Kaposi’s Sarcoma at the Oscars

Historically rare and indolent, Kaposi’s sarcoma (KS) emerged as a frequent and easily recognizable cutaneous manifestation of Acquired Immunodeficiency Syndrome (AIDS) in the 1980s. The visibility of KS rendered the disease a stigmatizing marker of the Human Immunodeficiency Virus (HIV) infection as it progressed into AIDS, often serving as a harbinger of death to those infected. KS has once again become uncommon since the advent of highly active antiretroviral therapy (HAART). The prestigious Academy Awards has recognized five outstanding non-documentary and three documentary English language films to date that employed KS to help convey the early HIV/AIDS era. Likewise, the Primetime Emmy Awards has nominated five productions that include KS. These movies are potential tools for educators seeking to teach students and the general public about the history of AIDS in the United States.


Introduction
The Academy Awards is overseen by the Academy of Motion Picture Arts and Sciences (AMPAS) and is inarguably the most lauded ceremony in the film industry. An Oscar nomination immediately cements a movie into the archives of cinematic history. The 2014 Academy Awards recognized two films, Philomena and Dallas Buyers Club, which utilized Kaposi's Sarcoma (KS) to help portray the dawn of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic. In total, five nondocumentary films featuring KS have garnered seventeen Oscar nods and received five wins ( Table 1) while one of three nominated documentaries has won the respective category (Table 2).
Before highly active antiretroviral therapy (HAART), HIV decimated the homosexual and drug addicted populations in major metropolitan areas. KS was a ubiquitous, cutaneous, and stigmatizing marker of disease progression to AIDS, often preceding death via other opportunistic infections. As such, KS remains a potent reminder of the initial phase of this terrifying era. The authors have previously analyzed many of the commercially available KS containing movies released through the first decade of the twenty-first century [1]. This paper explores two newly Oscar recognized films, reexamines the three previously nominated movies, and acknowledges three documentaries. These works reflect the significant impact of KS on the HIV/AIDS era that will likely continue to exert influence for generations to come.

Background
KS is predominantly a cutaneous disease that presents as solitary or disseminated erythematous to violaceous macules which often evolve into papules, plaques, nodules, or tumors. The lungs, gastrointestinal tract, and lymph nodes may also become involved [2]. In 1981, KS was first linked to homosexual men in a concerning medical report [3]. Sexual transmission of KS was later postulated based on the statistically disproportionate number of homosexual men with AIDS that developed KS compared to their AIDS stricken hemophiliac counterparts [4]. Finally, in 1994, human herpes virus-8 (HHV-8) was established as the etiologic agent [5] and homosexual men were found to be much more prone to contract both HIV and HHV-8 than women or hemophiliacs. Currently, HAART prevents and induces regression of KS [2].

Academy of Motion Picture Arts and Sciences recognized films
The drama Longtime Companion (1989) epitomized the time HIV/ AIDS and KS first emerged in New York and San Francisco in the early 1980s. Young, otherwise healthy men suddenly became seriously ill with unusual opportunistic infections creating a climate of trepidation across the United States. Sean's KS foreshadowed his declining health as he began contracting additional crippling opportunistic infections that reduced him to an invalid prior to death.
Cuban poet and novelist Reinaldo Arenas's memoir, Before Night Falls (2000), chronicled his early escape from an impoverished upbringing only to be punished for living a homosexual lifestyle and incarcerated for evading censor laws. Once freed, he immigrated into the United States to reside in New York City. There, he found himself captive to AIDS and orchestrated his death while riddled with KS.
The renowned film Philadelphia (1993) propelled HIV and AIDS onto the public's radar. The movie focused on Andrew Beckett, an upcoming associate attorney at a prestigious Philadelphia law firm. After a KS lesion appeared on his forehead, he was terminated from the firm under false pretenses. Beckett's struggles to find legal support led him to homophobic lawyer Joe Miller. Once Beckett revealed his KS ridden torso to the jury, he received justice, but soon thereafter perished from an opportunistic infection. (2013) depicted Ronald Woodroof's fight against the once unavoidable destruction of AIDS. As a heterosexual Texas rodeo enthusiast, electrician, and womanizer, he was shocked to learn of his diagnosis in 1985. After his physicians prognosticated his life expectancy at thirty days and referred him to a support group, he took action attempting to control his fate. Unable to wait for drug trials and desperate for treatment, he hustled zidovudine (azidothymidine, AZT) from the local hospital. After consuming toxic levels that almost killed him, Ron abandoned AZT, and traveled the world for therapies unapproved by the United States' Food and Drug Administration. Recognizing the marketability and demand of drugs that could alleviate symptoms and potentially prolong life, he recruited and befriended transgendered business associate Rayon. They created a "buyers club." For a monthly fee, members had unrestricted access to these unapproved experimental therapies. Multiple characters including Rayon are afflicted with KS throughout the film.

