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History of AIDS: 1993-1997

'Europe against AIDS' flying condom posterThese are some of the most important events that have occurred in the history of AIDS over the period 1993-1997.

1993 History

In January it was reported that some people with AIDS already had resistance to the drug Zidovudine (AZT) even though they themselves had never taken the drug.

"Some of the patients may have gotten the virus from other patients who have been taking AZT and who are now transmitting the resistant virus."

Researchers said there was an urgent need to develop new drugs to combat the epidemic.1

On January 6th the Russian ballet star Rudolf Nureyev died. His doctor said that "he died from a cardiac complication following a cruel illness", but it was widely reported that he had died from AIDS.2 3 He was buried in his evening clothes with his medals and his favourite beret.4

During January, 116 new cases of AIDS were reported in the UK, bringing the cumulative total to 7,045. One in six of these new cases were acquired through heterosexual intercourse.5

In Romania, despite the progress made since the overthrow of the Ceausescu regime, the number of children infected with HIV had increased. There were an estimated 98,000 infected orphans.6

China had reported one thousand cases of HIV infection, mostly in injecting drug users, but it was believed that this greatly understated the scale of the country's HIV epidemic.7 8 The Ministry of Health in China announced that soon only approved government blood donation centres would be able to collect and sell blood.9

In February the tennis player Arthur Ashe died, less than a year after announcing that he had been infected with HIV.10

In March, the House of Representatives in the USA voted overwhelmingly to retain the ban on the entry into the country of HIV positive people.11

In South Africa, the National Health Department reported that the number of recorded HIV infections had grown by 60 percent in the previous two years and was expected to double in 1993. A survey of women attending health clinics indicated that nationally some 322,000 people were infected.12

Princess Diana continued her HIV/AIDS advocacy work and spoke at the opening address of the 2nd International Conference on HIV in Children and Mothers in Edinburgh.

"By the year two thousand, only seven years from now - even the most conservative estimates predict there will be more than thirty million people worldwide with HIV - equivalent to more than half the population of the United Kingdom." - Diana - Princess of Wales, 1993

Romanian children living with HIVIn the UK in March, there were a large number of rather hysterical stories in the British press about the fact that a number of doctors in England had continued to practise medicine whilst knowing they were infected with HIV.13 The UK government responded by issuing new guidelines, according to which health care workers who believed that they had been exposed to HIV had to seek medical advice and testing.14

Meanwhile scientists had found that HIV 'hides out' in lymph nodes and similar tissue early in the course of infection.15

“The virus lies concealed for a decade or so, quietly seeding the destruction of the immune system, the researchers found. The finding resoundingly solves a mystery of AIDS: where does the virus secrete itself during the decade or so after an initial infection when patients feel well and little virus can be detected in their blood?”16

In early April the Ministers of Health and Finance from 39 countries met in Riga, Latvia, and launched an initiative to contain the spread of HIV in Central and Eastern European countries.17 During the Eighties, many countries of Central and Eastern Europe, the newly independent states, and the Russian Federation had introduced large-scale screening for HIV infection, with in excess of 20 million tests being carried out in the Russian Federation during 1993. One aspect of the Riga initiative was a refocusing of testing policies away from this mass screening and towards voluntary testing.18

The preliminary results were published of the large Anglo-French clinical trial of AZT known as Concorde.19 The results were interpreted as meaning that AZT was not after all a useful therapy for HIV positive people who had not developed symptoms.20

In the UK the radio DJ and comedian Kenny Everett announced that he was HIV positive, as did Holly Johnson, former lead singer with the group Frankie goes to Hollywood.21

The World Bank reviewed its HIV and AIDS activities Africa, and decided that AIDS should not dominate its agenda on population, health and nutrition issues. The World Bank believed that AIDS would have little demographic effect but recognised that it was a serious threat to health and economic development. With reference to blood screening, it was argued that this was costly and "might not be cost-effective under all circumstances".22

The ninth International AIDS meeting was held in Berlin, Germany. The general feeling of the meeting was one of disappointment. The message conveyed by the people who attended was once again to put more money and effort into effective prevention of HIV and AIDS.

