By Mark Katz, M.D.

AIDS is about to turn 25 -- virtually all high school and college students in the United States have never known a world without it. Since you started reading this piece, someone in the world has become newly infected with HIV. At least 40 million inhabitants of this planet live with this retrovirus within. According to the CDC, as of the end of 2003, the number of Americans diagnosed with AIDS was 929,985. Since then we must have crossed the one-millionth-American with AIDS mark, and the moment went unnoticed.

During the early years, people with AIDS, or HTLV-III (the former name for HIV), were known as "victims," and as victims do, they sought to blame. Of course, homosexuals were blamed; remember the flight attendant Gaetan Dugas, known as "Patient Zero"?

We blamed President Reagan for his apathy, for not mentioning AIDS until 1986. Some blamed another actor -- Rock Hudson -- for not coming out as a PWA sooner than three months before his death. Burroughs-Wellcome, instead of being praised for bringing the first anti-HIV drug to FDA approval (AZT in 1987), was accused of profiteering.

Is it any wonder, then, that in 1985, when I joined 80 other Angelenos in becoming emotional support volunteers for L.A. Shanti, one man in the group who actually had AIDS said nothing about it for the entire two weekends. "I had to stay in the closet," Cliff Arnold said to me and his support group later on, "I was too afraid of being rejected."

Out of shame and blame came a period of strident activism, from the late 1980s into the 1990s. One specific year, 1987, saw the beginning of ACT-UP, ADAP, and The Names Project Quilt.

Today we have achieved the goal of turning HIV into a "chronic, manageable disease," words at which people with HIV still shudder. "It's not exactly diabetes or arthritis," my friend Victor reminds me. I don't know of any inpatient AIDS units left in the United States (L.A. had seven, simultaneously, in the early 1990s).

While we endorse our victories (potent medications, virtual obliteration of major opportunistic complications, halting vertical transmission to fewer than 70 infected babies born in the United States last year, and compassionate activism), we still feel the pain of defeat (side-effects such as lipodystrophy and neuropathy; 560,000 infected babies born in Africa last year; and the absence from our lives of the likes of Dave Johnson, Mark Kostopoulos, and Connie Norman).

Today still we blame. We blame people who use crystal methamphetamine. We blame the bathhouse owners who supposedly facilitate its occurrence. We still blame the government (aptly so).

Perhaps we should step back and, instead of (or in addition to) blaming, ask, Why is this happening? With all we know about how HIV is transmitted, why are Americans putting themselves at risk, and the number of new infections increasing? The list of hypothetical answers is increasingly long and sociologically enticing: survivor guilt, substance use, prevention fatigue, invincibility of youth, and the success of antiviral medication.

The other question we should be pondering, is What about the rest of the world? I think of Zimbabwe, where life expectancy for a newborn has plummeted from 52 in 1990, to 34 in 2003. I think of 14 million sub-Saharan AIDS orphans. I think of antiviral drugs being available for only 7 percent of the world's population who need them.

You can often hear a politician, or an activist proclaim, as I myself have, words such as, "History will judge our response to AIDS as a disgrace." Nowadays I say, "We are already living this history."

-- Dr. Mark Katz is currently an internist at Kaiser Permanente of West Los Angeles with a large HIV practice. He also serves as Southern California Kaiser's regional physician co-coordinator for HIV/AIDS and has been active in L.A.'s HIV impacted community since 1985.