Dallas Buyers Club
In Philomena (2013) The Normal Heart Drama 1/9 -Documented Larry Kramer's Tony Award winning polemical drama aimed at the growing HIV/AIDS crisis in New York City -Highlighted character Ned Weeks, an articulate, confrontational, and incendiary gay rights activist intent on indicting the nation by targeting government, medical, and news organizations to gain issue attention The Oscars also acknowledges documentary films containing individuals afflicted with KS to communicate the desperation of the early HIV/AIDS era (Table 2). Common Threads: Stories from the Quilt combined archival news footage with video segments from the loved ones of several homosexuals, a young hemophiliac, and a drug addict, all afflicted with AIDS. Their lives were memorialized on a prodigious quilt. Further, The Broadcast Tapes of Dr. Peter (1993) highlighted key portions of the doctor's regularly televised Canadian news broadcast that focused on his battle with the illness. KS, along with other AIDS associated infections, impaired his daily life and ultimately led to his death. Finally, How to Survive a Plague, (2012) detailed the actions of the AIDS activist groups ACT UP (AIDS Coalition to Unleash Power) and TAG (Treatment Action Group) as they diligently fought for government recognition and government sanctioned treatments in the United States.

Discussion
While modern medicine usually prevents death from sexually transmitted infections, prior to HAART, many HIV infected individuals succumbed to the once fatal diagnosis of AIDS. These Academy Award worthy cinematic masterpieces all incorporate KS to portray HIV/AIDS in the 1980s and early 1990s when HAART was in its infancy. Televised primetime features have also utilized KS to depict this period and have been recognized by the Oscars' counterpart, the Emmys (Table 3).
These films construct a historical timeframe of the HIV/AIDS epidemic. Several comment on the initial inaction of the United States' government, which some may perceive as apathy. Certainly, the dialogue and physical interactions between the characters demonstrate the uncertainty and prevalent terror among the general public at a time everyone was largely ignorant about disease transmission. Movie makeup artists consistently place KS lesions on an actor's face and neck to dramatize AIDS, illustrate HIV's impact on the skin, and ultimately spur viewer empathy. The shame of those afflicted forced isolation and/ or attempts to conceal their lesions with makeup. In the end, KS unifies these characters. It embodies their suffering as it symbolizes disease progression to death and compels the audience to acknowledge human vulnerability.

Conclusion
KS is an archetype of the early devastation of the HIV/AIDS epidemic and will continue to be infused into films chronicling this era. With recognition by the AMPAS, the aforementioned HIV themed movies will persist as reminders of the time the disease first emerged and may serve as fuel for the public, the government, and the pharmaceutical industry to mobilize early to fight and curb future plagues. In the meantime, academic analyses of such films can benefit students interested in health care and historians captivated by the disease. Any curricula focused on HIV/AIDS could harness these cinematic features to help facilitate education. Perhaps these movies can also be used to engage, teach, and glean tolerance from the general public and younger generations on the subject.