“Dr. James W. Curran, who heads the AIDS Programme at the Centers for Disease Control and Prevention in Atlanta, said he left the meeting 'dispirited by the relentless assault of the virus'.”23

At the beginning of the year the CDC had expanded the US definition of AIDS to include people with certain opportunistic infections, as well as HIV infected adults with a CD4 count of less than 200. The expert epidemiology group of the European Centre for the Epidemiological Monitoring of AIDS together with the WHO's Regional Office for Europe accepted the inclusion of the additional indicator diseases but not the CD4 cell count criteria.24

In mid-1993 six United Nations organisations, including the WHO, began to seek agreement on forming a joint and cosponsored UN programme on HIV/AIDS.25

By this time it had been realised that HIV was also spreading rapidly in the Asia and Pacific regions, home to more than half the world's population, where more than 700,000 people were already believed to be infected.26

The drug 3TC was authorised by the FDA in the USA and the Federal Health Protection Branch in Canada, to be used in "compassionate" therapy in people who had not responded to other AIDS treatment or who are not eligible for clinical trials.27 Those patients who had developed a resistance to AZT were offered didanosine (ddI) and dideoxycytidine (ddC) - drugs that had been extensively studied. A number of trials were underway comparing the effectiveness of taking AZT on its own and in combination with ddI and ddC.28

Despite the years of litigation and number of newspaper accounts of the infection of haemophiliacs and transfusion recipients, no formal investigation of what had happened in Germany was undertaken until the 'scandal' of October 1993. In October, the failure of a small German blood supply company called UB Plasma to screen blood and plasma for HIV was made public. The company's misconduct was discovered by the Federal Health Office by chance, as a result of routine examination of positive HIV test results.29 The Federal Government also admitted that officials had covered up 373 cases of HIV-contaminated blood in the 1980s.30

On World AIDS Day, 1st December, Benetton in collaboration with ACT UP Paris placed a giant condom (22 metres high and 3.5 wide) on the obelisk in Place de la Concorde in Central Paris in an effort to waken the world to the reality of the disease. A symbolic monument to HIV prevention, it appeared on the covers of newspapers worldwide.31

At the end of 1993 the estimated number of AIDS cases worldwide was 2.5 million.32

Region Estimated Adult HIV infection Estimated adult AIDS cases
Australasia >25000 5000
North America >1 million 400000
Western Europe 500000 125000
Latin America & Caribbean 1.7 million 300000
Sub-Saharan Africa >9 million 1.7 million
South and South-East Asia 2 million >75000
East Asia and Pacific >35000 >1000
Eastern Europe and Central Asia >50000 4500
North Africa & The Middle East 75000 12000
Total >14 million >2.5 million

1994 History

In the US the CDC launched a series of 13 bold and frank AIDS advertisements breaking away from their previous low-key approach. The advertisements focused on the use of condoms, which were rarely seen or even mentioned on American television.

"One of the television ads, entitled Automatic, features a condom making its way from the top drawer of a dresser across the room and into bed with a couple about to make love. The voice-over says, 'it would be nice if latex condoms were automatics. But since they're not - using them should be. Simply because a latex condom, used consistently and correctly, will prevent the spread of HIV.'"33

Your pocket guie to sex - campaignIn the UK, the Department of Health vetoed an AIDS campaign promoting safer sex and condoms, developed at a cost of £2 million, on the grounds that it was too explicit.34 The campaign was developed by the Health Education Authority (a government funded body), who later in the year were banned by the Department of Health from distributing the book, "Your Pocket Guide to Sex".35

In February the film maker Derek Jarman died of AIDS. He had written in the preface of his autobiography:

"On 22nd of December 1986, finding I was body positive, I set myself a target: I would disclose my secret and survive Margaret Thatcher. I did. Now I have my sights on the millennium and a world where we are equal before the law."36

Randy Shilts, author of the book 'And the band played on' also died in February.37

In March, the actor Tom Hanks won an Oscar for playing a gay man with AIDS in the film Philadelphia.38

