early-stage AIDS. Late-stage AIDS patients often developed dementia, but "the big question was 'What about all the people who had been exposed to whatever was causing HIV?' " explains Saykin. "As a recently minted neuropsychologist at Penn, I was in the business of designing cognitive test batteries to try to be sensitive to subtle cognitive dysfunction."

So Saykin became a consultant to the CDC and had a chance to "go with the CDC team to the International AIDS Conference and present data." His research up to that point had focused on diseases with "a long research tradition behind them . . . epilepsy, schizophrenia, and Alzheimer's." But AIDS represented uncharted territory. "The etiology was just emerging," he points out. "It was a fatal disease. It was also very poignant in terms of working with these patients. We gave them about a three-hour battery of detailed cognitive tests, tests for anxiety and stress and depression, and so on." Saykin was touched by how cooperative and motivated the gay men he worked with were.

Saykin and Janssen's studies—one of which was published in the Annals of Neurology and another in the International Journal of Clinical Neuropsychology— found that HIV-infected people who had not yet developed AIDS exhibited mild neuropsychological deficits: subtle changes in language capability (such as fluency and ability to recall the names of objects), attention span, ability to process visual and auditory information, psychomotor speed, and memory.

"In general, the cognitive effects were quite subtle during these very early stages," says Saykin. "In fact, it became somewhat controversial as to whether people who were [HIV-positive] but had no other symptoms at all really had cognitive abnormalities. It was only when people developed more advanced disease, with these constitutional symptoms and so-called AIDS-related complex, that people really began to show more measurable cognitive changes."

Yet Saykin's research had major policy implications. "After the early reports, the

In 1986, Koop prepared a report on AIDS that he calls "the most frank report that was ever put in the federal register. I used four words which I thought, talking about AIDS, you couldn't avoid using . . . penis and vagina and rectum and condom."

military decided to test everyone for HIV," he explains. They "decided that people who were [HIV-positive] should not be running sensitive equipment" like planes and computerized tanks.

Later, when viral load could be measured, "it became clear there was a correlation between viral load and . . . cognitive performance," he says. Other studies showed that early antiretroviral treatments for AIDS patients with dementia helped them regain some cognitive function. "It was exciting to see a treatment developed and see a response on cognitive testing and brain imaging."

Saykin doesn't do much AIDS-related research these days. Since joining the Dartmouth faculty in 1992, he has focused on cognitive testing and brain imaging in people with Alzheimer's disease and other dementias. But among those populations are occasional patients who are HIV-positive, reminding him of his early experience with the epidemic.

Tending to teens
Dr. Karen Kramer Hein, DMS '68: now retired; formerly a professor of pediatrics and epidemiology at Albert Einstein College of Medicine, executive director of the Institute of Medicine, and president of the William T. Grant Foundation

Karen Hein likens the early years of AIDS to a whale-watching expedition. "Everybody's looking at the tail," she says, meaning where the epidemic has been evident. "Meanwhile, the 'whale' is going under the water—and where it's going to surface, where it's heading, is adolescents."

1991

• Basketball star Magic Johnson announces that he has HIV and retires from playing.
• The CDC recommends that infected health-care workers should be barred from performing certain procedures.
• The red ribbon is introduced as the international AIDS symbol.
• Two new drugs become available as monotherapy and increase the survival of AIDS patients. But doctors soon realize that they provide only 18 to 24 months of protection against the disease's progression.

1992

• AIDS becomes the number-one cause of death for American men aged 25 to 44.
• The first clinical trial of multiple-drug AIDS therapy gets under way.
• Tennis star Arthur Ashe announces that he has been infected with HIV via a blood transfusion.

1993

• CDC expands the definition of AIDS to include additional opportunistic infections, as well as HIV-positive adults with a CD4 count of under 200.
• A new scientific technique, quantitative polymerase chain reaction, allows patients' viral load to be accurately assessed.
• Ballet dancer Rudolf Nureyev dies of AIDS.

1994

• AIDS has become the leading cause of death for all Americans aged 25 to 44.
• The FDA approves the first non-blood-based test for HIV.
• The USPHS recommends the use of AZT by pregnant women who are HIV-positive to reduce prenatal transmission of HIV.
• The CDC launches a series of AIDS advertisements that focus on condom use.