RECOVERING FROM A PUBLIC HEALTH CATASTROPHE
The older of the coauthors (DBC) was a medical trainee when five previously healthy young men in Los Angeles were reported to have developed an unusual pneumonia caused by Pneumocystis carinii (now termed Pneumocystis jiroveci), which was fatal in two. Reported in the June 5, 1981, issue of the Centers for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Reports, these are now taken as the index cases of acquired immune deficiency syndrome (AIDS), a worldwide epidemic unequalled in human history. Several years later, after the causative agent was identified as human immunodeficiency virus-1 (HIV-1), banked serologic specimens from a handful of isolated earlier cases of undiagnosed catastrophic acute illness retroactively tested positive for the same agent. However, 1981 is the reference date for the current catastrophe, subsequent voluminous epidemiologic analyses, and recent (2011) reflections on AIDS reaching age 30 years.1
More than any other painful condition, HIV/AIDS exemplifies the public health perspective on disease as a population-based interaction among environment, pathogen, and host, as well as the World Health Organization's (WHO's) model of the social determinants of health. When author DBC helped convene a 1994 French–U.S. conference on pain in HIV/AIDS,2 the modern era of highly active antiretroviral therapy (HAART), also termed combination antiretroviral therapy (cART), was still 2 years away. HIV was then for the most part a rapidly progressive condition without a cure whose sufferers were at risk for a range of secondary infections and cancers along with metabolic disturbances contributing to wasting in the relatively short interval before their deaths. Research on and discussions of pain assessment and treatment in HIV/AIDS often emerged from palliative care services, as did Dr. Lefkowitz's chapter on this topic in the prior edition of this textbook.3 By 2002, when DBC was next involved in preparing a comprehensive review of pain in HIV/AIDS, it was clear that “[t]here is now a striking disparity between developed and developing nations in the epidemiology and natural history of HIV/AIDS.”4 Whereas those treated with cART in prosperous settings had life expectancies approaching those of HIV-negative individuals,5 those at the margins of prosperous society and virtually the entire developing world were unable to access effective preventive or maintenance therapies.
Thus, at present, we may be in the third phase of the HIV/AIDS story. The first phase was its explosive entrance worldwide as a fulminant fatal disease. The availability of cART heralded a second phase in prosperous Western nations. HIV/AIDS was transformed into a chronic disease with only a modest effect on life expectancy, particularly as drug therapy has become progressively more effective, less toxic, and easier to adhere to by virtue of once-daily oral formulations.6,7 Yet during this second phase, developing countries were left behind in what truly seemed like a hopeless pandemic. We are now in a third phase in which the demographics of HIV ...