Kaposi's Sarcoma and PCP in Homosexual Men

The first cases of the disease that would come to be known as AIDS came to light as early as October 1980, when Kaposi's sarcoma (KS) was diagnosed in several young homosexual men in Los Angeles. These and similar cases (21 in all) were reported in the following year (CDC, MMWR, June 5, 1981). Shortly thereafter, on July 3, 1981, the CDC reported five new cases of PCP in homosexual men in New York City, Los Angeles, and San Francisco (CDC, MMWR, July 3, 1981). Both KS and PCP are opportunistic infections that occur in individuals with severely weakened immune systems. In addition to reported cases of these diseases, there was an unusual increase in requests made to the CDC for a drug called pentamidine that is used for the treatment of PCP. At the time, this drug could only be dispensed through a physician's request to the CDC (Curran, Evatt interviews). With the possible outbreak of a new infectious disease in the United States coming to the attention of public health officials, the CDC established a task force in July 1981 to monitor the cases of opportunistic infections, to investigate additional cases, to formalize a definition of the disease, and to design a case/control study to examine the prevalence and epidemiology of the disease. The task force was headed by James Curran, chief of CDC's Venereal Disease Control Division (Curran, Foege interviews).

Because the early cases appeared in the gay community, the new disease was first called "gay-related immunodeficiency disease" (GRID). Many scientists and public health officials initially hypothesized that behavioral elements of the homosexual lifestyle (multiple sex partners, for example) were the cause. Another early theory was that "poppers" (amyl nitrates), drugs frequently used by some gay men to enhance sexual pleasure, were the cause (CDC, MMWR, June 18, 1982).

Opportunistic Infections Among Heterosexual Intravenous (IV) Drug Users and Haitian Immigrants

In June 1982, the CDC reported 355 cases of opportunistic infections, with an increase in the number of heterosexual patients, particularly among IV drug users. According to the report, "a laboratory and interview study of the heterosexual patients [was] in progress to determine whether their cellular immune function, results of virologic studies, medical history, sexual practices, drug use, and lifestyle [were] similar to those of homosexual patients" (CDC, MMWR, June 11, 1982). One month later, the CDC reported 34 cases of opportunistic infections in Haitian patients. The pattern of infections was "similar to the pattern recently described among homosexual males and IV drug users" (CDC, MMWR, July 9, 1982).

On July 16, 1982, the CDC reported the first three cases of PCP among individuals with hemophilia. All three were reported to be heterosexual males. At this time, the CDC postulated that the immune dysfunction symptoms were transmitted through blood and blood products:

The clinical and immunologic features these three patients share are strikingly similar to those recently observed among certain individuals from the following groups: homosexual males, heterosexual IV drug users, and Haitians. Although the cause of the severe immune dysfunction is unknown, the occurrence among the three hemophiliac cases suggests the possible transmission of an agent through blood products [CDC, MMWR, July 16, 1982].

On the same date, the FDA's Bureau of Biologics convened a meeting to discuss opportunistic infections in hemophiliacs. The meeting included representatives from the CDC, the National Hemophilia Foundation (NHF), the American Red Cross, the American Blood Resources Association (ABRA) (who represented the plasma fractionators), and the National Institutes of Health (NIH). The CDC presented an update of the epidemic of opportunistic infections, noting that the one common thread among all groups affected (i.e., homosexual men, IV drug users, Haitians, and individuals with hemophilia) was the presence of markers for hepatitis in more than 90 percent of each group (Hansen 1982).

In conjunction with the first cases among hemophiliacs, CDC Director William Foege asked public health officials to inform physicians caring for patients with hemophilia about the three cases of PCP among patients with hemophilia. He wrote to inform state and territorial health officers, industry representatives, the Assistant Secretary for Health, the FDA Commissioner, the Director of NIH, and all CDC regional offices that the CDC was conducting surveillance of the new disease and gathering additional information to determine the significance of the incidence reports. In addition, he asked physicians to immediately report cases of opportunistic infections or suspected acquired immune deficiency through state health departments to the CDC (Foege 1982a).

