When did AIDS become a manageable disease?

Factual Questions
1

I started wondering because I was watching a clip of Brian May discussing the last days of Freddie Mercury.

I looked up that Freddie died in November 1991 and also Magic Johnson announced that he was HIV positive in November 1991. I remember my cousin telling me about magic and thinking “damn, he’s gonna be dead in just a few years”. But he’s still with us 33 years later. I know there is a big difference between HIV positive and full blown AIDS, but were we really much closer to effective treatments in 1991 than lay people realized? In other words, if Freddie Mercury had managed to somehow hold on for another year or so, might he be alive and relatively healthy today?

2

It would depend on the stage of the illness, the prescribed cocktail of drugs given and the long term compliance with the regimen. Who knows?

My brother was diagnosed in the early 1990s and lived until 2008 when he took his own life. He was on a cocktail of very powerful drugs which could have conceivably kept him alive for many years had his mental health not deteriorated significantly.

3

In 2024, how dependent is survival on the stage of the illness? Is survival still dependent on early detection followed by the drug regimen or are we at the point where a person in the late stages can be brought back to just being HIV positive?

Also, in the late 90s or so when it began to be seen as a manageable illness, I remember hearing that the drug cocktail was outrageously expensive. Is that still the case or are there now generics where treatment is affordable to anyone with decent health coverage?

4

If you see from here the survival rate of people with AIDS goes up dramatically if they receive HAART (highly active antiretroviral therapy).

Two, 4-, 6-, 8- and 10-year survival probabilities of progression from AIDS onset to AIDS-related death in patients who received HAART were estimated to be 87%, 86%, 78%, 78%, and 61%, respectively, and 2-, 4- and 6-year survival probabilities of progression from AIDS onset to AIDS-related death in patients who did not receive HAART were estimated to be 48%, 26% and 18%, respectively.

As to how that therapy was developed, here is a long explanation.

But you are asking about when it became available, and AIDS became more manageable.

The FDA approved the first three protease inhibitors — saquinavir (Roche), indinavir (Merck), and ritonavir (Abbott’s Norvir®) — in late 1995 and early 1996. By 2000, Abbott (which spun off its pharmaceutical business as AbbVie in 2013) developed another protease inhibitor, lopinavir, and earned approval for use in children. And the company combined its two protease inhibitors in one drug, called Kaletra®. Today at least 10 protease inhibitors have been approved by the FDA.

So 1995 was when this kind of therapy was available to people, and it improved further in 2000.

As to whether or not it’s expensive, yes it is.

One study estimated that costs of this care could run anywhere between $1,800 to $4,500 each month during a person’s lifetime. Most of this, about 60%, comes from the high cost of ART medications.

Though the article goes on to explain ways to potentially lower costs, either by finding a generic version of one or more drugs, or getting insurance to cover some of it, or reaching out to organizations designed to help, the bottom line is that this is very expensive.

5

Great response. I never kept up with AIDS treatment after my brother died. It seems like a very manageable condition now.

AIDS in the late 1980s/early 1990s was a truly harsh experience. My brother lost so many of his friends at the time and he suffered some life threatening opportunistic infections until the improved treatments became available.

We were lucky to live near the University of Pittsburgh which had an awesome clinic set up at the time.

My father supported my brother through the ordeal but there were some difficult times with extended family members.

6

Very much so.

7

I think also - not a doctor - it seems that the course of many epidemics is that a disease bursts onto the scene with very strong ssymptoms, some variants cause death very quickly. Possibly it’s selective, that the variants of the disease that kill the host quickly are less likely to survive to pass on; the variants with less intense symptoms, the host survives longer to pass on to others. We saw the same with Covid, when it first appeared many of the victims died from it. Today, infections seem less severe (but not to be disregarded).

Of course, treatments - drugs, vacccines - also play a role in mitigating the lethality.

8

That does happen, but it’s a much slower process than that. From what I understand, the fact that later variants of covid were less deadly than the original strain was more due to luck than to natural selection. And HIV, with its long incubation times, would be even slower to evolve. Medical treatments, meanwhile, can evolve much more quickly: Even going from “what the Hell is this thing!?” to “This is the same thing those other patients had” can mean significant improvement in outcomes.

A friend of mine has it, and from what I understand, he’s gotten to the point where his hemophilia is much more significant to his life than HIV.

9

My point would be… those who caught aids and died in less than a year (presumably onset of symptoms within a few months) were less likely to transmit, while those with lesser strains were transmissible but not obviously sick for longer periods. Aids symptomless and infectious went from months to years. (And skipped to addicts using injection, who were less likely to be tuned to medical help.)

Covid, for example was transmissible for two days or more before symptoms appeared. Lesser symptoms also allowed those patients to wander around freely, spreading the virus longer.

