A History of HIV/AIDS Crisis: Global and National Contexts

I. Detection

In 1981, a rare form of pneumonia appeared in five young, previously healthy, gay men in Los Angeles. They also had the fungal infection candida, or thrush—most often seen in babies. At the same time, there were reports of men in New York and California with an unusually aggressive form of a generally benign skin cancer. On June 5th of that year the U.S. Centers for Disease Control (CDC) reported on these unusual clusters in its newsletter [1]. Over the following months, more of these disease clusters were discovered across the country, along with cases of generalized but abnormal inflammation of the lymph nodes. All of these are known as opportunistic diseases—diseases that occur more often or are more severe in people with weakened or compromised immune systems. By the end of the year, there were 337 reported cases of severe immune deficiency in the United States resulting in 130 deaths.

In June of the following year, a group of cases among gay men in Southern California suggested that the transmission of the immune deficiency was sexual. The syndrome was initially called Gay-Related Immune Deficiency. Soon, however, the disease was reported in heterosexual Haitian immigrants, hemophiliacs, recipients of blood transfusions, and intravenous drug users. In September of 1982, the CDC used the term “Acquired Immune Deficiency Syndrome” (AIDS) for the first time, defining it as, “a disease at least moderately predictive of a defect in cell mediated immunity, occurring in a person with no known case for diminished resistance to that disease.”[2] Initially, eleven opportunistic infections and diseases were considered specific enough to be diagnostic for AIDS. Cases of the illness were also reported in the Caribbean, Africa, and Europe. A global epidemic had begun that, forty years later, continues to kill nearly one million people every year.

II. Calculation

A. Global

According to the Joint United Nations Program on HIV/AIDS (UNAIDS) 75.7 million people have become infected with HIV since the start of the epidemic in 1981. In that same period 32.7 million people have died from AIDS-related illnesses. Globally, new HIV infections peaked in 1998 and AIDS-related deaths peaked in 2004.

Despite this apparent success in decreasing levels of infection and death, in 2019 (the last year for which statistics are currently available) around 1.7 million people were newly infected with HIV and around 690,000 people died from AIDS-related illnesses worldwide. Nearly forty-three million people globally are living with HIV in 2021.[3]

B. National

The United States Department of Health and Human Services (HHS) and the CDC report that, in the United States, more than 700,000 people have died of AIDS since 1981. As of 2018 there were more than 1.2 million people living with HIV. That same year 37,968 people received an HIV diagnosis, while there were 15,820 deaths among people diagnosed with HIV.

HIV continues to have a disproportionate impact on certain populations. People from ethnic minority groups make up eighty-eight percent of all new cases. Young people aged 25-34 have the highest rate of infection, making up nearly one-third of all new cases. The economically disadvantaged have a far higher incidence of infection. The CDC states, “The lower the income, the greater the HIV prevalence rate."[4] Gay men account for sixty-nine percent of all new cases. The highest rates of new diagnoses occur in the southern states [5].

C. Local

Over 50,000 North Carolinians have been diagnosed with HIV, according to estimates compiled from the North Carolina Department of Health and Human Services (NCHHS).[6] As of 2019, there were 38,400 people living with HIV in North Carolina. That same year 1,383 people were newly diagnosed with HIV/AIDS in the state.[7]

According to the CDC, North Carolina has the seventh highest rate of new diagnoses among US states.[8] Additionally, the CDC ranks the Charlotte metropolitan area (which includes the Belmont-Gastonia corridor) among the worst twenty-five percent of metropolitan areas in the nation for new HIV infections.[9] Because of this infection rate, Mecklenburg County is the target of an eradication program called “Getting to Zero Mecklenburg.”[10] However, in the southern United States, one quarter of new cases are identified in suburban or rural areas. Therefore, the state of North Carolina has allocated funds to expand Mecklenburg’s program of medical services and medication assistance to Gaston, Cabarrus, Union and Anson counties.[11]

III. Manifestation

Long before the symptoms of immunodeficiency were detected among men in California, before they spread to people in the cities and towns of North Carolina, it is likely that somewhere between 100,000 and 300,000 people, mostly in Africa, contracted the HIV virus. In or around the year 1908, in or near a wedge of land between two rivers in what is today Cameroon—and was then the German colony of Kamerun— the Simian Immunodeficiency Virus (SIV) was transferred from a chimpanzee into a human being through blood-to blood-contact, probably while hunting, creating the Human Immunodeficiency Virus (HIV). The virus began to spread slowly through human sexual contact along river, forest, and road networks. However, studies of variants of the virus reveal that this was not the first, nor the only, time the virus was transferred from a chimpanzee to a human being. In fact, there have been at least twelve, and probably many more, instances of cross-species transmission of HIV. In these other cases, spread of the virus was limited and halting, perhaps even dying out among its human hosts. This case would be different. The difference was Western colonialism.