At the July 16, 1982, PHS meeting, a Committee on Opportunistic Infections in Patients with Hemophilia was established to exchange information about the cases, to characterize their similarity to other risk groups, and to conduct surveillance of both hemophilia cases and antihemophilic factor (AHF) concentrate (Public Health Service July 1982). The committee held its second meeting on July 27, 1982; representatives from the PHS, CDC, FDA, NHF, ABRA and NIH attended. The committee, chaired by Dr. Foege, adopted the term "acquired immunodeficiency syndrome" (AIDS), and decided to focus on two goals: to determine if the underlying immunodeficiency seen in hemophiliacs had the same etiology as in other groups with acquired immunodeficiency, and to determine if certain blood products were risk factors for AIDS (Foege 1982b) (see further discussion below).

By September 1982, 593 cases of AIDS had been reported to the CDC. Of these cases, 445 of the patients were homosexual men, 77 were IV drug users, 36 were Haitians, 3 were hemophiliacs, and 32 had no defined risk; 41 percent had died (CDC, MMWR, September, 24, 1982). In an editorial note, the CDC defined AIDS as:

… a disease, at least moderately predictive of a defect in cell-mediated immunity, occurring in persons with no known cause for diminished resistance to that disease. Such diseases include Kaposi's Sarcoma (KS), Pneumocystis Carinii Pneumonia (PCP), and other serious opportunistic infections. … This case definition does not include the full spectrum of AIDS manifestations, which range[s] from absence of symptoms, to specific diseases that are insufficiently predictive of cellular immune deficiency to be included in incidence monitoring [CDC, MMWR, September 24, 1982].

The reference to an "absence of symptoms" suggests that as early as the autumn of 1982 researchers were beginning to establish that the new disease might have had an asymptomatic incubation period.

Increased Risk Among Individuals with Hemophilia and a Similarity to Hepatitis B

In a December 10, 1982, update on AIDS among patients with severe hemophilia A, the CDC reported that all three of the cases reported in the July 16, 1982, MMWR had died and that, in the intervening four months, four additional confirmed cases and one suspected case of AIDS in heterosexual patients had been reported. Two of the patients were children under 10 years of age. In an accompanying editorial note, the CDC stated that the hemophilia patients had all received large amounts of a commercially manufactured anticoagulant known as AHF (antihemophilic factor). None of the patients had any prior opportunistic infections, all had been profoundly lymphopenic, and all had exhibited reversed ratios of CD4:CD8 lymphocytes. According to the CDC, these cases provided a new perspective on AIDS by showing that children with hemophilia were at risk for the disease. The report also stated that the number of cases was continuing to increase and that patients with hemophilia might be at significant risk for AIDS. The CDC also reported that a national survey of hemophilia treatment centers had determined that 30 percent or more of all hemophiliacs had abnormal immunological tests. The coincidence of symptoms of AIDS and serologic evidence of hepatitis in the individuals with hemophilia added weight to the theory that AIDS was a disease with a pattern of transmission that mimicked that of hepatitis B (CDC, MMWR, December 10, 1982).

By December 1982, a total of 788 AIDS cases had been reported. Of the 788 reported cases, 42 (5.3 percent) belonged to no known risk group (e.g., homosexuals, IV drug users, hemophiliacs, and Haitians). Two of the 42 cases with no known risk factors were patients who had received blood products (not related to the treatment of hemophilia) within two years of the onset of AIDS (CDC, MMWR, December 10, 1982).

Further Evidence of Sexual and Blood-Borne Transmission of AIDS

The December 10, 1982 MMWR also reported a suspected case of transfusion-associated AIDS in a 20-month-old San Francisco infant who had none of the known risk factors for AIDS. One of the 19 donors of the blood components received by the infant during his first month of life was subsequently reported to have AIDS. The report suggested that blood transfusion was the means by which the infant had acquired AIDS. In an accompanying editorial note, CDC stated that

… if platelet transfusion contained an etiologic agent for AIDS, one must assume that the agent can be present in the blood of a donor before onset of symptomatic illness and that the incubation period for such illness can be relatively long. This model for AIDS transmission is consistent with findings described in an investigation of a cluster of sexually related AIDS cases among homosexual men in southern California [CDC, MMWR, December 10, 1982].

