Dr. Gottlieb goes on to detail the basics of two critical parts of the immune system, humoral and cell- mediated immunity, how they are impacted by the HIV virus, and the consequences to a person’s health. “The immune system is composed of various arms, much like the armed forces: The Navy, Air Force, and the Marines. They do different things. In the humoral immune system, or humoral immunity, it has to do with antibodies. Antibodies come from B-cells (a type of blood cell called a B- lymphocyte). B-cells are named because of something called the Bursa of Fabritiius, which is found in chickens. (Early research showed) If you removed this bursa, the chickens become immune deficient. B-cells come from the bone marrow, but they are educated in the Bursa of Fabritius. It is there they develop into plasma cells, which produce antibodies. Antibodies were thought to protect against bacterial infections, including those implicated in pneumonia, sinus infections, and bloodstream infections, but they also respond to viral infections and are especially primed when we challenge the body with vaccines, because antibodies have memory. But it’s thought that the principal protection against viral infections comes from the other type of immunity, the cell- mediated immunity.” These cells are also lymphocytes, but are called T-lymphocytes, or T-cells, and they include T-helper cells (CD4 cells), T- suppressor cells, and Natural Killer cells. These cells come out of the bone marrow and are educated or primed in the thymus gland in the chest. It’s the T-cell university, so to speak, where immature T-cells mature into cells that can recognize the difference between self and non-self. These are the same cells that principally will reject an organ transplant from you to me, because they see (the tissue) as non-self. But they will also see a virally infected cell, because the virus expresses some of its own proteins on the surface of a cell it infects. Therefore, the T-cell will see it as non-self and try to kill it.”

Since the HIV virus affects the T-cells, especially the T-helper subset of lymphocytes, otherwise known as CD4 cells, and depletes them, the virus can infect one cell, take over the cellular machinery inside, multiple, and explode into the blood stream, infecting other cells at an alarming rate, with devastating consequences to the immune system, and to the host, human beings. As a result, what’s known as opportunistic infections can take root. These are infections with organisms that abound in nature but would often be of no consequence to healthy people with intact immune systems.

“Someone who’s immune deficient can be exposed to Cryptococcus (an opportunistic fungus) and have a disseminated infection, whereas someone who’s immune competent might have a localized infection or fight it off completely or wall it off, because they have intact T-cell immunity,” says Gottlieb.

Gottlieb pauses his didaction. “This is Dutch. Come here Dutch. Dutch. Dutch. Dutch.” Gottlieb is a devoted animal lover, and Dutch has just ambled onto the scene. “Where have you been, Dutch? he asks. He’s my big boy. Just wandered in the back door one day. Had been roaming the neighborhood. So, I kept him. He has Feline immunodeficiency virus. He points toward the window where a cat is napping on the tiled floor in the pooled light of the sun. “Jack has cardiomyopathy (a heart disorder).” Gottlieb is serious. He is no ordinary pet-owner, and he seems to find immunodeficiency everywhere he looks, even in his cats! Apparently, as a pet-owner, as he did for his patients, he goes the distance.

Having AIDS can, and has, led to very bizarre manifestations of disease that have shocked many physicians, but the more common types of opportunistic infections are as follows:

CMV (Cytomegalovirus). A common virus that is often, but not always, of no consequence to people with intact immunity. CMV most commonly infects the neurologic system, the gastrointestinal system and the back of the eye, known as the retina, causing what is described as a “pizza pie” appearance to the retina on direct ophthalmoscopy, due to hemorrhages and optic disc swelling.

“You can get a CMV infection, but it may cause a brief illness,” states Gottlieb, “but it’s not going to cause an infection of the retina. Whereas in someone whose T-cells are depleted, it can cause a brain, eye, or heart infection. So, these are organisms which, for the most part, we can encounter and not get sick if we are healthy, but not if we are immune deficient.” Pneumocystis Pneumonia, as previously described, which causes subacute onset of shortness of breath, fevers, and intense inflammation of the lungs.

Toxoplasmosis, caused by the intracellular parasite, Toxoplasma Gondii. This parasite infects birds and mammals, especially the cat, which is the definitive host. Oocysts are shed in cat feces and contaminate the soil, which is ingested by birds, sheep, other mammals and humans, who serve as intermediate hosts. The disease ultimately affects lymphatic, muscle and brain tissue. It can cause encephalitis, or inflammation of the brain, and multiple mass lesions. Without proper anti-viral treatment for HIV, one-third of patients who had latent, asymptomatic exposure in the past, will develop Toxoplasma Encephalitis. Confusion, fevers, headaches, seizures and motor and cranial nerve deficits are common on presentation. For those unaware of their diagnosis of AIDS, it may be a common presenting illness. (Harrison’s Internal Medicine, 21st edition, pg 1761, McGraw Hill).

“Toxoplasmosis is often a reactivation," says Gottlieb. “It turns out if you eat steak tartare, toxo tends to be, or can be, in the beef. And so, the French, who favor of steak tartare, have a very high percentage of adults that are toxo-antibody positive. Toxo can be squirreled away and reactive if someone becomes immune deficient. Cats who are indoor-outdoor, who eat wild prey, they can excrete toxo and infect humans. Cats who are purely indoors and live on cat food, they don’t carry toxo.”

