As people in the United States mark World AIDS Day-perhaps with an overly optimistic sense that the pandemic is resolving-the sad reality is that most of the people expected to die from the HIV/AIDS pandemic will do so in the coming decades. Meaning that while a modest reduction in the incidence of new HIV infections has occurred (20% over the past 10 years), the scale of the pandemic is so large that some politicians are concluding that it has out grown global health budgets squeezed by economic woes.
It is hard to believe that HIV/AIDS first appeared on the radar screen of western medicine in 1981. A now famous CDC report issued on June 5th, 1981 described a cluster of five homosexual men in Los Angeles who all had a rare type of pneumonia caused by the microorganism Pneumocystis jiroveci. Feverish work on HIV/AIDS has for many patients turned what was once a death sentence into a manageable medical condition due to the progressive development and refinement of antiretroviral therapy.
However, HIV positive patients can, and do, fail antiretroviral therapy-leaving them no recourse to medically treat their condition. In addition, some HIV positive individuals are unable to tolerate the side effects of antiretroviral therapy. New evidence regarding the long term care of HIV positive patients has noted an increased risk of cancer, such as lung cancer, which previously had not been associated specifically with HIV/AIDS. Meaning that to declare victory over HIV/AIDS and relegate it to the status of just another chronic medical condition is premature to say the least.
Guidelines On When to Start Antiretroviral Therapy Being Debated by Infectious Disease Experts
Today infectious disease experts in the United States are debating whether or not everybody who tests HIV positive should begin antiretroviral therapy immediately. Although a person with HIV may appear perfectly healthy, the HIV virus appears to begin damaging the human body from the first day of infection. Health care research has also found that HIV positive patients who start antiretroviral treatment later in the course of their infection are sicker, reflected by low CD4 counts, and their care is actually more expensive overall than patients who start antiretroviral therapy earlier in the course of their disease. Therefore, a large initial investment in HIV treatment services would pay off in the long run.
The standard of care for HIV/AIDS patients concerning, when is the best time to start antiretroviral therapy, will have global implications. This poses a dilemma for HIV treatment programs in poor countries as such program focus on treating the very sick HIV positive patients first, such as those who have progressed to AIDS.
HIV Prevention Efforts Boosted by Pharmacological Trials
Without a doubt prevention is critically important, both to decrease the burden of HIV/AIDS patients on health care systems worldwide, as well as on the personal level as being HIV positive carries significant stigma and decreases a person’s quality of life.
A recent clinical trial discovered that the combination antiretroviral pill Truvada, (tenofovir/emtricitabine), has been found to offer 44% protection for men (and transgender women) who have sex with men. And a vaginal gel containing just tenofovir has been found to decrease the risk of HIV transmission in women by as much as 50%. Quite possibly other combinations, and dosages, of antiretroviral medications will be tested for use in the prevention of HIV infection.
Many experts believe that the back of the HIV epidemic in the United States could be broken if everybody got tested regularly and if those who tested positive were placed immediately on antiretroviral medications. While starting an HIV positive person on antiretroviral is good for them, it is also good for the public as it appears that antiretroviral therapy drastically decreases the risk that an HIV positive person will transmit the virus to another person.
Despite the successes of pharmacologic interventions designed to prevent HIV infection, public health workers must continually re-educate millions of young adults and teenagers each year as many sexually people don’t remember the early dark days of the HIV/AIDS pandemic. And the younger generations may underestimate the risks of HIV infections due in part to the successes doctors have had treating HIV/AIDS patients with antiretrovirals.
Global HIV/AIDS Pandemic by the Numbers
Overall, new HIV infections are down by about 20% over the past decade. In 1999 it was estimated that there were 3.1 million new HIV infections, and in 2009 that number dropped to 2.6 million. An improvement, though millions of people are still becoming infected each year. The reason for the drop is due to a number of factors, which include improved prevention in some countries, but could also be due to the natural course of the pandemic. In some areas in Central Asia and Eastern Europe HIV infection rates have been on the rise, and it is entirely possible that the global incidence of new HIV infections will rise in the future.
A record number of 33.3 million people are living with HIV, a number which is sure to increase in the decades to come. Though only about 5.1 million people are receiving the antiretroviral medications that they need to both stay alive, and to preserve their health in the longterm.
Global Recession Affecting HIV/AIDS Budgets
AIDS activists have increasingly become vocal against the Obama administration which has rebalanced global health dollars such that the number of poor people positive for HIV living outside the United States will only be slowly added to HIV treatment programs. The thinking, ostensibly, is that it other neglected infectious and preventable diseases, such as malaria, tuberculosis, and malnutrition shouldn’t necessarily be given less funding than HIV/AIDS treatment programs.
Though some commentators suspect that the US doesn’t want to get involved with HIV treatment programs which are “unsustainable”-meaning that treating an HIV positive person for life in the developing world is an expensive and open ended commitment when compared with a focused campaign to tackle malaria over a couple years.
