this respect, the epidemic has already had a profound social impact on science and medicine.

THE FIRST DECADE OF AIDS

The recognition of the first case of AIDS in the summer of 1981 was an abrupt event, but a basic understanding of its cause, epidemiology, and natural history evolved over a period of 5 years. During that time, despite great limitations of knowledge, many treatments were pursued and some therapeutic successes claimed.

Kaposi's sarcoma and Pneumocystis carinii pneumonia (PCP) were the two diseases that heralded the arrival of the epidemic. Both diseases had been seen before (in elderly and cancer patients, respectively), and drugs already licensed were commonly used to treat the disorders, generally with good results. Indeed, it was the sudden marked increase in requests for a drug long used to treat PCP, pentamidine, that provided one of the first pieces of evidence that AIDS was an epidemic disease.

Frustration that PCP and other complications in AIDS patients were not amenable to conventional therapies led to a host of alternative approaches, including vitamins, holistic therapies, and imported, non-FDA-approved drugs. At the same time, the failures led scientists to consider the infectious and neoplastic aftermath of AIDS's destruction of the immune system as essentially insurmountable and to concentrate on the central immune defect underlying the disease as the proper focus for drug research. Heroic interventions, such as bone marrow transplants in twins (one infected with HIV and one not) and aggressive chemotherapy for Kaposi's sarcoma, were attempted. As patients continued to die despite these measures, AIDS increasingly came to be viewed as an untreatable disease, and medical and lay literature emphasized the need to respect the rights and needs of individuals with a fatal disease of short duration, including their right to refuse intubation and resuscitation, their need for companionship and personal assistance, and the need to create low-cost, compassionate, out-of-hospital care.

The year 1985 was a landmark year in the epidemic. First, it was revealed that movie star Rock Hudson had AIDS and that he had traveled to France to obtain HPA-23, an antiviral agent that French researchers had hailed at a press conference as curing several patients with the disease. Patients in the United States, desperate for therapy, questioned why a potentially useful drug could not be brought into this country. Affected individuals became increasingly aware of the often painfully slow process of drug evaluation and licensing regulated by the FDA. When additional experience with HPA-23 did not confirm early promising results, however, the wisdom of traditional methods of drug testing seemed to be substantiated.

Second, suramin, an agent that had been licensed for over 50 years and



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