Fungal meningitis, most commonly from Cryptococcus Neoformans, commonly found in bird droppings, including the Pidgeon. First identified in the 1890’s, serologic evidence suggests widespread human exposure, but disease was rare until the mid-twentieth century with the advent of more treatments for cancer, thus causing an immunocompromised state, and likewise for people who later had organ transplants. With the arrival of AIDS, the diagnosis really took off, manifesting in severe headaches, stiff neck, confusion, fevers, nausea and vomiting, and memory deficits, often presenting over a period of several weeks, as opposed to acute bacterial meningitis, which presents over a period of hours and days. (Harrison’s Internal Medicine, 21st edition, pg 1668, McGraw-Hill).Kaposi’s Sarcoma. A devastating neoplasm, or tumor, of the skin, which could also affect the internal organs, as well as causing a pneumonia. Multiple vascular nodules occupy the skin, reddish to purple and often appearing almost like a bruise, with a propensity for the trunk, upper arms and the nose.

Lesions have been reported in virtually every organ and can even occur with early HIV infection with normal T-cell counts. Although treatments have evolved, early in the disease it was virtually untreatable and extremely noticeable and disfiguring, causing much discrimination, isolation, and even fear, of the victim. In the 1980’s, with increasing widespread hysteria about the disease, these lesions, coupled with cachexia or severe weight loss, were difficult to hide from public view.

Kaposi’s Sarcoma was a prominent clinical feature of the first cases of AIDS, occurring in 79% of patients diagnosed in 1981. By 1997, with adequate anti-viral therapy, the incidence had declined to less than 1%. (Harrison’s Internal Medicine, 21st edition, pg 1581, McGraw-Hill). According to Dr. Gottlieb, “it was like the Scarlett Letter. Some of these people would commit suicide over having

Kaposi’s Sarcoma.” AIDS soon became reported in nearly every country in the world, although some countries, like the Soviet Union, initially denied its presence. The disease had a devastating impact on the health and economy on every continent. Prior to the advent of combination antiretroviral therapy (ART) in the early 1990’s, HIV infection, and subsequent development of AIDS, was a death sentence, with 100% mortality, for over a decade. As a result, stigmatization and isolation of those infected and panic about acquiring the disease was widespread. AIDS incidence increased rapidly through the 1980’s and then began to decline in the mid 90’s with effective treatments available (MMWR June 1, 2001, HIV and AIDS—United States, 1981-2000).

AIDS had catastrophic consequences in nearly every corner of society. No profession or socioeconomic status escaped its scourge. Among the affected were physicians, lawyers, politicians, athletes, members of the arts and humanities, firefighters, policeman, friends, family and next-door neighbors. Some well-known and recognizable people who died of AIDS, most in the 1980’s, (where deaths peaked at 150,000 per year in 1987), and the early 90’s, are listed below:

Rock star Freddie Mercury, of Queen(1981), Actor Rock Hudson (1985), Gia Carangi, felt to be the first supermodel (1986), Tennis player and US ambassador to the United Nations Arthur Ashe (1993), hockey player Bill Goldsworthy, Hip hop artist Easy-E (1995), Robert Reed from the Brady Bunch (1992), Alvin Ailey, dancer and choreographer (1989), lawyer Roy Cohn (1986), Rudolf Nureyev, Russian dancer and choreographer (1993), Bruce Chatwin, English novelist (1989), Marlon Riggs, professor, poet, and gay rights activist (1993), fashion designer Perry Ellis (1986), actor Brad Davis, from Midnight Express fame (1991), musician Tom Fogerty, from Credence Clearwater Revival (1990), Egon Von Furstenberg, from the German aristocratic family Von Furstenberg (2004), and

Ryan White, who gained international prominence when he acquired AIDS from a blood transfusion given for his hemophilia, a blood clotting disorder in which patients bleed easily, either spontaneously or with minor trauma. White faced bullying and discrimination in his Indiana middle school and was initially banned from attending school in person because of his AIDS diagnosis (1990). (People Magazine, updated 2025).Particularly tragic, in a sea of AIDS tragedy, was Elizabeth Glaser, a patient of Dr. Gottlieb’s who was married to Paul Michael Glaser, of the popular TV show Starsky and Hutch. Glaser unknowingly contracted HIV during a blood transfusion at time of the birth of her daughter, Ariel, in1981. When Ariel developed AIDS, she was denied admission to multiple pre-schools due to stigma and fear of transmission to others. Ariel had developed AIDS through passage in Elizabeths mother’s milk, while breastfeeding. When the first antiretroviral was developed in 1987, AZT, Ariel was denied a trial due to a lack of testing in the pediatric age group. To compound the tragedy, her next child, Jake, contracted HIV through the placenta in 1984, but luckily, according to Dr. Gottlieb, he has a rare CCR5 gene mutation that protects his lymphocytes from the virus and he has not developed AIDS.

Ariel died in 1988, and Elizabeth succumbed in 1994, but not before giving an impassioned speech at the 1992 Democratic National Convention on the lack of AIDS research funding by the government and a lackluster response to the crisis. Overall. (Elizabeth Glaser, Wikipedia, and Dr. Michael Gottlieb).

In the early 1980’s, AIDS cases occurred mostly in whites, however blacks and Hispanic cases increased steadily and by 1996, more cases occurred among blacks than any other racial/ethnic population. 85% of cases of HIV have occurred within the 20–49-year-old age group. (MMWR, HIV and AIDS, United States, 1981-2000).

In the United States, through the year 2000, male to male sex has been the most common mode of exposure (46%), followed by injection drug use (25%), and heterosexual contact (11%). The number of people exposed through blood transfusion dramatically declined after all blood for transfusion was tested for HIV starting in 1985 (MMWR, HIV and AIDS in the United States, 1981-2000).