2.2 James Curran — Deciphering the Epidemiology of AIDS

Jim Curran: Thanks, Mike [Gottlieb], and Bruce [Walker], and all the organizers. It's nice to be here with all of the passionate, committed veterans working on HIV and AIDS. I'm going to talk mostly about the pre-HIV era. I want to start by just describing a little bit the context, the social and medical context of where we were. We heard last night a lot about [00:00:30] the virologic context into which AIDS came. It helps us, I think, to remember how new relatively, not only retrovirology but molecular biology and molecular immunology was in the late 1970s and early 1980s.

It was also an era, when I came into public health—probably like Tony [Fauci] and Bob [Gallo]—as a commissioned officer [00:01:00] during the Vietnam War. When we had a chance to work at the NIH or the CDC, some of our detractors called us yellow berets at the time because we were commissioned officers. Our careers were shaped in part by our own response to the Vietnam War and these—I'm not going to say you guys but me anyway—opportunities to do these types of things. I was an STD epidemiologist. At the time, [00:01:30] I was part of the only generation, again, as some of you, who started having sex in an era when sex didn't kill you.

After all, all previous generations worried about syphilis and the syphilis mortality rates in the 1930s were about the same as the AIDS mortality rates in the 1980s. There's just this one generation, really, when sex was relatively mortality free. [00:02:00] And we lived like it—not me, but our generation.

It was a time, however, also that we were considered to be infectious disease-free in the United States. The major infectious disease people were saying, with the infectious disease people from Seattle and stuff, [they] were saying: our time is over. We can now go back to the laboratory and only be consultants on the rare multiple myeloma patient who gets an infection.

I think it's one of the reasons that [00:02:30] astute clinicians who were immunologists like Mike Gottlieb or Tony Fauci or oncologists like Paul Volberding had the persistence in the long-term clinical ability to pay attention to AIDS. The ID [infectious disease] people didn't really take care of patients in the long run in the early 1980s. They were consultants. But the oncologists and the internists and the immunologists often had long-term clinics and caring for people. [00:03:00] They were really the astute people who paid a lot of attention to this in the beginning.

I spent my first year in New York City trying to learn by seeing patients on the wards and talking to a lot of the doctors like Susan [Zolla-Pasner] and Alvin [E.] Friedman-Kien and Bijan Safai, and Linda Laubenstein (1947–1992) and many others to see these patients and see what it was. It was the remarkable patients—if you've seen one, you'll never forget it—that characterized AIDS in those days. It was those doctors [00:03:30] who were the believers. We were not in the context of belief then.

I can tell you from working on STDs in 10 years, we were stigmatized just like the diseases were. Nobody wanted to work on STDs, or drug use, and gay men, except in maybe in New York and California, [they] spent most of their lives in the closet in the United States. I was working on chlamydia and infertility and a little bit on hepatitis B vaccine trials, but I wasn't exactly lauded in my community [00:04:00] or in my medical community for this work. People would laugh at me and snicker when you talked about dealing with these things. My own first experience meeting Bob Gallo—Oh, then the other thing was, it was 1981, Ronald Reagan had just become president supported by the Christian Coalition at the time, also buoyed up by high inflation, high unemployment, and a commitment to diminishing the domestic budget.

The NIH [00:04:30] was pretty poor then, and the CDC was even poorer. There was not a lot of money floating around. It was really the National Cancer Institute, to begin with, that showed a lot of interest in this. The important emergence of Tony Fauci shortly thereafter to bring NIAID along that really brought science forward, I think, with AIDS. The National Cancer Institute was interested because they've been doing the virus cancer programs. They'd seen Kaposi’s sarcoma and [00:05:00] other things like this in Africa.

I remember the first time I met Bob Gallo. I saw our role in the pre-HIV role of trying to get basic science engaged. I can remember the first Cold Spring Harbor meeting when, first of all, it was courage to Cold Spring Harbor to have the meeting, but we were filled with a lot of skepticism about what was going on. People would say, pediatric AIDS doesn't exist. These are people who should know—they were wrong, but they should know. Who are these people telling us [00:05:30], this is a big problem?