A statement released by Hillary Clinton for the 2010 December 1st World Aids Day reiterated the administration commitment to eradicate HIV/AIDS, but also their desire to use, “lives saved”, as a metric for success. Perhaps a reference to increased funding for global health programs such as malaria prevention, which might possibly save more lives per dollar than HIV treatment programs.
In the final analysis the sad fact is that more money is needed both for HIV/AIDS treatment programs and other global health priorities. However, in the case of HIV/AIDS treatment programs, decreased funding may lead to greater loss in effectiveness.
For example, consider a poor family living in the developing world where one person is on antiretroviral therapy. Let’s say that her sister then becomes HIV positive and also wants to start treatment but can’t due to decreased funding, the sister on treatment may then split her medication with her sibling-inadvertently making both her and her sister’s treatment much less effective.
Despite the need for continued ramp-up in funding for HIV/AIDS programs, the United States has grown increasingly upset with the lack of funding for global HIV/AIDS programs from other countries, such as rapidly industrializing China which has accepted about $1 billion in HIV/AIDS funds since 2002 and has donated only token amounts. The Obama administration has urged countries hard hit by HIV/AIDS to devote more of their budget to health care and the HIV/AIDS pandemic, and many of them already do this.
Declining News Coverage
Over the past two decades the media coverage of the HIV/AIDS pandemic has dropped by 70%, with the largest drop among American and French newspapers. This is ironic given that the HIV/AIDS pandemic continues to affect a growing percentage of the world’s population due to people with HIV living longer with new medications and to the relatively high number of new infections each year.
Pockets of High Prevalence of HIV Persist
South Africa has an estimated 5.7 million HIV positive citizens, out of a total population of about 48 million. And it is expected that even with increased funding there will be another 5 million infections over the next twenty years under the best case scenario, and possibly as many as 7.5 million should global HIV/AIDS funding remain steady. While many public health officials in South Africa wish that the country had focused more on prevention and treatment in the early stages of the HIV epidemic in the country, in the decades to come more countries could be faced with South Africa’s dilemma if funding for treatment and prevention programs is not drastically increased.
Can We Treat Our Way Out of the Pandemic?
The Institute of Medicine (IOM) recently released a report which judged the costs of antiretroviral treatment in Africa to be “unsustainable.” According to the IOM, by 2020 cases of HIV/AIDS will greatly outweigh resources for treatment with antiretroviral medications, such that preventive measures should be focused on to deal with a growing HIV/AIDS population which may reach 70 million by 2050. The lack of resources that the IOM describes is not merely monetary, but rather a human resource issue as well as many countries in Africa are lacking trained health care workers.
The IOM also referred to the 4 million sub-Saharan Africans receiving antiretroviral therapy as the “tip of the iceberg” in terms of the estimated 18 million people who are going to need treatment. A best case scenario offered by the IOM predicts, that by 2020, 7 million HIV positive Africans will be receiving treatment.
The IOM also evaluated the general concept of a “test and treat” strategy using regular testing and immediate treatment as a form of prevention-but concluded that large scale use of such a strategy has not been tested at the population level in well designed studies, and that it would likely not be logistically possible to use such a strategy in a resource poor setting at the present time. However, test and treat could theoretically work in a resource poor setting where treatment and monitoring were greatly simplified, according to the IOM, and could in the future become an important part of an overall prevention strategy.
New technology may boost the feasibility of such a test and treat approach. For example, rapid HIV tests are being developed which could produce test results within minutes, meaning that potential patients could be tested and started on treatment by the same person. Furthermore, should a novel form of antiretroviral therapy, such as a combination pills which just needs to be taken weekly, become available then HIV positive individuals could be given enough medication for a long period of time.
The most effective preventative measures outlined in the IOM reported were:
1. Prevention of mother to child transmission of HIV.
2. Male circumcision.
3. The vaginal microbicide containing the antiretroviral Tenofovir.
4. Large scale counseling and testing.
A disconcerting conclusion that the IOM makes is that the United States is stuck in an ethical dilemma concerning the provision of HIV treatment as some experts have concluded that HIV treatment is “not sustainable” for the vast majority of HIV positive Africans. The solution appears to be to shift the increasing burden partially on to the shoulders of poor countries in the hopes that the fast growing African economy will be able to pay for the bulk of this care of HIV positive patients in the decades to come. From a certain point of view, the IOM portrays the United States as trying to figure how to extradite itself from shouldering the major burden of the HIV/AIDS pandemic, as though the pandemic was a global health Vietnam which would drain American resources from more important efforts.
Pessimistic as the IOM report may be, it can’t of course take into account the evolving science of HIV prevention and treatment, which may over the next decade produce novel and highly effective new ways to deal with the pandemic.
Institute of Medicine
Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility
2010 Provisional Report Released in Advance of December 1st, 2010 World AIDS Day