By John Phair, MD
Artwork by Michelle Chabla.
In the spring of 1981 I was asked to see a patient with Kaposi’s sarcoma (KS) by the oncologists at Northwestern. The gentleman had been diagnosed at the Mayo Clinic, where a second diagnosis of Whipple’s disease had also been established by a bowel biopsy. He had a low-grade fever; the oncologists wished to start chemotherapy and asked if there was any infectious disease problem which prevented treatment of the KS. The patient was receiving tetracycline for the “Whipple’s disease” and there was no other obvious source of fever. He received one dose of cytoxan and developed a bilateral interstitial pneumonia. Bronchoscopy established the diagnosis of pneumocystosis and appropriate treatment was initiated, yet the patient died within several days. This series of events had no explanation and I was perplexed. In June of 1981 the CDC reported five similar cases in Los Angeles—all previously healthy young men who had sex with men, and each with a profound disturbance of his immune system. I asked the primary physician of our patient if he knew the gentleman’s sexual preference and he stated that he was gay. In retrospect, this man had been the first patient with AIDS seen at Northwestern Memorial Hospital (NMH). He had KS and pneumocystosis. Probably the rods noted in the colonic biopsy were Mycobacterial of the Avian Complex, not Tropheryma whipplei.
By the middle of the decade, ten percent of the medical beds at NMH were filled by men with AIDS. Dr. Robert Murphy, who joined the Infectious Diseases faculty to help with care of these patients in the mid-1980s, signed the most death certificates of any member of the medical staff. The impact of this epidemic changed to a large extent the focus of many of the NU Infectious Diseases faculty. Prior to AIDS we functioned as consultants, but now we were primary care physicians for patients with AIDS. We had nothing to offer these patients except management of complications of the immune deficiency—and compassion.
The epidemic arrived in Chicago later than on either coast. In 1986, we retrospectively assayed for evidence of HIV infection in sera collected between 1982-83 from approximately 80 men who had sex with men. From this cohort, only ten percent had antibody to HIV. One year later, in 1984, after we recruited 1100 men who had sex with men for the Multicenter AIDS Cohort Study, we found that forty percent of them were infected with the virus. Initially in Chicago the infection appeared to be localized to the white gay community and focused in the near north side. Soon, however, it became apparent that persons city-wide who injected drugs (IDUs) were infected, as were their sexual partners. With the spread of infection to women, it became apparent that infected pregnant women could infect their children either during childbirth or in utero. It also was recognized that blood products were infectious.
The Chicago Department of Health established an Advisory Committee to help plan a response to this epidemic. With the availability of Ryan White funds from the Federal Government and the opening of the CORE Center by Cook County Hospital and Rush University, a county-wide system of care was developed. The majority of medical centers in Chicago established clinics to care for HIV-infected persons and devised appropriate policies to prevent accidental infections of personnel and patients. At NMH, the administration was extremely supportive and developed a plan to care for HIV-infected persons in the hospital and in the newly established Infectious Disease clinic.
A number of Chicago infectious disease specialists participated in programs to help defuse concern (and often panic) among Chicagoans. Programs to educate police, firemen, EMTs, and school officials were undertaken. Individual physicians spoke at schools when concerns regarding the presence of infected children in class arose.
In 1987, azidothymidine (AZT) was rapidly approved by the FDA and there was hope that treatment would now be available for the viral infection. However, this agent was of limited efficacy and extremely toxic in doses used at first. Even with dosage reduction, nausea, anemia and myopathy presented problems for treated patients. In that year Northwestern, Rush, and later Cook County Hospital received funding from the National Institute of Allergy and Infectious Diseases to establish the Chicago AIDS Clinical Trials Unit. This was a component of the AIDS Clinical Trials Group (ACTG), a network of medical institutions in the US which evaluated therapies for HIV infection and its complications. The contributions of the ACTG included improvement in the management of peumocystosis, development of strategies to prevent infectious complications of HIV infection, improved treatment for KS and HIV-related non-Hodgkins lymphoma, prevention of maternal transmission of HIV to the child, and most recently refinement of the use of combined antiretroviral agents to suppress viral replication and partially restore immune function.
Although no cure is available, the story of AIDS has been one of success in developing methods of managing HIV infection and its complications. However, with prolongation of survival, diseases of aging including cardiovascular disease, diabetes, liver disease and kidney disease are appearing at an increasing rate in HIV-infected individuals. Moreover, it is estimated that close to a quarter of those infected in the US are unaware of their infection and serve as a source of new infections. In Chicago, as in the nation, there is a need to address this problem using innovative approaches that are sensitive to the different cultural characteristics of the persons at risk.
About the Author
John Phair, MD, joined the faculty of Northwestern Medical School in 1976 as director of the Division of Infectious Diseases. He led the Multicenter AIDS Cohort Study (MACs), an NIH-funded observational epidemiologic investigation of HIV infection and disease in men who have sex with men, from 1984 until 2012. From 1992 to 1994, Dr. Phair served as Chair of the Executive Committee of the AIDS Clinical Trials Group (ACTG), a network of academic centers evaluating antiretroviral therapy. In 2000 he stepped down as director of the Division of Infectious Diseases and assumed Emeritus status, but he continues to participate as an investigator in the MACS.