It was in New York and California and a few other places, but most of the country and most of the world had never heard of this disease. I was invited courageously by Vince DeVita to come and speak at the National Cancer Institute to try to buoy up their efforts to put some of their scarce money into this. I remember that's when I first met Bob Gallo, and I tried to devote my talk to him because I wanted to get the scientists involved. [00:06:00]

At CDC we didn't have the horsepower. We couldn't find this virus. We couldn't figure out what was going on. We needed the basic scientists. I think somebody told me later that I was the first person ever to talk about anal sex and fisting at a National Cancer Advisory Board Meeting. [laughter] Anyway, we were in different cultures that had to be brought together to deal with the problem. It's always been about people and it's been the people who were those clinicians in the beginning. The activists and the scientists who've [00:06:30] made all the difference.

Now we're going to talk a little bit about the pre-AIDS era. It was the courage also of Mike Gottlieb working with Wayne Shandera that brought the first five cases to be reported at a time when the cases were only being seen in New York and California, and allow the cases to be reported a few months before the peer-reviewed publications, the important ones, once it came out in December 1981. (1)

Five cases of pneumocystis in previously healthy gay men. [00:07:00] CDC actually decided to put this in the middle of the journal, not on the front page, take homosexual men off the title, probably because of their own homophobia at the time. It wasn't me—And the Band Played On that did it—but it did get done at CDC. (2) We formed a task force [in 1981, Task Force on Kaposi’s Sarcoma and Opportunistic Infections (KSOI)] , although CDC had no money. One of the things that CDC loves to do, and does reasonably well much of the time, is responding to epidemics. There was a big detail of all of these people [00:07:30] who were looking at reporting of Kaposi sarcoma and opportunistic infections.

The important thing we did at the time was to say that we thought that this was one epidemic we were studying. There were few oncologists like Paul Volberding and others and few infectious disease people that saw these as being the same thing even though they were mostly occurring in gay men. We thought it was important to unify that.

Probably the most important thing [00:08:00] we did was come up with a case definition for surveillance, and to conduct active and passive surveillance. I'll spend a minute on this. We thought, first of all, Kaposi’s sarcoma was extremely rare in the United States in people under age 60. The life-threatening or culture-proven opportunistic infections were also rare. Pneumocystis at the time had to be diagnosed by open lung biopsy. This was not undertaken real easily at the time. [00:08:30] At the time there had to be no underlying illness or history of immunosuppressive therapy. Many times we went out to investigate a case, only to find out that when we got there, the person had been diagnosed with cancer or had really been taking immunosuppressive drugs.

This case definition was mostly highly specific. This I think again, was the most important thing we did but with a lot of criticism. People were saying you're missing the whole iceberg. If you think about how we study [00:09:00] current diseases now for which we have no clue, things like autism spectrum disorder, chronic fatigue syndrome, what we want to do is we cover the whole iceberg and then we have trouble identifying person, place, time. We want to know, who's getting this? How often? Is it new? Where's it going? The specificity was the most important thing in identifying the epidemiologic pattern. The cases were so dramatic that it was hard to be wrong when you had a case. [00:09:30]

This was rapidly used for active and passive surveillance. We send EIS officers out to 18 cities, largest cities in the country, to review records going back five years. We knew it lacked sensitivity. First peer-review article came in the first week of month at the New England Journal of Medicine showing that even then with these graphs, they had pretty poor graphics [chuckles] in the New England Journal (3). You can see here [00:10:00] cases of KS and white PCP, but importantly, 10% had both. And this is onset of symptoms so it looks like it's going down, but the onset of symptoms went back to 1978. There was a clear trend going up and the point we wanted to make was this was one epidemic. In order to get the consensus at CDC, we submitted this article without authors' names. Maybe that was dumb, but that's [00:10:30] what we did.

We had icebergs too, and as a matter of fact, the first year and a half we send out 35,000 iceberg slides. What we hoped, because of our experience with hepatitis B, that this would be the iceberg and all these symptoms from New York—Donna Mildvan (at Beth Israel Hospital), Susan [Zolla-Pazner] and others—lymphadenopathy syndrome, unusual lymphomas, thrombocytopenic purpura, chronic [00:11:00] sinusitis. All of these things would be a form for us like with hepatitis B. Of course, somebody would find the cause, and then we'd have something relatively simple like hepatitis B to find the immune response, immunize everybody, declare victory and move on.