Official statistics for Brazil, with a population of about 154 million, indicated that some 46,000 cases of AIDS had been recorded, but estimates put the actual number at anywhere between 450,000 and 3 million cases. Two thirds of the known cases were in Sao Paulo state where AIDS was the leading cause of death of women aged 20-35.39

In France, on 7th April all the television networks, public and private, broadcast 'Tous contre le Sida' ('All against AIDS'), a special 4-hour AIDS programme. The aim was to heighten awareness about HIV/AIDS and to raise money.40 The estimated audience for the program was 33 million. Some 32,000 cases of AIDS had been recorded in France, with 15 deaths each day, and an estimated 150,000 people were thought to be infected.41

During the summer, the AIDS Prevention Agency in Brussels, in collaboration with the European Union, launched a campaign whose central image was 'the flying condom'. This was intended to serve as a visual reminder to young travellers of the risks of HIV infection. The logo was displayed in airports, railway stations, popular holiday destinations and other places young people visited during the summer.42

A large European study on mother-to-child transmission showed that Caesarean section halved the rate of HIV transmission.43

Research indicated that Thailand had reduced its rate of HIV transmission. This was largely due to action by the government, which had distributed condoms to brothels and insisted that they were used consistently; establishments that failed to comply were threatened with closure. Condom use in commercial sex had risen from 14 percent in 1989 to 94 percent in 1993.44

By July 1994 the number of AIDS cases reported to the WHO was 985,119. The WHO estimated that the total number of AIDS cases globally had risen by 60 percent in the past year from an estimated 2.5 million in July 1993 to 4 million in July 1994.45 It was estimated that worldwide there were three men infected for every two women, but that by the year 2000 the number of new infections among women would be equal to that among men.46

At the end of July, it was announced that the WHO's Global programme on AIDS would be replaced. The UN Economic and Social Council approved the establishment of a new "joint and cosponsored UN programme on HIV/AIDS". The separate AIDS programmes of the UNDP, World Bank, UN Population Fund, UNICEF and UNESCO would have headquarters with the WHO in Geneva, starting in 1996.47 Later in the year it was announced that Dr. Peter Piot, the head of the research and intervention programme within the Global Programme on AIDS, would be the head of the new UN program.48

An exciting study, ACTG 076, showed that AZT reduced by two thirds the risk of HIV transmission from infected mothers to their babies.49 Some people believed that ACTG 076 was:

“the most stunning and important result in clinical acquired immunodeficiency syndrome research to date.”50

And according to Dr Harold Jaffe of the CDC:

“It is the first indication that mother-to-child transmission of HIV can be at least decreased, if not prevented. And it will provide a real impetus for identifying more HIV-infected women during pregnancies so that they could consider the benefit of AZT treatment for themselves and their children.” - The New York Times -51

In early August 1994, the Tenth International Conference on AIDS was held in Yokohama, Japan. It was the first of the International Conferences to be held in Asia. No major breakthroughs emerged, and it was announced that in future the international conference would be held every two years.52

Meanwhile in the Russian Federation, deputies in the Russian Parliament, the Duma, voted at the end of October to adopt a law making HIV tests compulsory for all foreign residents, tourists, businessmen and even members of official delegations.53

India by this time had around 1.6 million people living with HIV, up by 60 percent since 1993. Local and state governments were accused of underusing and misusing HIV prevention funds.54

Pedro Zamora, an HIV-positive reality TV show starOn 11th November AIDS killed the 22-year old Pedro Zamora. He had become famous when he appeared on MTV's 'Real World' documentary about the real lives of a group of young room mates.55

In December, President Clinton asked Joycelyn Elders to resign from the post of US Surgeon General, following her suggestion during a World AIDS Day conference that school children should, amongst other things, be taught about masturbation. Gay activists defended the Surgeon General and criticised the president's record on AIDS. Fears were expressed that the president's action would discourage other government leaders from speaking frankly about sex education and AIDS.56

1995 History

By 1st January 1995, a cumulative total of a million cases of AIDS had been reported to the World Health Organisation Global Programme on AIDS. Eighteen million adults and 1.5 million children were estimated to have been infected with HIV since the beginning of the epidemic.57

Later in the month the CDC announced that in the US, AIDS had become the leading cause of death amongst all Americans aged 25 to 44.

