I wrote.

SLOW TO ACT

Looking back with the wisdom of hindsight, it seems as if doctors, the public, journalists, and governments were shockingly slow to recognize an epidemic in the making and take steps to try to contain it.

Because infectious diseases were no longer the major killers they had been even a few decades earlier, doctors had become vastly overconfident. Smallpox had just become the first disease in history to be eradicated and most doctors overlooked a basic fact of biology: that a new infectious disease could appear at any time.

By the end of 1981, there were only 152 cases reported of what would become known as AIDS. I did not meet anyone who predicted that in the next 25 years AIDS would kill 25 million people worldwide and infect 40 million more in one of the worst epidemics in history.

The disease was initially given a variety of names, including GRID (for Gay Related Immune Deficiency), because gay men were among the earliest victims. That name and others like it were misleading because they erroneously implied the disease affected only gay men. The Centers for Disease Control and Prevention (C.D.C.) named the disease AIDS (for Acquired Immune Deficiency Syndrome) in 1982.

MEDICAL MYSTERY

Researchers set out to investigate AIDS, but they were puzzled. Why did it seem to affect gay men? Could an infectious agent--something transmitted person to person--cause AIDS? If so, what was it?

In 1983, the first report that a virus, now known as H.I.V. (Human Immunodeficiency Virus), causes AIDS came from researchers in Paris. American scientists, initially skeptical, concurred two years later.

With new blood tests, scientists soon found that H.I.V. infected many women and heterosexual men too, and that the virus usually lies dormant in the body for about 10 years before producing AIDS. It thus became clear that AIDS was silently spreading around the world in the 1970s.

Scientists learned that the disease could be transmitted through sex; blood transfusions; needles and syringes used to inject drugs; and from mother to child in the womb.

In the early years of the epidemic, the disease was an almost certain death sentence, as it attacked a healthy immune system until a patient was no longer able to fight off any infections.

My worst fears about the magnitude of what was clearly a global epidemic came in 1985 when I reported on AIDS in Africa, where the disease had begun to take a devastating toll on both men and women. Only a few African countries let me in. Wherever I went, officials were in denial about AIDS. A Rwandan health official scoffed at the threat of AIDS in an interview. But later, in private, he questioned me closely about the disease because a member of his family had it.

Back in the U.S., because AIDS was often sexually transmitted, many people, including doctors, patients, and public officials, hesitated to speak frankly about it.

A public hysteria took hold of the country in the mid-1980s. Many people feared, without reason, that they could catch AIDS from drinking fountains and toilet seats or in restaurants.

SCHOOL PROTESTS

At a number of schools around the country, parents protested the presence of students with AIDS. Ryan White of Kokomo, Ind., a hemophiliac, contracted AIDS at age 13 from tainted blood products. In 1985, parents went to court to keep him out of his middle school classroom, although health authorities said he posed no threat to other students. "All our children have to give up their right to a safe education for him," Faye Miller, a parent at Ryan's school, told The Times.

Ryan became a spokesman on AIDS issues, trying to educate the public on how incorrect information about AIDS added to the plight of children with the disease. He died at age 18 in 1990, after Congress passed a law named for him that paid for health care and support services for H.I.V. and AIDS patients.

Some critics accused public officials, including President Ronald Reagan, of ignoring the epidemic. Reagan, who took office in 1981, the year I wrote that first AIDS article, gave his first major speech about AIDS six years later, when he called for wider testing. "Just as most individuals don't know they carry the virus, no one knows to what extent the virus has infected our entire society," Reagan said.

In 1987, a drug known as A.Z.T. was introduced. It was the first treatment that seemed to slow the progression of AIDS in those infected with the H.I.V. virus,

The most significant breakthrough in treatment came in the mid 1990s, when combinations of various drugs, popularly known as cocktails, not only kept H.I.V.-infected people alive, but allowed them to live much more normal lives. Magic Johnson, the former Los Angeles Lakers basketball star who announced he was H.I.V.-positive in 1991, is an example of successful therapy.

A STRICT SCHEDULE

Johnson, like others on the cocktail, must take the drugs on a strict schedule; missing doses runs the risk that resistant strains will develop and render drug therapy ineffective. And no one knows whether these drugs will work indefinitely.

Beyond that, health officials worry that stories about Johnson and others infected with H.I.V. living more normal lives might make people--especially teenagers, who weren't around when the epidemic began--complacent about how serious a disease AIDS remains today.

"While we can all celebrate the amazing advances in the treatment of H.I.V./AIDS, remember that this virus still causes a lethal disease," says Dr. Merle A. Sande of the University of Washington in Seattle. "AIDS is not curable, the drugs may still cause crippling side effects, and we still don't know how long the treatment will keep this virus in check."

Today, the United Nations estimates that 40 million people are H.I.V.-positive, of whom 4.9 million were infected in 2005. In the same year, 3.1 million died, bringing the total to more than 25 million worldwide since the epidemic was first detected.

