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The History of AIDS and ARC

The terms AIDS (acquired immunodeficiency syndrome) and ARC (AIDS-related complex) are historical artifacts, dating from the period between the recognition of an immunosuppression syndrome in gay men and the identification of HIV. In 1981 physicians in San Francisco and New York City began to see a pattern of unusual infections and cancers in young and otherwise healthy homosexual men. The first report in Morbidity and Mortality Weekly Report (MMWR) focused on the men's infection with an atypical pneumonia and a cancer that had been previously seen only in elderly men of Mediterranean descent.[133]

Early research quickly pointed to common trends among cases, but these were obscured by many extraneous factors. The most suggestive of these was the use of drugs, such as inhalant stimulants, by some of the affected men. As these leads were being pursued, more cases of the syndrome were diagnosed. While epidemiologically inconsistent with the toxin hypothesis, they had the same distribution as hepatitis B. Many victims were positive for hepatitis B acquired in the bathhouses. The most crucial evidence for an infectious agent was the appearance of the disease in persons who had no visible link with the bathhouses.

While a toxic agent might have caused the disease among homosexuals and intravenous drug users, it did not explain the development of the disease among recipients of blood and blood products. Initially a mystery, these cases were soon traced back to the blood donors: homosexual men dead or dying of AIDS. The traditional test for an infectious agent was satisfied, and the parallel to hepatitis B was complete. When the antibody test for HIV became available, it was found in frozen blood samples that had been saved during the study of hepatitis B in the late 1970s.

There was some controversy over what to call this syndrome. Terms such as GRID (gay-related immunodeficiency disease) were considered but rejected in favor of the more neutral AIDS.134 The CDC promulgated a broad surveillance definition of what it called acquired immunodeficiency syndrome to facilitate the reporting and investigation of this new syndrome:

For the limited purposes of epidemiologic surveillance, CDC defines a case of AIDS as a reliable diagnosed disease that is at least moderately indicative of an underlying cellular immunodeficiency in a person who has had no known cause of underlying cellular immunodeficiency or any other underlying reduced resistance reported to be associated with that disease.[135]

As cases were reported and analyzed under the broad CDC definition, common patterns emerged. It was found that various combinations of unusual infections, indirect measures of immune system function, and a rare cancer, Kaposi's sarcoma, characterized most of the reported cases. This lead the CDC to revise its definition of AIDS to reflect the most common manifestations presented by the reported cases.[136] The revised criteria took the form of a list of the unusual infections and cancers, abnormal immune system tests, and other diagnostic findings that were significantly correlated with symptomatic HIV infection.

These revised criteria were sufficiently restrictive to create a class of persons who were infected with HIV and had symptomatic disease but did not meet the CDC criteria for AIDS. These persons were identified as having ARC. Persons with ARC were not reportable, and their numbers did not count toward the CDC's running total of AIDS cases. Persons with ARC also had difficulty in qualifying for categorical programs funded for treating AIDS patients. Moreover, persons who were positive for the then newly discovered HIV but had no symptomatic disease were not reported and followed to track the epidemiology of the disease.

In 1987 the CDC definition of AIDS was broadened to include neurological symptoms, wasting syndrome, and more common infections such as tuberculosis.[137] This redefined many persons with ARC as persons with AIDS. In our view, once it was possible to test for the presence of HIV and it was proved that persons with AIDS or ARC were infected with HIV, then the presence of HIV or its antibodies should have become the reportable condition. Most states, however, persist in requiring AIDS cases to be reported but do not require the reporting of HIV-infected persons. This masks the epidemiology of the disease in women who do not fit the male-oriented standards for HIV.[138] Given that the latency of AIDS may exceed ten years, counting AIDS cases rather than HIV infection makes it difficult to predict accurately the movement of the disease into new population groups. If the CDC again revises the definition of AIDS to include low T4-cell counts, it is estimated the number of persons with AIDS will double.

[133]Karposi's sarcoma and Pneumocystis pneumonia among homosexual men--New York City and California. MMWR 1981 Jul 3; 30(25):305-8.

134Shilts R: And the Band Played On. 1987.

[135]Leads from MMWR, current trends; update: acquired immunodeficiency syndrome (AIDS)--United States. JAMA 1983; 250:1016.

[136]CDC: Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36(suppl 1S).

[137]CDC: Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987; 36(suppl 1S).

[138]Chu SY; Buehler JW; Berkelman RL: Impact of the human immunodeficiency virus epidemic on mortality in women of reproductive age, United States. JAMA 1990; 264:225-29.

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