Dr. [Harold] Jaffe and other colleagues [at the CDC] conducted a national case-control study with about 75% of the living gay men in the United States, and match controls, mostly from [00:11:30] California and New York where almost all the cases where, and found that even when the controls were gay men from STD clinics or doctor's offices, who are very much over-matched for sexual behavior, that the major variables that differentiated cases to controls were sexual behavior variables: a tendency of of multiple sex partners, lifetime sex partners, and bathhouses. (3, 4)

Something we don't think about now, but it's intuitive when it comes epidemiology of a [00:12:00] spectrum of disease issues, is that the first cases you identify, just like in people in an epidemic, are those with short incubation periods. A lot of the things that we learned initially from people who got sick fastest. As a matter of fact, some of the discoveries that we made could not have been made if they weren't for short incubation periods like cases associated with the dental practice or a cluster that I'll talk about later. It was that cluster again discovered [00:12:30] in Los Angeles with Dave Auerbach, the EIS officer, and some people who learned about people who had sexual contact with each other. (5)

Dr. Auerbach and his colleagues published in an American Journal Medicine [article] following an MMWR in early 1982, a cluster which showed the so-called Patient Zero, who's been outed by Randy Shilts (1951–1994, San Francisco Chronicle journalist and author of And the Band Played On) was a French-Canadian airline steward who had sexual contact with 9 of the first 13 [00:13:00] cases in the metropolitan area of LA and in 11 cities and seven states, 40 of the 90 people we interviewed in the United States had direct sexual contact with another case. (6)

In retrospect, only possible with these really early incubation cases with high viral loads, even though they couldn't have been measured then, because otherwise, how could we ever have connected all of these cases? If 5% of the men in the United States are gay, which is a [00:13:30] current estimate, and everybody had sex at random, the chance of this occurring by chance would be about 1 x 10^-12.

It's amazing how denial works. After all, there were only cases then in maybe 10 or 12 states. Most gay men even thought, "This only occurred in those promiscuous gay men. It could never happen to me."

What convinced people that this was due to a virus were the three cases in men with hemophilia A [00:14:00], investigated very carefully by Dale [N.] Lawrence, who's now been at NIH for the last couple of decades: three men in three separate states who had no contact with any other risk factors, only had severe hemophilia A and had pneumocystis. (7)

It was the dramatic nature and the specificity of the case definition that these three cases broke things open, at least from my point of view. The reason for that is in hemophilia A and B is a gender-linked clotting disorder, with a deficiency in clotting factors VIII or IX, and is treated with prophylaxis and treatment with lyophilized clotting factor concentrate since the 1970s. Ironically, the use of clotting factor concentrates in a lyophilized or freeze-dried form is paralleled about the same time as Stonewall and the sexual liberation. This was the liberation of hemophiliacs from strokes and deaths and hospitalization. It was thought to be a small price to pay for the inevitable [00:15:00] hepatitis that they got: hepatitis B, and what was then called non-A, non-B hepatitis, mostly now hepatitis C. But hemophiliacs were exposed to as many as 10,000 to 250,000 blood donors a year. The true viral canary in the coal mine for people.

This changed everybody's point of view who is skeptical about the viral cause, to realizing this had to be caused by a virus. At the time, with some semblance of national consensus quickly arrived—we changed the name of our taskforce, thank God, from KSOI to the Task Force on AIDS, much to the displeasure of people that produce the Ayds diet pills.

