As we observe World AIDS Day Wednesday during the 40th anniversary year of the AIDS epidemic, we would be wise to reflect on another anniversary: It’s been 25 years since The New York Times Magazine published Andrew Sullivan’s triumphalist essay “When Plagues End,” which essentially declared that the AIDS epidemic was over.
Sullivan was clairvoyant in anticipating more potent and simpler drug regimens, which would greatly improve clinical outcomes. Today, medications have become better tolerated and co-formulations enable people to take one pill once a day to maintain their health. HIV-positive people who adhere to these regimens are not infectious to their partners. The use of these medications for pre-exposure prophylaxis, when taken as prescribed, can prevent people who are highly vulnerable to HIV infection from ever becoming infected. A recent report of a second case of someone whose natural immunity has rid their body of HIV without other treatment raises additional reasons for optimism.
Even so, it was premature to declare the end of AIDS in 1996. Last year, more than 1.5 million people were newly infected with HIV. Today, approximately 40 million people live with the virus in every region of the globe.
The world should keep this in mind as we continue to do battle with COVID-19.
It is true that the virus that causes COVID-19 is much different from HIV. SARS-CoV-2 is readily transmitted through the air, while HIV transmission is more difficult, requiring the presence of HIV-infected blood, semen, rectal or vaginal secretions, or breast milk on the mucous membranes or in the bloodstream of someone who is not infected with HIV.
But the similarities between the two viruses should give us pause.
They are zoonoses, meaning that when these infections jumped from animals to humans, they were able to spread efficiently. Both viruses created globalized pandemics due to the ease and frequency of global travel. Each pathogen has spread via common human behaviors: intimate sexual contact and needle sharing for HIV, and large social gatherings for SARS-CoV-2. Each has also resulted in the deaths of more than 700,000 US residents, although it took less than two years for COVID-19 to reach this grim milestone.
Just a few years before Sullivan declared that we no longer had to worry about the plague, science journalist Laurie Garrett had put the world on notice with the opposite message. In her book “The Coming Plague: Newly Emerging Diseases in a World Out of Balance,” Garrett warned that the next pandemic was not a question of if, but when. She presciently listed the steps we needed to take to prepare for and respond to the next onslaught — and the one after that.
Garrett’s warnings were ignored, and many of the experiences of the COVID-19 pandemic echoed Marx’s dictum that history repeats itself “first as tragedy, then as farce.” Several US administrations did not follow Garrett’s advice to increase investments in sentinel surveillance, in which the frequency of specific diseases is monitored. We did not stockpile masks and protective gear. We did not create continuity-of-care plans outlining the responsibilities of government agencies and health care systems during a public health crisis.
The danger today is that, despite all that has happened over the past two years, we seem more inclined to take a Sullivan-esque approach to COVID-19 when we should be following Garrett’s advice from 1994. It is good that transmission and disease progression seem to be readily prevented by vaccines. But the full promise and hope of these vaccines will not be realized until everyone on the planet has been fully vaccinated. Meanwhile, we still don’t know whether vaccine-induced immunity will be sufficiently long-lasting or whether boosters will keep us ahead of the evolution of new coronavirus variants. The recent detection of the Omicron variant underscores the need for improved global molecular surveillance, international coordination to harmonize public health practices, as well as the need to rapidly ensure that everyone has access to protective vaccines.
When it comes to fighting infectious disease, there is only so much we can do. But we can do a lot. We can invest in a global infrastructure to quickly recognize emerging pandemics, widely share relevant information and protective supplies, and mobilize the public to adopt effective preventive strategies. After 40 years of HIV and two years of COVID-19, it would be unconscionable to do otherwise.
Dr. Kenneth H. Mayer is medical research director of Fenway Health, codirector of The Fenway Institute, professor of medicine at Harvard Medical School, and attending physician in the infectious disease division at Beth Israel Deaconess Hospital.