by Timothy Flanigan, MD, director of the Samuel and Esther Chester Immunology Center at The Miriam Hospital
Within the last six months, HIV- and AIDS-related deaths in this country have fallen dramatically. AIDS is no longer the number one cause of death among men and women between the ages of 25 and 44. What caused this dramatic change in an epidemic which first appeared just 15 years ago?
Within the last three years we have gained a new understanding of the biology of this virus, which now infects almost one million Americans. HIV replicates continuously at a rapid rate, infecting every organ of the body, and is never inactive. We can now track the level of replication through new measurements. Although we cannot cure HIV, we now can suppress it.
When HIV and AIDS were first identified, we fought the virus as we did in the early years of treatment of tuberculosis, by using one drug at a time and switching to another medication when the treatment effects started to wane. Within the last two years we have learned that (again like TB) we have to use multiple drugs simultaneously to actively suppress HIV and prevent resistance. With the advent of highly effective new drugs called protease inhibitors, our combination therapies now are able to inhibit HIV to the point that we can no longer detect it. Patients who are severely ill often recover dramatically in six months: many clinicians have described this as the "Lazarus Effect."
On the other hand, not all patients respond. The infection is not cured. Not all patients can follow very complicated medical regimes which may include taking 20 pills per day. Cost is an issue; depression, violence, and lack of support are also real barriers to care. Not all patients can break the cycle of drug addiction or alcoholism. Finally, few of the drugs are available to those in Africa, Asia and Latin America who are infected with HIV.
The newfound hope resulting from the discovery of highly effective antiretroviral therapy is exhilarating both for caregivers and for patients. The challenge is how to make it available to all patients and provide not just medications but support, care and compassion to persons afflicted with this virus.