25 Years with HIV

June 5 marks twenty-five years since the publication of the landmark report in the MMWR (Morbidity and Mortality Weekly Report) documenting what turned out to be the first five recorded cases of AIDS in the US. Since then, the number of people who have died from AIDS globally has exceeded 25 million, and last year the total number of people living with the virus grew to an all time high of 40 million. Two-thirds of these people live in sub-Saharan Africa, and new epidemics have broken out in Eastern Europe and Central Asia.

Within those 25 years, science has produced both great successes as well as disappointments. Scientists have not only identified the mode of transmission, the virus causing AIDS, and its genome but they have also developed nucleoside reverse transcriptase inhibitors (such as AZT), protease inhibitors (saquinavir), non-nucleoside reverse transcriptase inhibitors (nevirapine), and most recently, a drug that prevents viral fusion and entry into cells (enfuviritide or T-20). In the last two years, the World Health Organization delivered antiretroviral drugs to 1.3 million people, increasing the number of people receiving drugs in developing countries three-fold (and in Africa eight-fold) in only two years.

While arguably political and socioeconomic issues have failed to deliver on some of the possibilities that science has offered, there is still a great deal for researchers to confront: For example, why has a vaccination proved so difficult; how do so-called long-term nonprogressors remain symptom free; and why do viral reservoirs remain in the bodies of people with an undetectable viral load?

Still, the near-future looks promising. Clinical trials testing new tools to prevent infection - including one-pill-a-day pre-exposure prophylaxis and vaginal gels and creams that cripple HIV - will yield results in the next few years. And an infusion of more than $700 million dollars combined from the US National Institutes of Health and the Bill & Melinda Gates Foundation is reinvigorating the hunt for a vaccine for HIV/AIDS. People who have been on the front lines of HIV research from the beginning are still in full investigational mode. Robert Gallo, Bruce Walker, David Baltimore, Jay Levy, David Ho and many others remain hard at work, and in the following pages share the lessons they take from hindsight as well as their best guesses to what the future holds for the next 25 years.