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Journal Watch AIDS Clinical Care is about to turn 20, and to mark the event, we’ve asked our editors to provide us with a brief response to the question, “What do you feel is the biggest change in HIV medicine in the past 20 years?” We hope you agree that this anniversary is a cause for celebration, as progress in this field has been nothing short of astonishing. The first issue contained a review of gastrointestinal symptoms in AIDS, a primer on how to tell patients that they had AIDS, and a Q&A on whether positive attitudes and dextran sulfate influenced disease progression; my first task with Journal Watch AIDS Clinical Care was to write a Patient Education series, which included topics such as managing chronic indwelling venous catheters and the basics of opportunistic infection prophylaxis. Reading these documents today is a thrilling reminder of how far we’ve come in HIV treatment, as current topics focus more on non–AIDS-related complications and on how survival in our patients is beginning to approach that of people without HIV than on opportunistic infections and end-of-life care. Looking forward, we’re convinced that progress in HIV therapy will continue — not just in the developed world, but increasingly in the regions most devastated by the epidemic.
The availability of potent antiretroviral therapy in the developing world has highlighted the challenges of HIV and TB coinfection. The potentiating effects of TB and HIV on each other have created a unique set of challenges encompassing TB diagnosis, TB–HIV drug interactions, choice of ART regimen, decisions regarding when to start ART, adherence to both treatments, immune reconstitution inflammatory syndrome, TB drug resistance, and the operational difficulties in integrating HIV and TB care.
— Salim S. Abdool Karim, MD, PhD
Certainly, the advent of potent combination antiretroviral therapy, which transformed a uniformly fatal illness into a treatable chronic disease, comes to mind. But that alone does not capture the essence of the worst epidemic the world has ever seen, now affecting >1% of the world’s population, or the fact that, more than any other illness, HIV is affected by its sometimes overwhelming nonmedical aspects (political, sexual, financial, psychological, philosophical, etc.). For me personally, in the ’80s, when all mountains had been climbed and all seas had been catalogued, this epidemic gave me the chance to see (and be the first to describe) several illnesses that no one else had seen before. HIV also gave me the opportunity to meet, collaborate with, and fight this fight with many incredibly talented and remarkable people.
The most striking accomplishment in this field in the past two decades is the unprecedented collaborative effort in research that has led to countless advances in clinical care. HIV researchers and providers, working together, have been able to effect change in a dramatic way in a relatively short period of time. When I think about where we are today, in comparison to where we were 20 years ago, with regard to drug development, clinical care guidelines, and research and treatment in liver, cardiac, and oncologic complications, I am overwhelmed by how much can be accomplished when you combine compassion, dedication, and persistence, together with financial support.
The prognosis for someone diagnosed with HIV in the U.S. in 2009 is dramatically improved compared to 20 years ago, and armed with this new outlook, I now have the highest expectations of what is possible for my patients and their long-term survival. Fewer people living with HIV have failed all available treatment options, and when faced with someone in that situation, I now expect to be able to figure out a treatment that will work, rather than accepting the limitations of our treatments. It is now much, much harder to give up hope.
Having practiced HIV medicine for the past 20 years, I see two things as the biggest changes. One has been good — the availability of potent antiretroviral therapy and thus the fact that HIV has stopped being synonymous with a death sentence. And one has been not so good — the demographic shift we have seen in the U.S. in who is affected with HIV now compared to 20 years ago (see table).
The Distance Traveled in the Last Twenty Years
Internist again
Chantix, lipids, mammograms,
joyously mundane.
The biggest change has been the dramatic life-saving and life-prolonging benefit of antiretroviral therapy — and historic and successful extension of this treatment benefit to people living with HIV and AIDS in Africa and other resource-limited settings.
Dreams Come True
1989 seems like a nightmare so many years ago. At the time, the concept of simple, once-daily, effective AIDS treatments that could prevent disease, death, and transmission — allowing HIV-infected persons to lead near-normal lives — could only be imagined in a dream. Pinch me.
In 1989, perhaps the hardest part of being an HIV doctor was discussing the future with a new patient — what OIs to look out for, what expected survival was, what side effects came with AZT (the only treatment available), what happened after AZT stopped helping, how to sell your life insurance to get enough money to survive the years left — and doing all that while trying to keep a sense of optimism going. In 2009, perhaps the greatest pleasure of being an HIV doctor is discussing the future with a new patient — if you take your medicine, the chance of long, healthy life seems almost certain; taking the medicines is easier than most people believe; lots of options are available if the first regimen doesn’t succeed — and being an optimist is an easy part of the deal. What could be better?
The biggest change is the availability of effective therapy. I’ll never forget the first patient of mine who started a PI-based regimen in 1995 in a clinical trial — his CD4-cell count had been well under 50 for years, yet suddenly it was 110, and then a few months later over 200. Today he’s alive, working full-time, and his CD4 count is normal. This seemed like a miracle to me then — and still does today.
The big difference between then and now is that HIV/AIDS is rapidly normalizing into a disease just like any other disease. This change brings both good and bad: The best of the good, of course, is that effective treatment is possible. The worst of the bad may be the fact that our patients are now in the miserable medical marketplace along with everyone else — and that we are in there too!
