Progress against AIDS, but no time for complacency

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For those of us who had the tragic, frustrating experience of caring for AIDS patients in the last two decades of the 20th century, advances announced at last month s International AIDS Conference in Washington were nothing short of miraculous.

Our nation s drug regulators, the FDA, approved a pill to markedly reduce the transmission of HIV, the virus that causes AIDS, among high-risk patients who were HIV-negative. The drug Truvada is actually a 2-drug combination, and to achieve maximal protective efficacy it must be taken every day. But given the numbers of HIV positives in America, any reduction in transmission will yield significant benefits in terms of both lives saved and healthcare expenditures.

The other breakthrough was the approval for widespread use of a rapid, private, at-home test for HIV using saliva, not blood. This test called OraQuick costs only about $60 and gives a result in about one-half hour, with good (but not perfect) reliability.

Why is this test so important? The statistics about AIDS in the U.S. are surprising, indeed disturbing. Despite having several types of drugs to control (but not cure) HIV, fifty thousand Americans contract the virus each year, and almost twenty thousand die. While these figures are dwarfed by the epidemic s toll in Africa, Asia and Eastern Europe, given our advanced healthcare system, this toll is unacceptable. So why is it such a serious ongoing problem? Doesn t everyone know by now how to avoid contagion, and control it if infection occurs?

Well, yes and no. There are about 1.2 million HIV positive Americans, and one-fifth of them 240 thousand do not even know they are infected! It goes without saying that if you don t know you re HIV positive, you re not going to be too concerned about passing it on to a sex partner.

Those at highest risk of contracting the virus are men who have sex with men (MSM), women partners of HIV-positives, and intravenous drug users. This has been well known almost since the epidemic began here in 1981, but even then when being an HIV carrier was a death sentence many people in high-risk groups continued to practice unsafe sex, or to share needles with other addicts of unknown HIV status.

Vigorous educational campaigns helped to reduce unprotected sex among MSM until, paradoxically, the discovery and development of numerous effective drugs against HIV s proliferation led to an attitude of complacency. One isn t going to be quite as careful about asking tough questions of a new friend, nor in using condoms each time, when the virus can be considered a treatable chronic disease, versus a lingering death sentence.

The virus has reared its ugly head with increasing frequency because many who should be, don t bother to get tested: a head in the sand attitude, leading to lack of safe sex practices. Only about one-third of HIV patients are getting effective treatment, an unbelievable failure of public-health outreach. Those groups most likely to have and transmit the virus and get infected are the same groups least likely to be on good treatment: the young, black, and poor.

Modern anti-retroviral drugs, if taken as directed, would reduce viral loads to such a low level that not only would the patient not get sick they would be unable to spread the infection, with or without condoms.

Why has the disease not been tamed, then?

¢ Complacency mixed with fear of learning the truth, as I mentioned;

¢ Fear of being identified, among friends, family or co-workers;

¢ Expense: of seeing the doctor, of getting the (older) test, and especially of the medications: HIV pills costs run from a few hundred to over one-thousand dollars each month. Comprehensive, often employer-based health insurance will cover most of that cost, but the government-sponsored insurance for the poor, Medicaid, often does not (it varies from state-to-state).

This discussion illuminates why the recent advances may well prove to be a tipping point in the battle against AIDS. If a simple, rapid, private at-home test for HIV is widely available, hopefully a significant fraction of those whose HIV-positive-status is not known to them will find out, and take appropriate measures. And the pill to prevent infection in negative patients should also help to reduce transmission.

Does these new modalities mean the end of the AIDS epidemic? No. But they could indicate that the end is in sight.