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This weekend will bring a grim anniversary: It’s been 30 years since American physicians first reported an unusual illness that was affecting gay men, AIDS.
In San Diego, a physician named Douglas Richman knew something odd was happening even before the first report in 1981. He found himself treating sick gay men but couldn’t figure out what was wrong with them.
Since then, AIDS has killed more than 7,200 people in San Diego County. The epidemic has evolved, however. HIV infection is now treatable and most people don’t go on to develop AIDS, although it still killed 58 locally in 2009. While local statistics show that HIV remains a remote threat to heterosexual men who don’t do intravenous drugs, heterosexual women who don’t do those drugs account for an increasing percentage of all infected females. They’re often infected by bisexual men and men they know are HIV-positive.
Gay men remain the group most at risk of becoming infected, and they account for more than three-quarters of AIDS cases among males here. Last year, a study revealed that 18 percent of 490 gay and bisexual men tested in San Diego County were infected with the virus that causes AIDS. Of those who were infected, four in 10 didn’t know. The numbers, however, don’t necessarily represent the entire gay population, which is difficult to study.
Meanwhile, health officials continue to push for more HIV testing and more caution regarding sex. They’ve worried for years that “condom fatigue” and the brighter future for HIV patients will encourage people to be more careless.
Richman, director of the University of California, San Diego’s Center for AIDS Research, continues to treat HIV and AIDS patients in the Veterans Administration medical system. He also conducts research aimed at bringing an HIV vaccine closer to reality.
In an interview this week, Richman talked about the early days of AIDS, the unique aspects of the epidemic here and the prospects for the thousands of San Diegans who are HIV-positive.
Tell me about when you first came across AIDS.
We were seeing patients in the late 1970s, gay men with immune system problems and fevers we couldn’t explain. They were having mild symptoms.
I had a medical student who did a project in 1979. He collected plasma from 300 gay men in two clinics here in San Diego to study hepatitis B, which has an increased incidence in gay men. About half a dozen years later, it turned out that 15 percent of the men in that population were HIV-infected (in 1979).
This was before anyone had any idea what AIDS was. Why weren’t people dying of it at that time?
The average patient takes five to 10 years to die after being infected. These were people who were probably recently infected. We saw our first patients in 1981, and then we started seeing increasing numbers to the point until it was almost like a battlefield of medicine. The patients were coming at a remarkable rate.
By the mid-1980s, we realized that any patient who appeared with new symptoms had at least a 50-50 chance of being dead in 6 to 12 months. We didn’t have any specific treatments.
When you started seeing cases, what did you think was going on?
We did lymph node biopsies, we did blood studies, we looked for microorganisms and antibodies, we didn’t see any of the things that we knew about that caused these fevers and enlarged lymph nodes. We didn’t come up with answers.
How were you affected personally when people started to die?
One of the reasons I didn’t go into oncology was that just intellectually, I found it more gratifying to be able to understand the mechanism of disease, to know how to specifically treat each condition and have a high probability of success. And all of a sudden, it was beginning to get like a serious oncology practice, but at a rate that was really challenging.
We found ourselves working harder than the average person and presiding over a lot of terminal illness. We had people die without any way to reverse [the illness]. One has to develop a professional detachment so you can deal with all of that.
What’s been unique about the AIDS epidemic here?
On the West Coast, it’s predominantly a MSM (men who have sex with men) epidemic, and it’s never had much in the way of intravenous drug use. We didn’t have the tradition of needle sharing or shooting galleries as they did on the East Coast.
New AIDS medications begin making a difference in the mid-1990s. Do they still cause the noticeable side effects that they did early on?
What is remarkable about most of the newer drugs is that that their side effects are remarkably low, and we can usually find something that people can tolerate. What we have now is really quite remarkable.
People still develop AIDS in San Diego despite the powerful drugs that help the HIV-infected avoid developing the disease. Why is that?
We’re offering treatment almost universally now. The biggest group is those who don’t know they’re infected, or got a test years ago and they’re in denial, deferring treatment until they’re sick. That’s discouraging because the prognosis is much better the earlier the treatment begins.
The other group are those who are infected but have emotional or substance abuse problems that interfere with their ability to be adherent to medications.
What about the people who are still dying of AIDS? What’s their story?
Not everyone reliably takes their medications.
In the big picture, what’s next for AIDS and HIV?
A cure and a vaccine are much more than five years away.
Many people with HIV are expected to survive indefinitely if they take their medication. What’s next for them?
The vast majority of people are just getting older along with their doctor. We deal with the things that people have to deal with as they get older, like diet, weight, exercise. I spend more time on those things than almost anything else.
I have patients who complain about getting old. I tell them that there’s only one other alternative.