One week later, the CDC reported four additional cases of AIDS in children (all less than two years old) (CDC, MMWR, December 17, 1982). None of the four infants were known to have received any blood or blood products. The mother of one was a prostitute and IV drug user; two were the children of Haitian immigrants; and one was the child of an IV drug user mother who had died of immune deficiency. According to the report, although the nature of the immune function described in the four cases was unclear, it was possible that these infants had AIDS and that the death of one of the mothers from PCP was probably secondary to AIDS. The CDC further stated that although the etiology of AIDS remained unknown, a series of epidemiological observations suggested it was caused by an infectious agent (CDC, MMWR, December 17, 1982).

The similar patterns of transmission of AIDS and hepatitis B and the latency period in both diseases led the medical and scientific community to discount the hypothesis that "poppers" were the cause of AIDS (CDC, MMWR, November 5, 1982; Panem 1988). A few months later, some physicians, scientists, and consumers of blood and blood products endorsed the theory that blood products may be transmitting the infectious agent. Others, however, were unconvinced and continued to hypothesize that the cases in hemophiliacs may have been due to immune suppression from using AHF concentrate (FDA, BPAC, 1983; Foege 1983; Aledort, Bove, Osborn interviews). They were skeptical because of the small number of known diagnosed cases among hemophilia patients compared to the number who were exposed to blood products.

Evidence for heterosexual transmission of AIDS appeared on January 7, 1983, when the CDC reported immunodeficiency in two female sexual partners of men with AIDS. The editorial note contained in this MMWR stated that

… epidemiological observations increasingly suggest that AIDS is caused by an infectious agent. The description of a cluster of sexually related AIDS patients among homosexual males in southern California suggest[s] that such an agent could be transmitted sexually or through other intimate contact. The present report supports the infectious-agent hypothesis and the possibility that transmission of the putative "AIDS agent" may occur among both heterosexual and male homosexual couples. At this time, CDC has received a total of 43 previously healthy females who have developed PCP or other opportunistic infections typical of AIDS [CDC, MMWR, January 7, 1983].

On the same date, the CDC also reported on the occurrence of AIDS in 16 prison inmates. All inmates were reported to have had a history of chronic IV drug use. The report added weight to the hypothesis that AIDS was caused by an infectious agent transmitted sexually or through exposure to blood or blood products (CDC, MMWR, January 7, 1983).

Summary

By January 1983, epidemiological evidence from CDC's investigations strongly suggested that blood and blood products transmitted AIDS and that the disease could be transmitted through intimate sexual contact. The evidence that the AIDS agent was blood-borne was the result of two findings. First, AIDS was occurring in transfusion recipients who did not belong to any known high-risk group and in individuals with hemophilia who had received AHF concentrate. Second, the epidemiological patterns of AIDS was similar to that of hepatitis B, another blood-borne disease.

The CDC's Public Meeting

The purpose of the public meeting on January 4, 1983, was to identify opportunities to prevent AIDS. The CDC's objectives for the meeting were to tell the blood services community about the evidence they had gathered; to enlist the help of other PHS agencies, especially the FDA; and to formulate recommendations for the prevention of AIDS. According to data presented by the CDC, the manifestations of AIDS appeared 4–17 months after transmission of infection (Foege 1983).

The meeting produced a great deal of debate but no consensus on specific action (Bove, Curran, Evatt, Francis, Foege, McAuley, Sandler interviews). Donald Francis, assistant director for medical science of the Division of Virology at the CDC, recommended that the blood banks question donors directly about their sexual behavior and run blood donations through a series of surrogate tests (the use of nonspecific laboratory markers), including a test for the hepatitis B core antibody, which showed an 88 percent correlation with patients who had AIDS (Foege 1983; Evatt, Foege, Francis interviews). Some meeting participants opposed this recommendation because of the cost of the tests and other reasons (see Chapter 5). Gay activist groups objected to screening measures, claiming that they were discriminatory toward their members. Many meeting participants were not convinced by the evidence that AIDS was transmitted by blood or blood products (Bove, Curran, Evatt, Foege, Pindyck interviews).

Dennis Donohue, Director of the FDA's Division of Blood and Blood Products, stated that research on processes for inactivating viruses in blood products was under way. Oscar Ratnoff, a prominent hemophilia specialist, stated there was enough information about the danger of AHF concentrate to stop using it in favor of cryoprecipitate (Johnson 1983). Dr. Francis tried to establish a time frame for action or a minimum number of transfusion-related AIDS cases after which the FDA's Blood Products Advisory Committee would agree to take action to implement donor screening policies.

