Emory University Public Health - A Pioneer for AIDS

In June 1981, a CDC report described a cluster of previously healthy homosexual men from Los Angeles who had contracted Pneumocystis carinii pneumonia (PCP). Two of the five men treated for this rare form of pneumonia had died.
James Curran, dean of the Rollins School of Public Health (RSPH), remembers the cases clearly. Then an epidemiologist with the CDC, he chaired the task force organized to investigate the outbreak. Within three weeks, Curran's group confirmed more than 25 additional cases of PCP and other serious opportunistic infections among homosexual men in Los Angeles and New York City. In addition, the agency reported several cases of Kaposi's sarcoma (KS), a rare form of cancer, among gay men in New York. The subsequent case definition for disease surveillance put in place by Curran and colleagues at the CDC was adopted worldwide, allowing early and consistent recognition of a new global epidemic.
What experts detected was AIDS, short for acquired immune deficiency syndrome, so named by the CDC task force in 1982. For the past quarter century, Curran and others around the world have made it their mission to halt transmission of the disease and find a cure. Here, he looks at the past, present, and future of HIV/AIDS.

Q. Why did the first cases of PCP and KS attract
your attention?
A. Prior to these cases, CDC epidemiologists had investigated a variety of new outbreaks, including toxic shock syndrome, Legionnaire's disease, and swine flu. When the first cases of PCP were reported, many of us who had worked with gay men in studies of hepatitis or sexually transmitted diseases knew quickly it was an important problem that deserved focused and immediate attention.
These cases were important because previously healthy people were dying of an unexplained disease. It was clustered among gay men, it was fatal, and the cause was unclear. We needed to find out was it new? Was it restricted to Los Angeles and New York? Was it restricted to gay men? Was it increasing? And what was the extent of the problem?

Q. How did you and the CDC confront this problem?
A. The first step in understanding this apparently new epidemic was to develop a case definition and conduct intensive surveillance for cases of Kaposi's sarcoma and opportunistic infections, which we later termed as AIDS. The case definition was intended—and subsequently proven—to be highly specific. This definition was rapidly adopted worldwide. It allowed for precise and consistent identification of epidemiologic patterns in the United States and other parts of the world with sophisticated health care.

Q. How did the disease come to be named AIDS?
A. After a year or so, we felt a need to pull together the collections of opportunistic cancers and other conditions under a name that could replace the various terms being used—Kaposi's sarcoma, opportunistic infections, GRID
or gay-related immune deficiency. The CDC started to use the name AIDS—acquired immune deficiency syndrome—to best describe the underlying problem that ultimately was found to be caused by HIV (human immunodeficiency virus) in 1983.

Q. How did HIV/AIDS evolve?
A. The period between 1981 and 1986 was a time of tremendous discovery. During the first two years, modes of transmission were defined. Scientists confirmed the disease among gay men, intravenous drug users, and their sexual partners. They also investigated three cases of PCP among men with severe hemophilia A and no other known risk factors. The identification of these and other people with hemophilia provided solid epidemiologic evidence that a blood-borne and sexually transmitted pathogen caused AIDS. Completing the picture, investigators confirmed AIDS was transmitted from mother to child and through heterosexual contact. The CDC took important steps to protect health care workers and blood supplies and to educate the public about transmission and prevention. In 1983, investigators at the Institute Pasteur in France identified HIV as the virus that causes AIDS. In 1984, the diagnostic test to detect HIV in the blood became available. By 1986, Dr. Meade Morgan, a colleague at the CDC and an eminent RSPH alumnus, predicted a total of 270,000 AIDS cases through 1991, thus forecasting enormous morbidity, mortality, and health care costs for the nation in the ensuing years.

Q. During this time, you led the CDC's effort to formulate recommendations to protect the nation's blood supply. What was the result?
A. In early 1983, before the discovery of HIV, the CDC and the U.S. Public Health Service recommended that persons at increased risk for AIDS not donate blood. Testing the blood supply was a breakthrough. There were relatively few tests for infectious diseases that were implemented before the AIDS era. Now there are more than a dozen tests to protect the blood supply. This was because of a tremendous effort to eliminate infectious diseases from blood.