[laughter]

Then shortly thereafter, the non-believers of people explaining immunodeficiency in infants, thanks to Arye Rubinstein, and [00:16:00] Jim Moleski, and Art Ammann started to believe, and Rich O’Reilly in New York, that this could be transmitted whatever it caused to infants. (8)

The first documented heterosexual transmission came from New York with Carol [A.] Harris, Neil Steigbigel (Montefiore Medical Center, New York), Gerry [Gerald] Friedland and colleagues, I think quite definitively showed it that this was occurring in people who are sex partners with people with AIDS. (9)

And the problem is, the thing [00:16:30] that I'm most happy with it that we were able to accomplish in public health in the pre-virus era, were prevention recommendations. (10) People mention being afraid. There are so many stories of people who are afraid to receive specimens, or afraid to work with the specimens, or afraid to take care of patients. At Grady Hospital in Atlanta, we had people leaving trays by the side of the room and not wanting to feed people with AIDS. Once people became concerned that it was caused [00:17:00] by a virus, they went from not caring about it to panicking about it and say, "Oh my God, I can get it any way I want."

Using the guidelines of hepatitis B, we're able to publish in late 1982 guidelines to protect clinical and laboratory staff. Then shortly thereafter, the public health service, CDC, NIH, HRSA, and others publish consensus guidelines on prevention of AIDS [00:17:30] before the virus was discovered. They don't even look too bad nowadays, although—oh, I skipped a slide. This is the slide I just want to show you that I looked young once. [laughter] This is a meeting—Tony Fauci was there, but he isn't in this picture, I think—It was a meeting with blood bankers. (11) The blood bankers, I guess you could say, were not very helpful initially. They wouldn't let us investigate the single transfusion cases [00:18:00] until hemophilia cases were published.

After the hemophilia cases were published, then we're able to issue prevention recommendations that were consensus from the public health service in March of 1983. (12) The first was the people in the so-called high-risk group should avoid multiple sexual partners and people shouldn't have sex with people with AIDS. That all of these groups should temporarily stop donating blood. I can say even before the blood was tested for HIV [00:18:30] in March of 1985, there already been about an 80% decline in transmissions through the blood supply because the FDA implementation of these recommendations. Then we should look at some temporary laboratory tests. People were thinking about hepatitis B core antibody. Physicians should limit the use of blood if they can and use autologous donations. And there should be work toward the development of safe blood products.

One of the relatively few basic [00:19:00] science contributions we made was in the late Steve McDougal's (1945–2014) lab demonstrated that HIV could be inactivated by heat, and very quickly heat-protected products were developed.

I don't think people mention Howard Temin's (1934–1994) role in the naming of HIV and the committee to do that. The discovery of HIV was truly the landmark that really got things going.

We were so happy that we started to have reagents, [00:19:30] and we could test thousands and thousands of blood specimens we collected epidemiologically. The blood banks finally opened up their donor file. In this paper that resulted from those publications, we found in each case, there'd be a typical man who would have a bypass surgery and then have transfusions from a dozen donors, and we would investigate all the donors and we'd find a still healthy gay man with [00:20:00] lymphadenopathy and a CD4-to-CD8 ratio that was inverted in a single case and, of course, the chance of that happening was extremely rare. (13)

Paul [M.] Feorino, who is the head of our lab at the time, using reagents that we got from the National Cancer Institute, was able to go back and isolate HIV from all of those blood donors. (14) Here you had living, asymptomatic blood donors and people who had received their virus [00:20:30] who had already died, who all still had this. The very bad thing we learned and the most depressing thing I learned is that our iceberg idea sucked.

Basically, once you were infected—When the antibody test was first licensed, there was a tendency to say it's just an antibody test, it's not an infection. I think this was one of the first papers to show that if you had a positive antibody test you were infected and that a positive antibody test meant infection. [00:21:00] Actually, it was equivalent to it.

The next thing that was even more depressing, we'd been working with hepatitis B, and we had collected in San Francisco almost 7,000 specimens from gay men in the late 1970s in preparation for hepatitis B vaccine trial, and this is another really old slide from Dr. Jaffe's paper, but it's extremely important because it dealt with the iceberg again and was the beginning of the [00:21:30] [epidemiological] modeling for HIV. (15)

What we found when we looked at the 7,000 gay men, these are the cases of AIDS reported on the right. By [June 5,] 1981, when the Gottlieb MMWR came out, there were four cases of the 7,000 in the San Francisco cohort, and by '84—again, this is before the antibody test was licensed, so it wasn't available to people—there were about 25 cases, but at the antibody testing [00:22:00], it was up to 70% almost by 1984.

