HIV / AIDS treatment dramatically reduces mortality and helps limit transmission

There is still no cure or vaccine. People are still dying. Transmission rates are still alarming in some parts of the world (sub-Saharan Africa) and in parts of the United States (the South-East).

And yet, and yet …

There is no doubt that HIV / AIDS mortality rates have dropped from a peak in the United States of 41,699 in 1995 to 6,456 in 2015 (the latest year for which statistics are available). HIV / AIDS treatment is a story of success in health care. In 1994, HIV / AIDS became the leading cause of death among Americans aged 25 to 44 years. In the United States, an estimated 675,000 people have died of AIDS since the first report on a mysterious lung infection in North America. Weekly report on morbidity and mortality in 1981. There is now serious talk of eradicating the disease in this country, starting with Robert Redfield, director of the CDC and former AIDS researcher. "I think it could be done in the next three to seven years, if we think about it," he said in March.

And on an individual basis, the message addressed to a patient is quite different and optimistic. "We can literally tell people newly diagnosed with HIV that if they take their medications, their survival will be measured in decades, not months or years," says Paul E. Sax, MD, clinical director of the HIV and AIDS program. from the Division of Infectious Diseases at Brigham and Women's Hospital Boston. "And that they can live as long as a person who is HIV-negative."

The first discovery took place in 1987 with AZT, the first FDA-approved antiretroviral drug to show some efficacy against HIV, although it had serious side effects, including anemia. In 1995, the FDA approved the first protease inhibitor, saquinavir, which was approved by ritonavir and indinavir. They marked the beginning of an era of treatment with highly active antiretroviral therapy (HAART). In 1997, HAART became the new standard of care and AIDS-related deaths decreased by 47% in 1997 compared to 1996.

The success of HIV / AIDS treatment has had a ripple effect, notes David Hardy, MD, AIDS researcher at George Washington University. The obvious example, he says, are the antiviral drugs for hepatitis C.

Paul E. Sax, MD

So why are there no annual parades for victory? On the one hand, the slow response of the government at the beginning of the epidemic means that many people have suffered and died. And there is danger in complacency, notes Sax. "Because with infectious diseases, if you turn your back on them, you're not providing enough resources and support, they can come back in strength."

HIV transmission remains a major public health concern. Condoms help. Adherence to HIV / AIDS treatment reduces the risk of transmission by infected individuals. Pre-exposure prophylaxis (PrEP) is another tactic used by those at risk of contracting the infection, but who have not yet been. The therapeutic regimen for PrEP is taking daily doses of tenofovir and emtricitabine (they are combined into one tablet and sold as Truvada, a brand name drug). According to the CDC, this can reduce the risk of contracting HIV infection by 92%.

"You know that for people who attend the clinic regularly and who are involved in the care, the compliance is actually quite good," says Sax. For many of his patients, it's like running on wheels. "These are the kinds of people who, when they change their time zone, always take their medications at the same time. But there is a small group of people who just can not get together to take the medicine. And that's one of the challenges. It seems difficult to get these people treated.

Another challenge is to take care of people living with HIV / AIDS in their last years. They have higher rates of heart disease, but also strokes, diabetes, liver disease and kidney disease. "It may be due to drugs or long-term infections," says Hardy. That's what he said in April in a Washington Post story about this problem.

More study is needed. Or, as Hardy says, we still do not know.

We do not know for sure because people living with HIV did not live long enough for providers to document their long-term health needs. And that brings us back to where we started.

"It's really amazing," says Sax, "of the evolution of HIV / AIDS from a death sentence to a treatable chronic disease. "This is one of the great success stories in the history of medicine."