Q. When did the global extent of AIDS first become known?
A. Data collected by researchers at Project SIDA in Zaire demonstrated an extensive epidemic there in 1984. It was the highest estimated HIV infection rate in the world at the time. This year, the Joint United Nations Program on HIV/AIDS reported more than 25 million deaths by the end of 2005 and nearly 40 million people infected worldwide. With nearly 3 million deaths in 2005, HIV/AIDS is now the fourth leading cause of death in the world. With 4.1 million new infections in 2005, deaths will likely continue to rise.

Q. When did the first drug therapies for AIDS become available? How did they progress?
A. In 1987, AZT (azidothymidine) was licensed as the first antiretroviral drug to treat HIV. In the 1990s, the biggest news concerned two discoveries. First was that providing AZT to HIV-infected women during pregnancy could reduce the risk of transmission to newborns. The second was the availability of highly active antiretroviral therapy or HAART. This therapy, which combines at least three drugs, has greatly prolonged lives and improved the well-being of millions of people throughout the world. Antiretroviral drugs were discovered by a variety of people, mostly in this country, and Emory has played a major role in their development. Two of the major drugs—3TC and FTC—were invented here by researchers Dennis Liotta and Raymond Schinazi.

Q. At the time of these discoveries, you observed a sense of complacency about HIV/AIDS. Why?
A. In the early 1990s, a sense of complacency emerged, particularly in the United States and developed countries, when the number of HIV/AIDS cases began to level off. There was a feeling that the horizons were clear and that people could understand who was at risk and who wasn't. The general population began to implicitly accept the current number of cases.

Q. How do you combat that sense of complacency?
A. We all exist in a social, cultural, and economic context. We also live at a certain level of health and a certain level of public health. But there are great differences in the health of some populations and in the health of some countries. When a new epidemic or disease comes along, we are tempted to say, "Oh my goodness, we've become such an obese country. Oh my goodness, we have 40 million cases of AIDS throughout the world. That's just the way things are. We'll just have to accept that." Improving the health of a population or country requires looking for ways to redefine the unacceptable and rise above the status quo.

Q. How do you maintain commitment to HIV prevention?
A. It's important to realize that 4 million people are having sex for the first time each year in the United States and that education and prevention efforts must continue. We can't sit back and say, "Well, we did comprehensive sex education 10 years ago. Why do we need to do it now?" There's a need for constant renewal of information to go along with the renewal of potential risk.

Q. From the beginning, HIV/AIDS has been a source of social controversy. At one point, protesters spit on you, and your face appeared on 20,000 postcards sent out by activists. How did you react to that?
A. I, Tony Fauci of the NIH, and others from the CDC were speaking at a public engagement when we were targeted. Many government scientists were seen as representatives of the U.S. government as a whole. To some extent, you have to take that kind of protest and figure out the meaning of it and not take it personally. Is it legitimate? Why is it being conducted? Is there truth in what they say?

Q. Was there truth in what they were saying?
A. There was an enormous amount of impatience regarding the government's response to AIDS. People were dying. The diagnosis of HIV or AIDS was a death sentence, so they were impatient to help find more effective therapies. And they were mistrustful of government, particularly homosexual men and women and injecting drug users who felt their behavior, and sometimes their very existence, was seen as criminal by some people.

Q. What lessons from HIV/AIDS can be applied to other diseases?
A. There were lessons to be learned from tracking and combatting the disease and working with communities and the social environment. There were advantages in the discovery of drugs to combat it. For example, 3TC, which was invented here at Emory, is also effective against the hepatitis B virus. The social activism of the 1980s, which brought public and private attention to AIDS as a health problem and as a public health problem, has been shown to be effective for cancer and other diseases.

Q. In 1995, you left the CDC to become dean of the RSPH. What was the HIV/AIDS research culture like at Emory?
A. There were a number of investigators working on HIV/AIDS across Emory. Most of their work was domestic. There was little work globally. David Stephens, director of the Division of Infectious Diseases in the School of Medicine, and I formed an AIDS interest group. From there came a desire to grow and coordinate AIDS research more effectively and to recruit more expert faculty. In 1997, the RSPH, the School of Medicine, and the Yerkes National Primate Research Center formed the Emory Center for AIDS Research (CFAR), with funding coming from the NIH a year later.

Q. What has CFAR enabled Emory to do?
A. Emory is one of 21 federally funded Centers for AIDS Research in the United States. Our center is unusually broad in its vision and initiatives. Prevention is a central theme—health education, research on preventing transmission among adolescents, developing and testing of HIV vaccines, testing microbicides, and prevention and treatment of antiretroviral infections and tuberculosis to prevent complications from these diseases. We work with colleagues in Atlanta, throughout the United States, and in several developing countries, including Rwanda, Zambia, South Africa, Ethiopia, and India. Emory doctors care for 6,000 to 7,000 patients annually. That's one of the largest HIV/AIDS patient groups in the country.