The Blood Bank Community's Statement

A week after the Atlanta meeting in January 1983, the American Association of Blood Banks, the Council of Community Blood Centers, and the American Red Cross issued a joint statement that ''direct or indirect questions about a donor's sexual preference are inappropriate." The statement recommended questions to detect possible AIDS exposure (i.e., a donor health history), but did not recommend any laboratory screening tests. At this time, the PHS agencies had not completed their own recommendations (Donohue, Foege interviews), and the FDA did not issue any recommendations.

Position of the National Hemophilia Foundation

The next day, the Medical and Scientific Advisory Council (MASAC) of the NHF met and recommended that cryoprecipitate (a blood product produced from the serum of a small number of donors), rather than AHF concentrate, be used for newborn infants and children under four, newly diagnosed patients, and those with mild hemophilia. According to the report, there was insufficient evidence to develop specific recommendations about blood product use (i.e., AHF concentrate or cryoprecipitate) in the treatment of severe hemophilia. Additional recommendations included delaying all elective surgical procedures and the use of a synthetic substance, DDAVP (desmopressin acetate), to elevate Factor VIII levels in patients with mild or moderate hemophilia A. MASAC also stated that it was important to screen and exclude all high-risk donors from the blood and plasma supply for the production of blood products used for treatment of hemophilia. The NHF directed their recommendations to treating physicians, regional and community blood collection centers, and plasma fractionators; in some instances, the NHF also told their chapters to distribute the information to the chapter members.

Position of the Plasma Fractionation Industry

On January 28, 1983, the American Blood Resources Association (ABRA), which represents the plasma industry, issued recommendations about donor screening and deferral to reduce the risk of AIDS. The recommendations focused on donor education, donor screening, and surrogate laboratory testing. The ABRA recommended issuing a brochure that would describe AIDS, tell how individuals in high-risk groups could reduce their risk of exposure, and discourage high-risk persons from donating. The ABRA also recommended that prospective donors, prior to donating, be required to read the information about AIDS and indicate that they were not members of a high-risk group. Individuals who identified themselves as members of high-risk groups or were unwilling to reply would be excluded from donating plasma (donor deferral). The ABRA recommended against large-scale surrogate testing of donated blood until ABRA had evaluated its feasibility.

On December 17, 1982, prior to ABRA's recommendations, Alpha Therapeutics, one of the four commercial manufacturers of AHF concentrate, had begun excluding all plasma donors who identified themselves as having been in Haiti, having used IV drugs, or if male, having had sexual contact with another man. Alpha had notified all its affiliates that this policy was effective immediately and that unscreened plasma should no longer be sent to Alpha. By the early part of 1983, each of the companies had in place donor education and screening programs requesting members of high-risk groups to identify themselves and refrain from donating plasma (FDA, BPAC, 1983b).

Federal Recommendations on the Prevention of AIDS

In a March 4, 1983 report, the PHS promulgated its first official recommendations on the prevention of AIDS. The recommendations stated that the evidence suggested the disease was a severe disorder of immune regulation caused by a transmissible agent (CDC, MMWR, March 4, 1983). As evidence, the report indicated that the transmission routes of AIDS paralleled that of hepatitis B and that blood or blood products appeared to be responsible for transmitting AIDS to hemophilia patients. Suspected cases of transfusion-associated AIDS had been reported, but none were yet proven. According to the report, the evidence suggested a latency period of two months to two years between exposure and onset of symptoms. Brandt noted that a significant proportion of individuals in high-risk groups had no symptoms of AIDS, suggesting that the pool of persons potentially capable of transmitting an AIDS agent may be considerably larger than the known number of AIDS cases.

The PHS made the following recommendations for preventing AIDS transmission:

• Sexual contact should be avoided with persons known to have or suspected of having AIDS.
• Avoid sex with multiple partners or those who may have multiple partners.
• Members of groups at increased risk for AIDS should not donate plasma and/or blood products.
• Studies be conducted to evaluate screening procedures for their effectiveness in identifying and excluding plasma and blood with a high probability of transmitting AIDS—including lab tests and physical exams.
• Physicians should adhere strictly to medical indications for transfusions.
• Work should continue toward development of safer blood products for use by hemophilia patients.

