HIV Today: What’s Encouraging; What’s Discouraging
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By Lee Jacobs, MD

This and the next few issues of The Permanente Journal will have several excerpts from presentations at the 2007 Fifth National Kaiser Permanente (KP) HIV/AIDS, STD, and Hepatitis Conference held in April in Napa, CA.

I remember the first HIV meeting held in the mid1980s: it was the first interregional conference convened by KP on a clinical topic. I doubt anyone attending that meeting could have foreseen the tragic impact this virus would have on people throughout the world.

What’s Encouraging

During the past few years, there has been real progress in controlling this infection--in the United States and in the developing world. Prenatal transmission in the US is now rare. Viral suppression can be effectively sustained with antiretroviral agents. With the use of antiretrovirals, opportunistic infections have decreased and subsequently the death rate from HIV has fallen dramatically. Rapid HIV tests provide immediate results in cases of occupational exposure and when women with undocumented HIV status arrive for delivery. In the developing world, there is availability of testing and antiretroviral therapy (ART).

What’s Discouraging

Even though there is much to find encouraging, there is still much that is discouraging. There is still a steady rate of HIV acquisition. There are over one million people infected with HIV, 25% of whom, between 250,000 and 300,000 people, are unaware of their HIV infection--and they are infectious! Despite probably being the most knowledgeable group, men having sex with men continue to represent the majority of new infections. Widespread opt-out HIV testing is not being done; thus, patients are only diagnosed when they present with a preventable opportunistic infection. Despite tremendously effective medications, poor adherence by patients results in viral mutation and subsequent failed suppression is all too common. The developing world still has ART acquisition and distribution problems. Although it remains promising, therapeutic and preventive vaccines probably will not be available in the near future. And still there is no cure for HIV infection.

Challenges for the Next Decade

Many perplexing questions highlight challenges for the next decade: Why would a person aware of the risks participate in risky behavior in the face of such a deadly disease? Why would a person who has engaged in risky behavior not present for testing while they are asymptomatic? Why would a person not take their ART medications when the risk-benefit ratio is clear? Take it correctly, you live; don’t take it, you die. What will happen to developing countries when the first wave of antiretrovirals lose effectiveness and newer, more expensive agents are needed?

What Can You Do?

All members of the care system need to be vigilant and to intervene to diagnose the unknown infected early and then take steps to encourage appropriate adherence with therapy.

Specifically, practitioners and other members of the health care team can:

1. Order HIV testing on all patients using the “opt out” approach

2. Take sexual histories as part of all general evaluations and educate as appropriate

3. Continue to emphasize the importance of never missing a dose of ART

4. Offer your professional services to agencies, churches, or other organizations assisting countries throughout the world devastated by this epidemic.

Conclusion

Yes, after 26 years, there is some very encouraging news; there have been major strides forward as a result of ART. However, there is still much to be done if this epidemic is to be slowed pending a future cure. As individual clinicians and health care organizations, we can adopt interventions that will decrease the incidence of new infections and improve the quality of life and longevity of those already infected with this virus.

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