Now, if you are an elderly infectious disease epidemiologist who has lost all caution, like me, what you could say then was: if this were extrapolated to the United States, by the time those first five cases were reported by Gottlieb in 1981, there were already 250,000 gay men in the United States infected with HIV. And by the time 1984, [00:22:30] just before the antibody test was licensed, that number was well over half a million HIV infected gay men, and almost all now have died.

When people say, "Why couldn’t we have done something sooner?" A lot of it is the damn virus. It was insidious and it infected all of us, and infects communities just like it does individuals. It becomes epidemic before it's found, just like it does in people. [00:23:00]

One thing we did that was bold, Bob [Gallo] and Tony [Fauci] probably remember this, there's a mosquito-ridden conference center called Coolfont outside of [Washington] DC, not recommended for anybody to go to—but there was this quasi-secret meeting of top people during the Reagan administration about what's going on with AIDS. They made a mistake of inviting in a couple of reporters. I don't know why [chuckles] they did it, but they did it. I think Walt Dowell was running the thing, and we had [W.] Meade Morgan and my staff come [00:23:30] up with using the San Francisco cohort data and the reports—and the reporting of AIDS was, we thought about 95% complete in the United States, it's not like an infectious disease because these people are all going to hospitals and they're all dying, so the reporting could be pretty good. And what Meade did was he showed—and this is the original slide from the 1986 meeting—that if you took went from the first 8,000 cases, by the end of [00:24:00] 1991 there'd be 270,000 cases in the United States.

We did this because we wanted to show that this epidemic was going to cause a lot of health concerns and financial concerns. The other thing we did that we probably would have been killed for now is we published this quickly without getting it cleared, which I thought was important. (16) [chuckles] I'm happy to say that we were a little worried about the estimates but by 1991 there were [00:24:30] 272,000 cases reported.

I met Jonathan Mann (1947–1998, then-administrator of the World Health Organization), and it was fortunate to be able to recruit him to set up what became the largest HIV conference study in Africa. The first papers they published along with colleagues like Henry Francis (NIH) and Tom Quinn from NIAID and many others, was that AIDS, even in 1984 was 30 times more common in Kinshasa than it ever would be in the United States [00:25:00]. (17)

Here's a picture in Brazzaville of some of the original people just to show another group of people who are younger once, there's Jonathan Mann, Joe McCormick (b. 1942, CDC), and eventually Robin Ryder from CDC, and me. I look taller here but that's because he's short. [laughter] We have Tom Quinn and Skip Francis from NIH, Peter Piot (b. 1949, Belgian microbiologist), Joe [Robert] Colebunders from Belgium (Antwerp), and our Zairean colleagues. Courageous people. [00:25:30]

Some lessons. One of the most important things we were able to work with is that surveillance is critical initially to track epidemics and help direct etiologic investigations, formulate prevention recommendations. Now it needs to be used to evaluate prevention efforts. It's really hard. You can half believe the UNAIDS numbers but don't completely believe the UNAIDS numbers.

The other thing it's really important for all of us as an innovative science can overcome [00:26:00] skepticism. When I was in medical school we'd say you could treat a bacteria but not a virus. The virus was discovered extremely quickly really, advances in diagnostic testing. Who would have thought of viral loads, my God, and a retroviral drug can be effective? AZT seemed to be a miracle, a discarded cancer drug from the 1970s. Then a very courageous epidemic—headed by somebody from the National Institute of Child Health and Human Development, [00:26:30] much criticized for giving AZT to pregnant women but demonstrated a cure and prevention .

Then finally in 1995, the most recent real miracle of all, that HAART gives life. So why not? Further things in ARV therapy as prevention, the Mike Cohen stuff, PrEP, everything else. Don't be skeptical now. Why not think about an effective HIV vaccine and curative therapy even though it does seem [00:27:00] extremely hard.