The largest number of cases today are in sub-Saharan Africa, where up to one in three adults are infected and AIDS is ravaging entire societies.

STILL A THREAT

Women are infected as often as men in much of Africa, where some governments continue to resist efforts to deal with AIDS, and the cost of drugs remains too high for most patients. Looking ahead, the regions of greatest concern for further spread are Eastern Europe, China, and India.

The C.D.C. estimates that 1 million people in the U.S. are H.I.V.-positive, but that 25 percent of them do not know it. And despite all that we've learned in the last quarter century about how AIDS is contracted, spread, and prevented, 40,000 people in the United States become newly infected each year.

LESSON PLAN 4: HISTORY

1981: AIDS EPIDEMIC BEGINS

BACKGROUND

A widely accepted theory about the origin of AIDS traces it to chimpanzees or green monkeys in West Africa sometime between 1930 and the 1970s. Scientists believe hunters who ate infected animals contracted Simian Immunodeficiency Virus, which is very close to H.I.V., the virus that produces AIDS in humans.

CRITICAL THINKING 1

* Dr. Altman notes that in 1985 he was greeted with skepticism about AIDS in Africa, even though the disease had begun to take a "devastating toll" there.

* Ask students why they think African officials were reluctant to recognize the disease. Were the denials about AIDS by African officials similar to or different from the reluctance to speak frankly about AIDS in the U.S. at the time?

CRITICAL THINKING 2

* Discuss the reality that physicians "overlooked a basic fact of biology" in their early AIDS investigations. Why might medical experts overlook a basic fact of biology? (Altman suggests that earlier successes led doctors to be overconfident. What might cause doctors and scientists to become overconfident?)

DISCUSSION QUESTIONS

* What factors do you think might help explain the fact that AIDS is much more prevalent in sub-Saharan Africa than it is in other parts of the world?

* Why do you think that in spite of all that is now known about AIDS, some 40,000 Americans become infected each year?

WRITING PROMPT

* Write a title and subtitle for a TV documentary designed to alert Americans about the threat of AIDS.

FAST FACT

[right arrow] The CDC says that by 2010, at current rates of infection, 18 million children in Sub-Saharan Africa will have lost one or both parents to AIDS.

WEB WATCH

http://familydoctor.org/165.xml The American Academy of Family Physicians presents information on sexually transmitted diseases and tips for preventing them. Note: Explicit information and illustrations.

1981: THE AIDS EPIDEMIC BEGINS > Pages 24-27

1. AIDS came as a surprise to medical doctors. The article says that doctors were overconfident because

a they thought infectious diseases were no longer the threat they had once been.

b the only reported cases were in New York.

c men were the only victims of the disease.

d some of the infected responded to treatment.

2. In the early days of the disease, many people, including doctors, were hesitant to speak frankly about the disease because

a it was largely confined to poor people.

b the government required confidentiality.

c it was often transmitted sexually.

d they didn't want to frighten people.

3. Why was AIDS able to spread so widely before being recognized?

4. AIDS kills people by

a infecting the heart.

b impairing the ability to breathe.

c constricting blood flow.

d rendering the body unable to fight infection.

5. Which of the following is not identified as a means of transmitting AIDS?

a blood transfusions

b sharing clothing

c pregnancy

d needles and syringes

6. Briefly describe what an "AIDS cocktail" is and the importance of scheduling doses.

7. Briefly summarize what the taw named for Ryan White does.

IN-DEPTH QUESTIONS

1. One of the side effects of AIDS in Africa has been economic decline in areas where the disease is widespread What do you think might be the [ink between AIDS and economic problems?

2. Why do you think many people at first disregarded health experts explanations about how HIV is transmitted and tried to keep young people like Ryan White out of schools?

QUIZ 2 > PAGE TE 5

1. [a] they thought infectious diseases were no Longer the threat they had once been.

2. [c] it was often transmitted sexually.

3. It had a 10-year dormant period. (Similar wording is acceptable.)

4. [d] rendering the body unable to fight infection.

5. [b] sharing clothing

6. It is a mixture of drugs that must be taken on a strict schedule. (Similar wording is acceptable.)

7. It pays for health care and support services for H.I.V.-infected people. (Similar wording is acceptable.)

Dr. Laurence K. Altman writes about health for The New York Times.

AIDS WORLDWIDE IN 2005 (numbers rounded)

                                   PEOPLE with            AIDS
REGION                          H.I.V. or AIDS          DEATHS

Sub-Saharan Africa                  26 million     2.4 million
North Africa/Middle East               510,000          58,000
South/Southeast Asia               7.4 million         480,000
East Asia                              870,000          41,000
Oceania                                 74,000           3,600
Caribbean                              300,000          24,000
Latin America                      1.8 million          66,000
Eastern Europe/Central Asia        1.6 million          62,000
Western & Central Europe               720,000          10,000
North America                      1.2 million          18,000

Global Total                      40.3 million     3.1 million