	A Research Powerhouse
	By pooling resources and expertise, the Emory Center for AIDS Research (CFAR) has become a powerhouse in the global quest to help individuals, families, and populations affected by HIV/AIDS. Since its startup in 1997, funding for HIV/AIDS research has more than tripled to $55 million a year. Currently, 163 studies are under way. Essentially, the Emory CFAR is a giant umbrella encompassing the RSPH, where the center is housed; the School of Medicine; Yerkes National Primate Research Center; the Emory Vaccine Center and the Hope Clinic for vaccine and microbicide testing; Emory Crawford Long Hospital; the Ponce de Leon Center, a highly regarded outpatient HIV/AIDS clinic operated by the Grady Health System; and the Atlanta Veterans Affairs Medical Center. More than 100 Emory faculty members are engaged in CFAR through collaborations in behavioral and social science, medicine, nursing, statistics, virology, pharmacology, and immunology and through partnerships with government agencies, private AIDS researchers and clinicians, and other universities. Several service cores spread across campus support their research in prevention science, vaccine development, AIDS pathogenesis, and clinical science. Three of those units—the Biostatistics Core, directed by Michael Kutner; the Social and Behavioral Sciences Core, directed by Gina Wingood; and the Administrative Core—are in the RSPH. CFAR faculty stay attuned through a website and through the Vaccine Dinner Club and the CFAR AIDS Soiree, successful programs featuring prominent speakers. Just as important, CFAR provides funding to help junior faculty jump-start their research programs and to recruit key investigators. Three co-directors lead the center. James Curran, dean of the RSPH, serves as CFAR's principal investigator. Carlos del Rio (below left), an expert on HIV/AIDS in developing countries, treats patients at Grady Memorial Hospital and the Ponce Center. Eric Hunter (below right), a Georgia Research Alliance Eminent Scholar, is among the world's leading experts on retroviruses and maintains a laboratory at Yerkes. To learn more about CFAR, visit the new website at www.cfar.emory.edu.

Q. What is CFAR's greatest accomplishment to date?
A. CFAR crosses schools and centers to create a multidisciplinary research environment. We now have three directors—myself and Carlos del Rio and Eric Hunter, who are both in the School of Medicine. We bring complementary talents, interests, and geographic settings to the endeavor. There's a huge difference in awareness, capacity, and accomplishments among AIDS researchers at Emory compared to nine years ago. We have an active group of more than 100 faculty who are really making a difference. In the past nine years, funding for AIDS research at Emory has more than tripled to $55 million per year.

Q. What comes to mind when you think of the face of HIV/AIDS?
A. Many times in public health, we categorize health in terms of numbers, economic impact, social impact. We talk about rankings in terms of deaths, increasing numbers of cases, decreasing numbers of cases. But the true impact of the problem affects individuals.
They are people who suffer and die, often needlessly. They are people who survive and overcome enormous difficulties to become the beneficiaries of science and care and who become leaders in their own right.
They are people who work on the problem. People who study it. People who volunteer with organizations. Young graduate students who are inspired to go into public health because of concerns about AIDS or people they know with the infection. Generations of people who often take their passion and mission in life from their experiences or concerns about friends or citizens. They are scientists, doctors, nurses, public health workers, and policymakers who willingly use their time, social capital, and influence to deal with the problem. All of these individuals have a personal stake in HIV/AIDS.

Q. What lies ahead for people with HIV/AIDS?
A. The next 25 years of HIV/AIDS will go by in a heartbeat, just like the first 25 years. The high rates of infection in sub-Saharan Africa will level off through intervention and a growing capacity among people to speak frankly about risks, stigma, and HIV counseling. HIV/AIDS tends to settle in places where poverty is greatest and where resources are often diverted to other problems. It's still on the rise in China and has become a substantial problem in India and Eastern Europe. Ultimately, HIV/AIDS will remain a huge public health problem, barring the availability of creative therapies and a vaccine. We need both.
I'm optimistic they will become available and the world will find a way to use them. In the absence of that, prevention is vital for a world where people, communities, and nations can talk openly and comfortably about sexuality and the stigma of HIV/AIDS.