An epidemic usually means something has suddenly hopped into a whole new host who has not developed any immunity, and it can spread like wildfire. A particularly lethal virus sort of limits its own opportunities to spread. There’s selection at work.

But yes, human behaviour - things like medicines, quarantines, etc. - tend to be a valid response to epidemics making them less likely to spread. But that is precisely when more stealthy variants do better.

10

Right, I got your point. The process you describe is real. It just takes longer than you suggested.

11

In 1999, my son got a degree from MIT and I went to the graduation. One of the two main speakers was David Ho, noted AIDS researcher and the main thrust of his talk was that HIV was now a manageable chronic disease. (The other main speaker was Bill Clinton. The security was awesome.)

12

Nearly 400,000 people a year die from AIDS-related illnesses, almost entirely in developing nations and primarily in Africa. I’d say we’re still a long way from “manageable.”

13

That proves it’s not managed. That doesn’t mean it’s not manageable.

14

Yeah, we have treatments and preventatives now that work really well. Now we just need to get those treatments and preventatives out to the people who need them.

15

I was in high school and college 1981 - 1990. I was a virgin until I was almost 19 (and in college), and HIV had a lot to do with that decision. First guy I slept with, I made get an HIV test. I got one too as a “good faith” act. We still used condoms.

I also lived in Indiana at the time, and I followed the Ryan White story very closely.

Magic Johnson found out he was HIV positive as the result of a test he was given when he applied for life insurance.

Freddie Mercury found out because he got an AIDS-related illness.

1981 was the year of lots of diagnoses, and AIDS dominating the news. I remember thinking that unless being gay was not only genetic, but made you susceptible to a virus straight people were immune to, it would eventually be everybody’s problem. My money was on the latter.

There was a test in 1985 that the Red Cross began using, and insurance companies were using, but people who suspected they had been exposed were not getting, because it wasn’t available. The Western Blot test came out in 1987, and the rapid test in 1992.

The 1985 ELISA test peroduced a lot of false positives, which was good enough for the Red Cross, but not for testing asymptomatic people. It still took an illness to get a diagnosis. It was the Western Blot that started individual testing.

Freddie Mercury I think, was positive for quite a long time before informing the public-- he informed the press only the day before he died. But I don’t know whether he was disgnosed by the Western Blot, or a related illness.

Magic Johnson was asymptomatic, and his sample was tested by the insurance company, most certainly using the Western Blot.

Mainly preventatives. There are a lot of cultures that simply WILL NOT use condoms, despite their availability, and have high rates of infection.

16

How bad lack of condom use is depends on other sexual habits. And the problem gets especially bad when you have myths circulating around, like that sex with a virgin will cure AIDS.

17

IIRC, there was also at the time the stigma of “getting tested” without asking why. Some early on associated getting tested with the likelihood you did have AIDS or had the relevant lifestyle and treated people accordingly. I.e. some insurance and employment questionnaires asked if you had ever been tested for AIDS?

(Isaac Asimov apparently contracted AIDS from a blood transfusion when he had heart surgery. The family never admited it until long after he died because of the stigma)

18

As noted, Freddie had already been quite ill with AIDS for several years by 1991; it appears that he first had AIDS symptoms (a lesion on his tongue) as early as 1982, and according to his partner, Jim Hutton, he was diagnosed with AIDS by 1987. By that time, there were frequent rumors about his health (as he became increasingly thin), which he and his bandmates consistently denied (though the rest of Queen likely knew the truth by around 1986 or 1987).

Johnson learned he was HIV positive a few weeks before Mercury died, but he was, AFAIK, not yet suffering from AIDS. My understanding (and someone please correct me if I’m wrong) is that the HIV drugs, particularly what was available in the early-to-mid 1990s, were of more use for someone who had HIV, but who had not yet developed full-blown AIDS.

So, given that, my understanding is that, even if Freddie had managed to “hold on for another year or so,” it still wouldn’t have made a difference, as I don’t think that the medications would have been able to help someone with advanced AIDS.

19

There have been three cases where someone after years of treatment for HIV has quit taking that treatment and has continued to live for many years. One was in 2006, one was in 2019, and one was in 2022. This doesn’t necessarily mean that there is no longer any HIV viruses in their body, just that it has become impossible to detect any of them there anymore. There are nine cases where HIV was detected and then without any treatment the HIV virus in their body has been undetectable for years:

Cases of HIV cure | aidsmap.

20

In the early 1990s, average mortality from time of diagnosis (HIV or AIDS, probably since many didn’t get diagnosed and treated on the early end of this or were asymptomatic) was in 6 months without treatment, and 2 years with treatment. HAART (highly active anti-retrovirus therapy) became available in 1996 and was much more effective (and by that time, there were more effective treatments for some of the opportunistic infections as well). However, by 1996, all of my friends who had acquired HIV before the virus was known were dead.