“The dramatic rise is due to the accumulating toll from AIDS and is almost certain to continue because of AIDS deaths reflect infections from HIV, the AIDS virus that were acquired several years earlier.” - Dr. Harold W. Jaffe of the CDC -58

Two research reports provided important new information about how HIV replicates in the body and how it affects the immune system.59 60

Meanwhile in the USA, two reports by government scientists recommended that the Clinton administration lift the ban on federal funding for needle exchange programs, because the programmes had been shown to be effective in reducing the spread of disease.61 62

In March the VII International Conference for People Living with HIV and AIDS was held in Cape Town, South Africa - the first time that the annual conference was held in Africa.63 The conference was opened by the deputy President, Thabo Mbeki, who spoke about how:

"the impact has begun to cut deep. Those affected are from the young and able-bodied work-force as well as young intellectuals."64

The South African Ministry of Health announced that some 850,000 people - 2.1 percent of the 40 million population - were believed to be HIV positive. Among pregnant women the figure had reached 8 percent and was rising.65

Peter Piot - former UNAIDS executive directorThe conference was also addressed by Dr Piot, the Director of the new Joint United Nations Programme on AIDS (UNAIDS). Dr Piot confirmed his commitment to involve people living with HIV/AIDS in the planning, shaping and guiding of the global response to the epidemic.66

In July, the US Senate voted to extend the Ryan White Care Act, which provided care and support services to those affected by HIV and AIDS.67 As a result of the first five years of the Act:

"in the place of activists there were now thousands of AIDS organisations throughout the country - the AIDS "industry" made possible by the Ryan White Care Act".68

By the autumn of 1995, 7-8 million women of childbearing age were believed to have been infected with HIV. The WHO spoke out about the 'inadequate international response':

"The impact of the HIV/AIDS epidemic on women … is not yet receiving sufficient political awareness, commitment or enough action of programmes responding to the specific needs of women."69

Also in August, researchers announced the results of a study in Tanzania, which found that treating people for sexually transmitted diseases such as gonorrhea substantially reduced their risk of becoming infected with HIV.70

In September two clinical trials, the Delta trial and the ACTG175 trial, showed that combinations of AZT with ddI or ddC were more effective than AZT alone in delaying disease progression and prolonging life.71

On 1st December, World AIDS Day, Nelson Mandela called on all South Africans to

"speak out against the stigma, blame, shame and denial that has thus far been associated with this epidemic."72

The FDA approved the first of a potent new family of anti-AIDS medications. The drug saquinavir belonged to a class of drugs called protease inhibitors. Its approval in record time was said to be:

"some of the most hopeful news in years for people living with AIDS."73

By December 15th, the World Health Organisation had received reports of 1,291,810 cumulative cases of AIDS in adults and children from 193 countries or areas. The WHO estimated that the actual number of cases that had occurred was around 6 million. Eight countries in Africa had reported more than 20,000 cases.74

Other organisations estimated that by the end of 1995, 9.2 million people worldwide had died from AIDS.75

Worldwide during 1995, it was estimated that 4.7 million new HIV infections occurred. Of these, 2.5 million occurred in Southeast Asia and 1.9 million in sub-Saharan Africa. Approximately 500,000 children were born with HIV.76

The WHO's Global programme on AIDS closed as planned on 31st December 1995.77 They estimated that by the end of the century, 30 to 40 million people would have been affected by HIV.78

1996 History

The new Joint United Nations Programme on AIDS (UNAIDS), bringing together six agencies belonging to or affiliated with the UN system (WHO, UNDP, UNICEF, UNFPA, UNESCO and the World Bank), became operational on January 1st.79

In February the heavyweight boxer Tommy Morrison was identified as HIV positive after being tested prior to a fight.80

"'I thought AIDS was something that happened to gays and drug addicts. A macho guy like me who loves ladies and is superfit - he doesn't get AIDS.' Tommy Morrison."81

In March, a government appointed panel issued a report sharply criticising the US government's domestic response to AIDS:

"The Government's $1.4 billion AIDS research program is uncoordinated, lacks focus and needs a major overhaul to attract new scientific talent and spur novel and imaginative ideas."82

Meanwhile the effect of AIDS was continuing to be felt at a community level. In the USA there had been a cumulative total of 81,500 AIDS cases in New York, and:

"despite two world wars, the Depression and epidemics, nothing in this century has affected the life expectancy for New Yorkers as greatly as AIDS."83

In May the US Food and Drug Administration (FDA) approved the first 'home sampling' system of HIV testing. Until then the FDA had insisted that all tests for HIV (whether blood or oral fluid) had to be done under the supervision of health professionals. Under the new system, someone would buy a sampling kit from a shop or by mail order, collect a sample of their blood, send it to a laboratory for testing, and receive their results by phone.

"'Too many Americans do not know their HIV status. Knowledge is power, and power leads to prevention', said HHS Secretary Donna E. Shalala. 'The availability of a home test should empower more people to learn their HIV status and protect themselves and their loved ones.'"84

Meanwhile in China it was estimated that the number of AIDS cases could be as high as 100,000. Two thirds of the reported AIDS cases had occurred in the southern province of Yunnan, where the use of heroin and the sharing of needles had helped the spread of HIV.85

NevirapineIn June the FDA approved the drug Viramune (nevirapine), the first in a new class of drugs known as non-nucleoside reverse transcriptase inhibitors (NNRTIs).86 Another treatment development that took place was the introduction of the viral load test, which provided information about the risk of disease progression.87

Throughout 1996 there was excitement and optimism about the treatment of HIV infected people.88 The health of many improved enormously when they started taking combination therapy. For some people, particularly those had been ill in hospital and were then able to go home, the improvement in health was so dramatic that it was referred to as the "Lazarus Syndrome".89

At the start of the 11th International Conference on AIDS in Vancouver in July:

"the air was electric with excitement and anticipation about the findings on combination therapies to be reported during the meeting."90

Some scientists even declared that:

"aggressive treatment with multiple drugs can convert deadly AIDS into a chronic, manageable disorder like diabetes."91

One doctor suggested that giving combination therapy to patients in the first few weeks of infection might mean that the virus could be completely eliminated in two or three years.92

However, Nkosazana Zuma, the health minister of South Africa, reminded the conference delegates that:

"most people infected with HIV live in Africa, where therapies involving combinations of expensive antiviral drugs are out of the question."93

It was also reported that there were limitations on the use of the drugs, such as severe side effects and the difficulty of taking large numbers of pills each day.94

"If you think the cure is here, think again. The cure is not here. We are a long way from a cure, even for the rich who can afford the treatments." - Eric Sawyer95

The government of Brazil pledged to begin providing free combination antiretroviral treatment by the end of the year. It said it would spend up to $45 million on protease inhibitors over the following twelve months.96

In October, in Washington D.C., the AIDS Memorial Quilt was displayed in its entirety for the last time, but it was also the first time that a display of the quilt had been visited by an American president.97 98

"What it has done always in the past, and will continue to do, is to put a face on this epidemic. It makes this epidemic human." - Anthony Turney99

In December, the White House announced its first ever AIDS strategy. This called, amongst other things, for sustained research to find a cure and a vaccine; a reduction in new infections; guaranteed access to high quality care for AIDS patients; and fighting AIDS-related discrimination.

"None of us can afford to sit by and watch this epidemic continue to take our neighbors, friends and loved ones from us" - President Clinton in a letter accompanying the AIDS plan100

AIDS advocates said that much would depend on how the stategy was implemented.

"It doesn't require rocket science to figure out what to do, what it requires is the political will to back it up." - Paul Donato101

New outbreaks of HIV infection were erupting in Eastern Europe, the former Soviet Union, India, Vietnam, Cambodia, China and elsewhere.

"The epidemic is starting to skyrocket in Russia and the Ukraine where transmission is from everything - injecting drugs, poor hygiene, and heterosexual and homosexual intercourse." - Dr Peter Piot102

At the end of the year UNAIDS estimated that during 1996 some three million people, mostly under the age of 25, had become newly infected with HIV, bringing to nearly 23 million the total number of infected people. In addition an estimated 6.4 million people - 5 million adults and 1.4 million children - had already died.