About three weeks later, on March 24, 1983, the FDA notified all establishments collecting source plasma and human blood for transfusion and all manufacturers of plasma derivatives of steps to be taken to decrease the risk of blood or plasma donation by persons who might be at increased risk of transmitting AIDS. These steps included implementing standard operating procedures to quarantine and dispose of any products collected from donors known or suspected of having AIDS. The FDA also advised the blood and plasma collection facilities to establish educational programs to inform persons at increased risk for AIDS that they should stop donating and to train personnel who screen donors to recognize the early signs of AIDS. The FDA also announced that it had approved a new heat treatment to inactivate viruses in AHF concentrate. The treatment was purported to help protect individuals with hemophilia from hepatitis B, and perhaps from AIDS (Petricciani 1984).

Summary and Comment

Government and private agencies identified, considered, and in some cases adopted strategies for dealing with the risk of transmitting AIDS through blood and blood products. The recommended safety measures were limited in scope, which reflected a lack of consensus about the nature and magnitude of the threat (especially among physicians and public health officials who were unprepared for the unique epidemiological pattern of AIDS), and uncertainty about the costs, risks, and benefits of the proposed control strategies.

Summary and Comment

Blood safety policies changed very little during 1983. Many officials of the blood banks, the plasma fractionation industry, and the FDA accepted with little question estimates that the risk of AIDS was low ("one in a million transfusions"), and they accepted advice that control strategies (such as automatic withdrawal of AHF concentrate lots containing blood from donors suspected of having AIDS, or a switch from AHF concentrate to cryoprecipitate in less severe hemophiliacs) would be ineffective, too costly, or too risky. During this period, there were missed opportunities to learn from pilot tests to screen potentially infected donors or implement other control strategies that had been rejected as national policy. (These local attempts to screen are discussed briefly below, and in more detail in Chapter 5.)

The Public Health Service Effort

As discussed earlier, the PHS Committee on Opportunistic Infections in Patients with Hemophilia held its second meeting on July 27, 1982. On the same date, the committee distributed two recommendations to the assistant secretary for health, the FDA commissioner, the NIH director, CDC regional offices, and state and territorial health officers. The first recommendation was to establish an active surveillance system at once to identify new suspected cases of AIDS occurring in individuals with hemophilia. In November, the CDC, the NHF, and the regionally based network of hemophilia treatment centers agreed to cooperate in this effort. The second recommendation called for (a) laboratory studies of the immunologic competence of individuals with hemophilia who had no symptoms of opportunistic infections, and (b) applied research to determine practical techniques for eliminating the risk of infection from AHF concentrate (Foege 1982b). The meeting summary also noted concerns about the adequacy of funding to support these activities, stating that existing federal grants and contract mechanisms were not "responsive to rapid funding of urgent problems" (Foege 1982b).

The PHS committee also recommended studies to evaluate the effectiveness of screening procedures for identifying and excluding high-risk donors but did not propose a source of funding for the studies. Several blood banks did initiate pilot studies on safety measures such as anti-HBc as a surrogate for HIV (Irwin Memorial Blood Bank), the use of a reversed T-cell ratio test (a test indicating immune dysfunction) to exclude high-risk donors (Stanford University Blood Bank), and confidential unit exclusion to allow donors to self-defer (New York Blood Center). The results of the studies did not provide strong enough evidence to convince those who attended the December 15–16, 1983, BPAC meeting (discussed above) to recommend surrogate testing or other measures to reduce AIDS transmission.

In March 1983 Assistant Secretary of Health Edward Brandt announced the formation of a PHS Executive Committee on AIDS. The purpose of the committee was to coordinate the activities of PHS agencies and share information on upcoming meetings, grant awards, and new developments. In addition, Assistant Secretary Brandt directed the NIH, in collaboration with the CDC and FDA, to support studies to evaluate screening procedures, including laboratory tests, for their effectiveness in identifying and excluding blood and plasma donors at increased risk for AIDS (Brandt 1983). In response to this request, the NIH director, Dr. James Wyngaarden, designated the National Heart, Lung, and Blood Institute (NHLBI) to lead NIH's effort in determining if any test "would merit experimental validation and possible preparation for an Request for Application (RFA)" (Wyngaarden 1983). In the following year, the NHLBI sponsored several conferences on AIDS.

