Lessons from another pandemic
Thirty-five years ago, a different pandemic hit Cape Cod, with lessons that reverberate through our current battle with COVID-19.
In the early 1980s, doctors began identifying HIV and the disease it caused, acquired immunodeficiency syndrome, or AIDS, as it is best known. The disease interfered with the body’s ability to fight infection. By 1998, Provincetown had the highest cumulative AIDS case rate in the state, according to that year’s Community Health Needs Assessment Project, produced by Barnstable County.
Decades later, there are effective treatments for HIV and AIDS but no vaccine, and both are still with us. From 2014 to 2018, there was an average of 8.2 cases per 100,000 population of HIV in Barnstable County, according to the commonwealth’s Bureau of Infectious Disease and Laboratory Sciences. In comparison, as of Sept. 23, all towns on Cape Cod had a COVID-19 rate of under 4 cases per 100,000, according to the Barnstable County Department of Health and Environment.
The HIV/AIDS experience was different from COVID-19 in many ways, but current and retired Cape Cod Healthcare infectious disease experts say there are similarities that are instructive to caregivers treating the new virus. For example, in any pandemic, the two most important weapons are testing and treatment, said Valerie Al-Hachem, director of the Infectious Disease Clinical Services Department at Cape Cod and Falmouth hospitals and one of the organizers of the HIV clinics at both hospitals.
Between 14 and 17 percent of people living with HIV don’t know they are infected, yet are responsible for up to 50 percent of new transmissions, she said. The best strategies to stop viral transmission, in line with federal guidelines, are universal testing followed by treatment, she said.
“There are great medications out there,” Al-Hachem said. “If people adhere to the medication, and we find the right match, and they keep taking them, that will have the effect of bringing the viral load down to undetectable levels.”
Science has shown that at least with HIV, undetectable equals un-transmittable, she said.
“It’s a message that needs to get out more to the public, because just as with any epidemic, it’s the stigma and discrimination that ends up killing,” she said.
COVID requires the same approach, she said. “You have to know who has it. You have to know who’s exposed to it. You have to nonjudgmentally make testing services and treatment services accessible to those people who either have it or have been exposed. That’s how you don’t just flatten the curve, you bend the curve to zero.”
She defines the goal as “90,90,90.”
“You want 90 percent of people who have the infection to be identified. You want 90 percent of the people who are identified to be in care. And, you want 90 percent of people on medication to be virally suppressed.”
Nationally, with HIV/AIDS, she said, “we’ve been making steady progress.”
One big difference between COVID and HIV is the rapidity with which the COVID genome was identified, said Laurel Miller, MD, the former head of the infectious disease unit at Falmouth Hospital and Cape Cod Hospital. Dr. Miller was a social worker before becoming an infectious disease physician. She first moved to Massachusetts to work with HIV/AIDs patients at the Greater New Bedford Community Health Center, where an infectious clinic is named in her honor.
“Science has evolved so rapidly that we now have the capability to sequence a whole genome in a day. Back then, it took years,” she said. “But the parallels are obviously that until you have adequate testing, you couldn’t really come up with a meaningful diagnosis. And, without a diagnosis, you really couldn’t start to do the epidemiology to figure out how the disease was transmitted.”
The increased speed of epidemiological investigations, as well as the number of COVID patients, may make it easier to do studies on treatments or vaccines for COVID-19 than in the era of HIV, she said.
“With HIV, even though it seemed like there was so much disease, it was hard to put together a clinical trial that would show effectiveness within a few months,” Dr. Miller said
Like COVID, the HIV/AIDS battle has been political, due to the stigmas of sexual transmission and prevalence among gay men and intravenous drug-users, Dr. Miller and others said. As with the coronavirus, there was a lot of fear and misunderstanding in the beginning. But organizations like the AIDS Support Group of Cape Cod did a good job of advocating for funding and local support, keeping the issue in the public eye, and promoting preventives such as safe needle exchanges and condom distributions, she said.
The Cape’s response to HIV/AIDS became more focused in 2000 after Cape Cod Hospital received a Ryan White planning grant from the federal Health Resources and Services Administration, said Diane Marino, the first director of the Infectious Disease Clinical Services department, IDCS, at Cape Cod Hospital and the other co-founder of the HIV clinics in Hyannis and Falmouth. The grants are named after an Indiana teen who died in 1990 of AIDS contracted from a blood transfusion.
The grant, the formation of the IDCS department at Cape Cod Healthcare, and the opening of HIV clinics sparked an evolution in public health, she said, in the way the health system responded to public demand. It also put infectious disease doctors in the spotlight, a discipline that is often in the wings, Marino said.
“I think they are undervalued physicians as a specialty,” she said.
Not so coincidentally, the leaders during the HIV/AIDS pandemic were some of the same experts we are relying on now, such as Dr. Anthony Fauci, said Dr. Miller.
Even as infectious disease experts focus on COVID, we are still fighting HIV/AIDS, noted Al-Hachem. For now, physicians have to document verbal consent for an AIDS screening, but she would like to see it be part of routine blood work.
“We still have people admitted to the hospital that are getting simultaneously diagnosed with HIV and AIDS,” she said. “Each time, it’s tragic.”