And I want to just end to go back to people. I think never in history have we had such a contribution of people with HIV itself in the epidemic. I mentioned before the caregivers, the real believers from the beginning, were the passionate people who saw those people dying of what we now know is HIV had the courage not only to care for them but to speak up. The scientists who are populating this room and there are thousands of others who have taken up [00:27:30] the cause and made it extremely important contributions and other concerned leaders like Bono and others. The late Ryan White (1971–1990) who got some initial care at NIH, unfortunately died before HAART, was helped by Elton John (b. 1947) and Michael Jackson (1958–2009) and many others. He now be 46 years old if he were alive today.

And my friend Jonathan Mann and his second wife, Mary Lou Clements-Mann (1947–1998), and researcher who had [00:28:00] passed away in an air flight to WHO, where they were going to be taking over another job. He had just spoken, he was a controversial guy, but he was the one who tied the fight against AIDS to social justice globally. And he had given a talk at the 12th International AIDS Conference in Geneva a couple months before he died and he said the following, he said, In regard to AIDS, "When the history of AIDS and the global response is written, our most precious contribution may well be [00:28:30] that at a time of plague, we did not flee, we did not hide, and we did not separate ourselves." It's the activists, it's the Mark Harringtons of the world, the clinicians, the Paul Volberdings of the world, the scientists and many others who working together had made a difference. Thanks to all of you and congratulations on your future productivity.

[applause]

Mike Gottlieb (Moderator): [00:29:00] Thank you very much, Jim, we have time for a couple of questions. There we go the back, gentlemen.

Audience 1: Thank you, great talk. What I've always been wondering is why do you think the HIV/AIDS in the heterosexual community was missed for such a long time if the virus was really available?

Jim: [00:29:30] First of all, the recognition of the importance of AIDS in countries where it was predominantly heterosexually transmitted like Haiti and sub-Saharan Africa came later then it did in largely in gay men in Europe and Australia and the United States. In the United States, the origins of the heterosexual epidemic, and most people [00:30:00] always think of gay men and bisexual men, but it was really the heterosexual injecting drug use community, mostly in New York, New Jersey, Puerto Rico. It was very hard to separate that both in people's minds and other places.

That's one of the reasons I think the work they did at Montefiore [Medical Center, Albert Einstein College of Medicine] where they would actually interview people and demonstrate to their satisfaction that they weren't drug users too, made such a difference. The heterosexual denial was enormous. [00:30:30] My own colleague and friend Dave [David Judson] Sencer (1924–2011), for example, refused to report cases of no identified risk and attribute them to heterosexual transmission in a formula we did at CDC because he didn't want to panic people in New York about heterosexual transmission.

People didn't want to believe it. They published a lot of stupid articles about the anal canal and the vagina and all—the protective vagina and it was a bunch of nonsense. It was mostly denial because it made no sense. [00:31:00] There are not infections that can only be transmitted homosexually, but the heterosexual community didn't want that to be true. I think  that there was a lot of denial and it was the confounding [factor] with the drug-using community and our difficulty improving it in the pre-viral age among the Haitians that lead to that.

Mike: Susan, yes, [unintelligible 00:31:26].

Susan Zolla-Pazner: [00:31:30] I'd like to mention a story that I was talking to Jim [Curran] about last night. We were having monthly meetings in New York City at the Department of Public Health started in the fall of 1981 and in the spring of 1982. Jim and other people from the CDC were coming up for these meetings. I was pregnant at the time and prevented from going to that meeting, so Jim came up to our apartment to have [00:32:00] lox and bagels and tell me what was going to happen at the meeting.

Jim: We have small per diem then. [chuckles]

Susan: Probably I wasn't allowed to do that by today's rules. You owe me for the lox and bagels. And so I'm sitting there with my feet up and Jim said, "One of the things I'm going to do today is announce that what we're going to call this epidemic, this disease is Acquired Immunodeficiency Syndrome or AIDS." I said, "That's [00:32:30] a terrible name." He said, "Why?" I said. "Because there are other acquired immunodeficiency syndrome, which of course there are, and that's going to confuse the fact." I also was working on studying the increase in immunoglobulin levels in patients, and B cell activation, I said, "It's not just immunodeficiency." He said, "Give me another name." On the spot. Of course, I couldn't. [00:33:00] He told me last night, I think it's worth telling other people how that name came up.

