But in two remarkable years, political pressure on the U.S. government and a competitive threat from producers of low-cost knockoff versions of AIDS drugs have dramatically improved the odds that AIDS treatments will reach millions who previously had no hope.
A core of American legislators, some of them tested in the early years of AIDS, are also turning their attention to the global threat.
"We could see a total wipeout of generations in sub-Saharan Africa,'' said U.S. Senator Dianne Feinstein, who was mayor of San Francisco when the epidemic began. "The global AIDS problem is a crisis. We have to meet it with education and drugs at the cheapest possible prices.''
Feinstein has repeatedly introduced legislation that would allow poor nations to sidestep patents on AIDS drugs to ensure a supply of low-cost generic medications.
Yet even at the U.S. $350-a-year price quoted by Indian drug maker Cipla, treatments will remain out of reach for millions, and drug expenses are only part of the cost of treating AIDS. Medications are all but useless where there is no clean water and no money to pay for the simplest blood tests. Without a vaccine, prevention efforts remain the best hope of curtailing the epidemic.
In April, U.N. Secretary General Kofi Annan put a price tag on the problemU.S. $7 billion to $10 billion a yearand called on wealthy nations to contribute to a global fund to fight the epidemic.
When President Bush responded with a pledge of U.S. $200 million, U.N. AIDS officials were publicly grateful, but the amount seemed shockingly low to AIDS activists.
"It's beyond being insufficient. It's an insult. It's immoral,'' said Eric Sawyer, a New York activist who has worked closely with the international effort to lower the costs of AIDS drugs.
Sawyer said that 20 years of AIDS has been a tragedy of missed opportunity.
"We were sending out a call to arms in the gay community 20 years ago,'' he said. "At that time, the number of cases was in the hundreds.''
But it took a ballooning death count, and the passing of celebrities such as Rock Hudson, to stir America out of its indifference.
In Twenty Years, A Billion Cases of AIDS?
Now, the world is paying attention to the implications of a global pandemic, but it may already be too late, Sawyer said: "In India, there are three to four people sharing beds in hospitals, and two or three more on the floor, waiting for their shift. This is not an old epidemic. It is just starting. In 20 years, we could be talking about a billion cases of AIDS.''
Current efforts to bring cheap AIDS drugs to Africa are highlighting how medical technology has become a new measure of the great gap between rich and poor.
"HIV continues to point its finger at everything that is wrong with our society,'' said Tom Coates, director of the University of California at San Francisco AIDS Research Institute.
In the developing world, AIDS is thriving in an environment where health services are minimal, and the plague is accompanied by other diseases such as malaria and tuberculosis, as well as famine and warfare.
AIDS in the United States began among gay white men and remains largely confined to homosexuals, drug users and their sexual partners. In Africa and the rest of the developing world, AIDS is a heterosexual epidemic, and young African women bear the brunt of new infections.
Still, the epidemic in Africa at its core shares a fundamental trait with those that are occurring in Western nations: AIDS is a slow killer that works its way through populations long before the first signs of illness.
Gottlieb sensed this 20 years ago, when he identified the first cases of a previously unknown disease. Two decades later, he is still chilled by its stealthy efficiency.
"This is a deadly and tricky virus that takes advantage of our blind spots,'' he said. "It works the blind spots in the human immune system and the blind spots in human consciousness. It plays on denial.''
(c) 2001 The San Francisco Chronicle
AIDS at 20 Part 2: A Disease That Changed Our World