A few weeks ago one of my brothers texted me–“Can you liken this to anything in your career [as a pulmonary critical care physician]? I guess HIV-AIDS…” My immediate response was “no” in light of the different viruses but as time went on, and with further reflection, I came to the realization that my career had been bookended by two viral pandemics both of which were approached in very different ways. Here is my perspective.
The Acquired Immune Deficiency Syndrome, most commonly referred to as AIDS, reared its ugly head in the early 1980’s. As a third year resident (1983) I remember reading a detailed article about it in the “Annals of Internal Medicine.” Unusual diseases (pneumonia, parasitic infections, uncommon cancers) were cropping up in a segment of the population defined as “the 4 H’s”–homosexuals, hemophiliacs, heroin addicts, Haitians, with the largest group at that time being homosexuals. While the diseases were recognized as manifestations of what appeared to be an altered immune system, no specific underlying cause of this alteration was known at that time although a viral etiology was suspected. Also, it was not totally clear how easily or by what means the underlying cause for AIDS could be spread. Blood and semen appeared to be logical conduits for transmission in light of some of the affected populations but what about saliva? or a sneeze? or a cough? or sweat? What was your risk for developing AIDS if an AIDS patient scratched you or if you just accidentally stuck yourself with the needle you just pulled out of the arm of one of these patients? If you were infected with whatever was the presumed causative agent, but not manifesting and AIDS symptoms, what was the risk of passing the agent on, for example, by swimming or playing sports (especially contact sports)?. All unchartered territory.
As a pulmonary fellow I held the distinction (I think) of being the first physician at our institution to bronchoscope a presumed (subsequently confirmed) AIDS patient. He was a homosexual, freshly arrived from the baths of San Francisco, who, when respiratory symptoms began and after being informed by a physician there he likely was developing an AIDS illness, decided to come back home to Pennsylvania not by plane but by car. While he phrased it more crudely than what I write here he explained that by traveling this way it gave him the best opportunity to spread as much love as he could across the nation. In light of a constellation of symptoms and an abnormal chest x-ray, the infectious disease docs wanted tissue confirmation of a pneumonia. Hence the bronchoscopy. I asked my Chief what precautionary measures we (he, and others, would be in the room with me) should take. He didn’t know. With a little literature digging I found an article suggesting what might be appropriate to wear while bronchoscoping an AIDS patient. As I was the primary bronchocopist extra protection was recommended. My attire on the day of the bronch included a lead apron first (we needed fluoroscopic {x-ray} guidance when doing the lung biopsies), head covering, double gowns and gloves, mask, and goggles. I could barely move. One of the RT’s snapped a picture (Polaroid) wearing my finest and for years the picture hung in the RT break room as “AIDS patrol.” Little did I know that I, as well as everyone else, had just been introduced to what in later years would be called “personal protection equipment” (PPE)–minus the lead apron.
One of the tenets in Infectious Disease mitigation in time of widespread infection is quarantine. This was a hotly debated topic at that time but eventually was not pursued out of concern that a quarantine would drive infected people “underground”and away from healthcare. So, what were the treatment options at that time? Very limited; mainly symptomatic relief with an occasional respite from a particular type of pneumonia affecting AIDS patients with use of a sulfa based antibiotic. In essence, an AIDS diagnosis was a death sentence.
Government and the healthcare system, slow at mobilization at first (read, “And the Band Played On”), eventually began to ramp up. The human immunodeficiency virus (HIV) was ultimately found to be the underlying cause of the immune system dysfunction. Over time it became apparent that one could have the virus (HIV+) and be totally asymptomatic. Only when a person developed manifestations of disease related to immune deficiency was the term “AIDS” applied. So asymptomatic HIV+ patients could spread the virus (e.g. blood, semen, vaginal or rectal fluids, needles) and never manifest an AIDS scenario. One of the saddest cases I knew about was of a young mother who developed AIDS after she was infected by her HIV+ husband who “played both sides of the street” and never let her know. Since one did not know who was HIV+ a universal premise in hospitals was established–assume everyone was infected. Thus the advent of “universal precautions.” This lead to the routine use of gloves when dealing with patients and establishment and ongoing refinement of disposal policies for needles and other “sharps”, soiled bandages and blood products. Protocols for dealing with a healthcare worker injured by needles or other sharps were developed and refined.
Universal precautions eventually became standard everywhere and remain in place today. Screening of blood donors took on a new aspect with a pre-donation questionaire given to all. One of the questions, controversial at the time, inquired if the donor believed they were in one of the risk groups (the 4 H’s) or engaged in activities which might place them at risk for an HIV infection. If the answer was “yes” the policy was to let that person leave with no further questions asked. In sports protocols were established to deal with a bloodied player. For example, basketball games would be stopped briefly so that a player displaying a bloody (no matter how minor) injury could leave the court to be treated (note the gloved trainer). The use of PPE (gloves, gowns, face shields, masks, head/foot gear) also became standard and was tailored to the type of patient being cared for, with gloves always the minimum requirement.