Jim: We were going around with this KSOI thing and we thought we needed an acronym. I mean, main thing we need to do is call attention to the problem. We wanted to let people know what was going up and up and we needed something that was a better acronym. We needed something was more descriptive, and then also tied everything together more than this. And also to recognize [00:33:30] that there was an iceberg, et cetera. The government couldn't recommend this exactly but the government had to go along with it. We had a meeting in Washington—Tony [Fauci] might have been there too. I talked to Don Armstrong (1931–1998, infectious disease specialist) before the meeting and I said, "When we get to the end of this meeting, we were talking about the blood supply and hemophilia." I said, "It would be a good time to suggest that we change the name [00:34:00] of our task force and what we call this." We had MMWR all written on this blood supply stuff. He raised his hand and said, "I think we should call this AIDS." It wasn't exactly like the movie, but it was Don Armstrong.

Mike: Thank you, Jim. I think we need to go ahead.

[applause]

One more question.

Cody Warren: Do you mind? Do you have time? [00:34:30]

Mike: Give him a mic.

Gottlieb: Please, Go right ahead.

Cody Warren: I'm curious if you could comment on the role the CDC played in recognizing that this isn't just something isolated in the United States or in European countries among the homosexual population and the broader impact this may have had on the globe.

Jim: The case definition that we developed, was instituted essentially throughout the world almost immediately and surveillance began in Europe instantaneously, I think [00:35:00] within about two months. I went to Rotterdam, and the difference between how the Netherlands dealt with this—they had one case, but in their one case, they had leaders from the gay community, leaders from their national health system. They had all these different groups together and we had no way to do that in the United States. I mean, we had such a different view of homosexuality and things than they did in Europe.

Europe actually responded more quickly and we were always in very, very close [00:35:30] contact with the people in Europe. You know, developing countries came more slowly. The first cases in Africa really diagnosed mostly in Belgium and France among people who are going up there, Nathan [unintelligible 00:35:40] and a bunch of other people and then the Haitians were diagnosed in the US mostly in Miami, to be in with, Margaret [unintelligible 00:35:46]  and other people.

Citations:

1. Gottlieb, Michael S., Howard M. Schanker, Peng Thim Fan, Andrew Saxon, Joel D. Weisman, and I. Pozalski. “Pneumocystis Pneumonia—Los Angeles.” MMWR Morbidity and Mortality Weekly Report 30, no. 21 (June 5, 1981): 250–52.
2. Shilts, Randy. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin’s Press, 1987.
3. “Epidemiologic Aspects of the Current Outbreak of Kaposi’s Sarcoma and Opportunistic Infections.” New England Journal of Medicine 306, no. 4 (January 28, 1982): 248–52. doi:10.1056/NEJM198201283060432.
4. Jaffe, Harold W., Keewhan Choi, Pauline A. Thomas, Harry W. Haverkos, David M. Auerbach, Mary E. Guinan, Martha F. Rogers, et al. “National Case-Control Study of Kaposi’s Sarcoma and Pneumocystis Carinii Pneumonia in Homosexual Men: Part 1, Epidemiologic Results.” Annals of Internal Medicine 99, no. 2 (August 1983): 145–51. doi:10.7326/0003-4819-99-2-145.
5. Rogers, Martha F., David M. Morens, John A. Stewart, Rose M. Kaminski, Thomas J. Spira, Paul M. Feorino, Sandra A. Larsen, Donald P. Francis, Marianna Wilson, and Leo Kaufman. “National Case-Control Study of Kaposi’s Sarcoma and Pneumocystis Carinii Pneumonia in Homosexual Men: Part 2, Laboratory Results.” Annals of Internal Medicine 99, no. 2 (August 1983): 151–58. doi:10.7326/0003-4819-99-2-151.
6. Centers for Disease Control (CDC). “A Cluster of Kaposi’s Sarcoma and Pneumocystis Carinii Pneumonia among Homosexual Male Residents of Los Angeles and Orange Counties, California.” MMWR Morbidity and Mortality Weekly Report 31, no. 23 (June 18, 1982): 305–7.
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Index 