The virus spread downriver to the cities of Brazzaville and Léopoldville (today Kinshasa) built as the respective capitals of French Equatorial Africa and the Belgian Congo, facing off against one another across the Congo River. The European colonial powers promoted single-crop agriculture, resource extraction, and urbanization that led to increasingly concentrated populations. The majority of the labor force was male. This disrupted traditional customs around marriage and family, leading to more casual sexual activity with an increased number of partners. The women in the developing urban areas, though smaller in numbers and in percentage of the population, were also somewhat liberated from traditions regulating their behavior. Many remained unmarried or divorced for long periods. Some turned to sex work, which was encouraged by colonial authorities. Moreover, forced labor camps had poor sanitation, meager diets, and grueling labor demands, creating a perfect storm of conditions for the development of weakened immune systems. The workers on colonial enterprises supplemented their diet with wild game, which contributed to an increase in hunting that was exacerbated by the growing availability of firearms and the environmental disruptions caused by colonial exploitation. This likely led to further incidence of human exposure to SIV.

Even well-meaning attempts to vaccinate people against smallpox, dysentery, and sleeping sickness may have had catastrophic consequences. Multiple injections to hundreds or thousands of people were administered with only a handful of syringes. One 1916 sleeping-sickness control expedition treated 89,000 people using just six syringes. Although the importance of sterilization techniques were well-understood, they were not applied to African populations. Transfer of pathogens was inevitable. Serial inoculation against smallpox—relying on the derivation of new vaccines from the pustules that grew upon recently vaccinated people—possibly led to further spread of the virus. The technique had been abandoned in Europe twenty years before, as the likelihood of infectious transmission was well-known. It was still used in the African colonies. (A theory suggesting tainted oral polio vaccines may also have helped to spread the HIV virus has been largely, but not entirely, discredited.) Despite the growing numbers of people who were infected with HIV during this period the virus remained undetected given the high mortality rates, rudimentary or nonexistent health care, and wide range of opportunistic diseases across colonial central Africa. What is certain is that, by the late 1950s, Africans were contracting HIV and dying of AIDS.

IV. Expansion

On the 30th of June, 1960, the rapacious Belgian government reluctantly relinquished the Congo. Belgian administrators abruptly departed in droves. Their departure created a huge vacuum in the newly independent nation, as the Belgian administration had specifically avoided educating its subjects or developing the structures of a functioning state. There were no Congolese doctors and very few teachers. Outsiders had to be recruited as physicians, educators, and lawyers, functionaries, administrators, and professionals. Many came from Haiti, already speaking French, proud of their African roots, and with few opportunities at home. Close to five thousand Haitians took up positions in the Congo, the second largest contingent of foreigners serving in the country. The turmoil of the early years of independence led to the US-sanctioned assassination of the first prime minister, Patrice Lumumba, the adoption of the name Zaire for the country, and the rise of the US-backed dictator, Joseph Mobutu Sese Seko. It also led to the exit of most Haitians from the country by the early 1970s. Some of those who returned home to Haiti brought HIV with them.

The disease spread rapidly through the Haitian population. Later studies of five hundred young Haitian mothers revealed that by 1982 almost eight percent of them had been infected with HIV. At the same time, Americans began harvesting Haitian blood for the growing American market for plasma. Haitians were paid three dollars per liter to undergo a process that filtered out the liquid plasma while returning the rest of the blood cells to the patient. It did not filter out blood-borne viruses. Patients could be infected by the blood of others undergoing the procedure. They could also pass along any infection to those who were ultimately transfused with the plasma. One company, Hemo-Caribbean, exported sixteen hundred gallons of plasma to the United States monthly in 1971. This plasma was used by American hemophiliacs, many of whom ultimately died of AIDS. Meanwhile, Haitian migration to the United States, particularly to Miami, was increasing. Haiti itself was also a sex-tourism destination for gay men. Sometime between 1966 and 1972, genetic sequencing of HIV reveals, the virus migrated, one way or another—from an infected person, or infected plasma—into the United States, first to New York City, then, by 1976, to California.[12] [13]