A breakthrough in testing for HIV occurred in 1985 with development of ELISA assays. Now that there was a way to “track” the virus, drugs related to treating the underlying HIV infection could begin to be developed. Testing improved over time as did drugs for the treatment for HIV+ patients with the goal to suppress/destroy the virus in an effort to maintain a healthy immune system thereby preventing the development of AIDS. Anti-virals appeared in the late 1980’s and were continued to be refined over the ensuing 10-15 years. Different drugs in different combinations (“cocktails”) came to the forefront with greater and greater success at treating the infection. For a growing number of people the specter of the inevitability of AIDS was no more as, if the virus could be suppressed, the immune system would remain intact.
Now to present day and the coronavirus, aka “Covid-19”. Did the approach to HIV give us a “leg up” in dealing with this current pandemic? Undoubtedly these are different viruses with different manifestations of infection and contagion. However, I think there are several observations which can be made.
1) Testing–AIDS was the visible result of an HIV infection but it would take time before HIV was recognized as its cause since genomic testing was in its infancy. In light of the explosion in genomic testing since then the coronavirus genome was mapped within the first month or so of the first patient becoming symptomatic.
2) Contagion–Early in the AIDS epidemic, before HIV was discovered, there was a large degree of uncertainty regarding the ease of contagion. In time it became apparent that asymptomatic HIV+ patients could not spread the disease just by being, for example, on a cruise ship or plane or where there are/were large social gatherings. Now as we are more and more a global society the coronavirus spreads much more easily, especially since early warnings were not forthcoming (China) or played down (WHO) or response times were slow (many governments), thereby giving it a “head start.” The coronavirus contagion shares this similarity to the influenza virus of 1918 in contrast to HIV.
3) Personal protection equipment (PPE) and Universal Precautions–as noted above had its beginnings with the AIDS epidemic. As I look at pictures of those currently decked out in their PPE, I often think about that “AIDS patrol” picture taken long ago.
4) Treatment–“social distancing” is the phrase of the day and the strategy appears to be working. But don’t fool yourself, this is about as close to a quarantine as one can get short of utilizing the true draconian measures that have been periodically used in times past. However, social distancing, i.e. avoidance, isn’t treatment in the true sense of the word. That’s where drugs and possibly plasma infusions come to the forefront. Recall that drugs to treat HIV took years to develop and numerous trials before released to the public. Currently there are several drugs, both antibiotics as well as anti-virals, being investigated. The debates rage–compassionate use? seat of the pants? trials?–as the debates did then for HIV. Currently there are more options being looked at than ever were in the early days of HIV.
5) Prevention–there are no vaccines for HIV but there is hope and expectation that sometime within the next 12-18 months there will be a vaccine for the coronavirus. The rapidity with which efforts are being made to this end are breathtaking. What has yet to be answered is whether the vaccine will offer “once and done” protection or will it be like the influenza vaccine where yearly “boosters” are required. And what about the anti-vacciners? (As an aside, I recently spoke with an older woman who says she NEVER gets a flu shot but would consider getting a coronavirus “shot”).
6) Unknowns–we’ve had 40 years to “work out the kinks” regarding HIV and the knowledge base is solid. Not so with the coronavirus. How long can a patient infected with the virus remain contagious? Outside of the 14 day “window” will there be asymptomatic people who could be carriers for extended periods of time? With recovery from infection is there immunity and is it transient, lifelong or something in between? Will the coronavirus take its place along side influenza as a seasonal recurring infection? Will the virus play along with the rules of “herd immunity”? What is the true infection rate as many people infected with coronavirus will remain asymptomatic?
Lastly, but as importantly, is the economic effect. HIV never affected the economy to any large degree, let alone shut it down. Covid-19 obviously has and to potentially devastating effects. While not able to contrast HIV/Covid-19 in this light, I wondered about the 1918-1919 influenza pandemic–were there economic parallels? If you are curious I refer you to a very interesting paper (written for the layman), “Economic Effects of the 1918 Influenza: Implications for a Modern Day Pandemic,” by Thomas A. Garret, written in 2007. The link is: www.stlouisfed.org/…research-reports/pandemic_flu_report.pdf (or Google or Bing it). To me it was an eye-opener as to how that pandemic was eerily similar in many, but not all aspects, of what we are seeing today regarding urban vs rural mortality, density population mortality, white vs non-white mortality, age mortality, and effects on local, as well as the national, economy. And, once the pandemic abated, this paper points out that overall economic recovery was rapid for most. Hopefully this will be the same this time.
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