• 2.0 Michael Gottlieb — Introduction to Session 2
• 2.1 Paul Volberding — The First Patients
• 2.3 Mark Harrington — The Importance of Activism to the US Response
• 2.4 Robert "Bob" Gallo — Discoveries of Human Retrovirus, Their Linkage to Disease as Causative Agents & Preparation for the Future
• 6.3 Bruce Walker — Role of T Cells in Controlling HIV Infection
• 12th International AIDS Conference, Geneva, 1998
• ACTG trial 076 (1991–1994)
• activism, civil rights, protests, and social movements
• Africa, sub-Saharan Africa
• Ammann, Arthur J. (b. 1936)
• antibody test, antigen test, serological test, serology
• antiretroviral therapy (ART)
• Atlanta
• Auerbach, David
• Australia
• AZT (azidothymidine)
• biopsy
• blood — banks, donors, plasma, screening, transfusions, clotting factors (factor VIII)
• caregiver, caregiving
• carrier, asymptomatic carrier
• case-control study
• CDC (Centers for Disease Control and Prevention, US)
• chlamydia
• clinical trials (phases of clinical research)
• Cohen, Myron S. "Mike" (b. 1950)
• cohort study
• Cold Spring Harbor Laboratory (CSHL)
• Colebunders, Robert
• Congo (Rep. Congo-Brazzaville, D.R. Congo-Kinshasa/Zaire)
• contact tracing
• demographic cohort
• DeVita, Vincent T.
• disease surveillance
• Dowell, Walt
• Dugas, Gaëtan (1952–1984)
• early names for AIDS — gay cancer, gay pneumonia, GRID, 4H, KSOI, slim disease, etc.
• education and early career
• Epidemic Intelligence Service (EIS)
• Europe, European Union
• fear
• Francis, Henry "Skip"
• Friedman-Kien, Alvin E.
• funding and grants
• gay men, gay community
• Grady Memorial Hospital
• Haiti
• hemophilia
• hepatitis
• heterosexual transmission of HIV
• highly active antiretroviral therapy (HAART), combination antiretroviral therapy (cART)
• homophobia
• iceberg of disease
• immunosuppression, immunosuppressive drugs
• incubation period
• infectious disease (medical specialty)
• intravenous drug use
• Jackson, Michael (1958–2009)
• Jaffe, Harold W.
• Kaposi's sarcoma (KS)
• lab safety, biosafety levels, safety protocol
• lab vs. clinic
• Laubenstein, Linda (1947–1992)
• Mann, Jonathan M. (1947–1998)
• McCormick, Joseph B. (b. 1942)
• McDougal, John Steven "Steve" (1945–2014)
• medical school, residency, and fellowship
• military service and "Yellow Berets"
• MMWR Morbidity and Mortality Weekly Report
• models (model systems, model organisms, modeling)
• Morgan, W. Meade
• mother-to-child transmission of HIV
• National Cancer Institute (NCI)
• National Institute of Allergy and Infectious Diseases (NIAID)
• National Institutes of Health (NIH)
• New York
• O'Reilly, Richard J.
• oncology
• oncovirus
• pediatrics, pediatric AIDS
• Piot, Peter (b. 1949)
• Pneumocystis pneumonia (PCP)
• pre-exposure prophylaxis (PrEP)
• prevention of HIV/AIDS
• public health
• Quinn, Thomas C.
• Reagan, Ronald (1911–2004)
• Ryder, Robin
• Safai, Bijan
• scientific controversy and consensus
• Seattle Biomedical Research Institute (SBRI)
• sensitivity and specificity; false positive, false negative; biological specificity
• Session 1: The Story of Animal Retroviruses
• Session 7: Prospects for an HIV Vaccine
• Shandera, Wayne X.
• Shilts, Randy (1951–1994)
• Special Virus Cancer Program (SVCP), 1964–1978
• Stonewall riots, 1969
• styles of scientific thought
• Temin, Howard M. (1934–1994)
• United States
• vagina
• Vietnam War
• viral load
• Warren, Cody
• White, Ryan (1971–1990)