Early in 1983, NIH redirected some of its research budget ($165,000 in supplemental funding) to scientists working on studies of Kaposi's sarcoma (Thomas 1983; Panem 1988). In addition, the NHLBI established an interagency agreement with the CDC to evaluate immunologic changes in hemophiliacs and patients receiving blood and blood products (Sloand 1994). A total of $61,500,000 was allocated to the PHS budget in fiscal year 1984 for AIDS-related research; this represents a 114 percent increase from the $28,700,000 allocated in fiscal year 1983 (Stoto, et al. 1988).

Isolation of the Virus and Development of a Screening Test

Investigators at the Pasteur Institute in Paris reported the isolation of novel virus that they termed LAV from an individual with lymphadenopathy syndrome in 1983. These investigators suspected that LAV might be involved in the causation of AIDS, but due to difficulties they experienced in propagating the virus in large quantities and the lack of an effective serologic test to identify LAV-infected persons, this hypothesis could not be proved at the time. In April 1984, researchers at the National Cancer Institute of the NIH reported the isolation of a virus they called HTLV-III from a number of persons suffering from AIDS and from asymptomatic or moderately symptomatic persons from groups of persons at risk of AIDS (Popovic, et al., 1984). The NIH investigators described for the first time a method to prepare large quantities of HTLV-III in the laboratory and provided convincing evidence that this virus was the etiologic agent of AIDS.

The discovery that a virus caused AIDS shifted some research efforts toward a focus on the biological aspects of transmission of the disease and its interactions within the human body. The public's reaction to the discovery of HTLV-III (later renamed HIV) included an increased fear of casual transmission and of infection through the act of donating blood (Fee and Fox 1988; Brandt 1987). As a result of the isolation of HTLV-III, blood and plasma collection organizations, anticipating the quick development of a direct test for the virus, did not implement any additional donor screening procedures until such a test was developed. Meanwhile, during 1982–1984, U.S. manufacturers were completing the development of a process for inactivating the hepatitis B viruses by heating AHF concentrate (see Chapter 4). In October 1984, the CDC announced that laboratory experiments showed that the heat treatment process also inactivated HIV.

During 1984, however, researchers remained focused on developing a screening test for HIV. Once the virus was identified, several companies began developing tests to screen blood by detecting antibodies that would indicate exposure to the virus. In April 1984, NIH developed and patented a prototype screening test for antibodies to HIV, and by May it had solicited applications from companies interested in commercial use of the tests. Five companies were selected in June. The first tests used an enzyme-linked immunosorbent assay (ELISA), and the FDA received an application for licensure from a company in December 1984. By March 1985, the FDA had granted two licenses for commercial use of the tests; it also notified all blood facilities that the test was available, and it scheduled a workshop on its use [50 Federal Register 28477]. Subsequently, all blood banks and plasma collection centers implemented the ELISA.

The first ELISA tests detected 96–98 percent of HIV-infected blood samples. However, despite a high degree of specificity, false seropositive results occurred. For this reason, a second, more costly, less sensitive, but more specific screening test called the Western Blot was used to confirm or refute the positive results of the ELISA test. Neither test could detect HIV antibodies during the six-to-eight-week window period (i.e., the time between HIV infection and the evidence of antibodies in a donor's blood). Since the implementation of the initial ELISA test, several more sensitive tests have replaced it because they reduce the length of the window period. Through the widespread use of this test, the current risk of HIV transmission through screened blood is estimated to be less than 1 in 420,000 units (Lackritz, et al. 1995; Busch, et al. 1995).

Summary and Comment

In the early 1980s, the CDC's surveillance program identified AIDS patients and characterized the disease swiftly and thoroughly. Dr. Gallo at the NIH isolated and characterized HIV in less than two years. Meanwhile, laboratories of the plasma fractionation industry were developing viral inactivation methods for AHF concentrate. The pace of virus inactivation research in the 1970s had been slow, but accelerated in the 1980s in response to hepatitis and was complete by 1984. Most of the PHS research effort was concentrated on identifying and characterizing the virus. Research into other potential ways to safeguard the blood supply, such as surrogate tests, was not pursued vigorously, and there was relatively little research on blood safety issues perse.