1997 History

Children at a school in Illinge, South AfricaEarly in 1997 it was reported that, for the first time since the AIDS epidemic became visible in 1981, the number of deaths from AIDS had dropped substantially across the USA.103 This was excellent news but:

"The decline in deaths leaves more people living with AIDS and HIV infection. We do not want to be a wet blanket here, but we still need programs that assure good access to treatment and care for infected people." - Dr John Ward104

In New York City the decline was even more dramatic, with the number of people dying from AIDS falling by about 50 per cent compared to the previous year.105 The number of babies being born HIV positive had also declined dramatically.106

By the spring it was clear that although excellent for many people, the antiretroviral drugs did have unpleasant and in some cases serious side effects. Resistance could also occur, even when three drugs were being taken, and adherence was an important issue as many pills needed to be taken each day.107

A number of treatment guidelines were published, and some doctors, particularly in the UK, disagreed with the more aggressive approach taken by the US guidelines.108 109 Some doctors were particularly concerned about the recommendations concerning the beginning of treatment when patients did not have symptoms.110 The US approach was sometimes referred to as the "hit early, hit hard"111 approach to treatment.

Later in the year a number of studies were published which showed that HIV could not after all be eradicated by two or three years of treatment, even if three drugs were taken and the treatment was strictly followed.112

In May 1997 President Clinton set a target for the USA to find an AIDS vaccine within ten years, so it could be the "first great triumph" of the 21st century. To help attain this goal Clinton announced that a dedicated HIV vaccine research and development centre would be established at the National Institutes of Health.

"With the strides of recent years, it is no longer a question of whether we can develop an AIDS vaccine - it is simply a question of when. And it cannot come a day too soon." - President Clinton113

In July the CDC reported that it was likely that there had been a case of transmission of HIV as a result of "deep kissing", although other routes of transmission in this case could not definitely be excluded. The HIV positive man had sores in his mouth and gums that regularly bled, and his female partner also had gum disease with inflamed and sore areas in her mouth.114

In August, at a UNAIDS-organised meeting in Nepal, an appeal was made for urgent joint action by South Asian regional governments to check the spread of the pandemic. Estimates of HIV/AIDS cases in India, Myanmar (Burma), Bangladesh and Nepal were put at 3 million, 350,000, 20,000, and 15,000 respectively.115

At the end of the year, UNAIDS reported that worldwide the HIV epidemic was far worse than had previously been thought. More accurate estimates suggested that 30 million people were infected with HIV. The previous year's estimate had been 22 million infected people.116

"The older estimates were based on data that came from a small number of countries. It was assumed that one could extrapolate similar rates of transmission for all countries in a particular regional factors would be pretty much the same. It turns out that the assumption was wrong." - The New York Times117

It was also estimated that 2.3 million people died of AIDS in 1997 - a 50% increase over 1996. Nearly half of those deaths were of women, and 460,000 were children under 15. UNAIDS said it was likely that, in terms of AIDS mortality, the full impact of the epidemic was only just beginning.

Worldwide, 1 in 100 adults in the 15-49 age group were thought to be infected with HIV, and only 1 in 10 infected people were aware of their infection. It was estimated that by the year 2000 the number of people living with HIV/AIDS would have grown to 40 million.118

In Latin America and the Caribbean the disease was already having a major impact. Earlier in the year a doctor in San Pedro Sula, Honduras had said:

"We will go from a city that is predominantly young to a city of old people and children. We are in over our heads with AIDS cases. It is devastating us. And all we can do here is watch people die, nothing more."119

The United States Agency for International Development (USAID) said it believed that 40 million children in developing nations would lose one or both parents to AIDS by the year 2010.

"It is a crisis of staggering proportion, that is going to affect not only the future of these countries, it is going to affect the entire global network of trade, diplomacy and development. What we are talking about here is something that has never been seen before, which is countries with one-sixth to one-quarter of all children without one or both parents."120

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