The first time that I remember hearing about HIV/AIDS was the day the principal of my elementary school retired in 1993. We were at an assembly and the principal was speaking, giving a resignation speech. I was paying more attention to my feet than anything else but as he finished, I looked up and saw that all of the adults in the room, including my mother, were crying. I asked her what was wrong and she told me he had AIDS. It would be a long time before I really understood what this meant. (correction: my mother informs me she does not remember this happening).
Flash forward: I am a college graduate working in a multidisciplinary clinic caring for HIV positive patients and I have been given the opportunity to attend the International AIDS Society conference in Washington DC. It is absolutely incredible how far medicine has progressed in less than 10 years.
In remembrance of 1993: there was only one drug available for treatment. Zidovudine, which was first marketed in 1987, is a nucleoside reverse transcriptase inhibitor or "NRTI". It is the only anti-retroviral drug currently available in intravenous formulation and is still used in patients today. However, in light of the most current guidelines, it is shocking to think of using a single medication in treatment of HIV, which mutates rapidly. Current drug regimens typically include two NRTIs and a third medication from a different medication class. The first protease inhibitor did not become available until 1995. In 1993, there were already multiple case reports of drug resistant strains of HIV to the only available drug, zidovudine, developing after the patient had been on the medication for six months or longer.
Aside from the vast medical advances we have made in the treatment of HIV, it is also worth reflecting how global society has changed since the CDC first recognized HIV in 1981 to the day my principal retired in 1993 to today. In the 1980s, a diagnosis of HIV, a virus well known but not well understood, was a death sentence. The introduction of antiretrovirals provided hope but fear continued to run deep in 1993 and today.
A week ago at the AIDS 2012 conference Hillary Clinton called for an AIDS free generation, an incredibly bold statement that may in fact be feasible if governments, societies, and health-care professionals continue to fight. I think that making a distinction between an "HIV free generation" and "AIDS free generation" is important to make at this moment. Hillary's plan outlined in her speech focused primarily on increasing efforts at prevention of new infection, but separating the idea of an AIDS free generation from that of an HIV free one would indicate that improving the quality of care for our HIV positive patients could prevent AIDS and allow all patients with a positive status the right to a long and healthy life.
AIDS, or Aquired Immune Deficiency Syndrome, occurs when the human immunodeficiency virus has destroyed enough of the immune system that it is no longer able to prevent the patient from contracting infections that healthy individuals would not be subject to. Preventing AIDS would include:
- Test more people: many patients receive a diagnosis of AIDS along with a HIV diagnosis upon initial presentation. The CDC recommends that all individuals between 13 and 64 years of age receive at least one HIV test in their lifetime and more frequently if they engage in high risk behavior, ie unprotected anal sex and sharing needles.
- Improve follow up. Many patients receiving a diagnosis of HIV/AIDS never follow up and therefore are unable to receive treatment which would likely result in the progression of their disease to AIDS.
- Get more patients on treatment: medications are expensive but there are a number of assistance programs available. From a global perspective, many countries reserve treatment for when patients develop AIDS because limited treatment options in certain countries increase the risk of developing resistance or losing control of the epidemic if resistant strains are widespread. The type of intervention for improvement would depend on the country.
- Get more patients to an undetectable viral load on treatment: This means that the medication is working and the patient is taking it like they are supposed to. Unfortunately, HIV hides in certain cells and there is no cure for HIV currently, but having an undetectable viral load allows for the immune system to recover. In a presentation at the conference, it was estimated that about 50% of HIV positive patients (including those not yet tested) had an undetectable viral load versus about 25% of HIV positive patients in the United States.
I was also fortunate enough to attend a profound session moderated by Laurie Garrett, the author of "The Coming Plague", the book that sparked my interest in epidemiology and public health. She began with a quote from the World Health Organization:
"The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries." In other words, how do government, health care structure, social norms and culture influence a person's health?
Also on the panel was Dr. Nono Simelela who ran (runs?) the South Africa AIDS counsel and continues to work closely with the current president. Ms. Garrett set the stage discussing that in a society where 1/3 of the population is HIV positive, people in the society became fatalistic. They saw HIV as unavoidable with death at its heels, and as a result, this fatalism contributed to increased unemployment and further reduced morale.
Dr. Simelela responded saying that it truly is an epidemic of depravation. Aside from looking for funding for HIV programs, South Africa analyzed the gains already made and uses allotted funds to not only move forward, but to ensure that the gains made are not lost. On striving for an AIDS free generation, she discussed the need to get more people involved. It will not work if it is only government officials changing laws, everyone will need to be an educator. Patients may spend a few hours with a health care professional per year if they choose to access the health system, but that does not account for the 5000+ hours spent doing everything else. HIV is an issue that needs to be discussed from different angles. If people are not talking about it in terms of helping things progress, then little will be gained by society.
I could go on for pages over what I saw at the conference and what was said in this session, but I will end with a quote from a member of that panel, Michaela Clayton, who works in Namibia:
We don't defend human rights because people have HIV, we defend human rights because people have human rights.
References:
http://www.kff.org/hivaids/timeline/hivtimeline.cfm
Erice A et al. Primary infection with zidovudine-resistant human immunodeficiency virus type-1. The New England Journal of Medicine 1993; 328:1163-5.
http://www.who.int/social_determinants/en/
Asch DA et al. Automated hovering in health care - watching over the 5000 hours. The New England Journal of Medicine 2012; 367(1):1-3.
In remembrance of 1993: there was only one drug available for treatment. Zidovudine, which was first marketed in 1987, is a nucleoside reverse transcriptase inhibitor or "NRTI". It is the only anti-retroviral drug currently available in intravenous formulation and is still used in patients today. However, in light of the most current guidelines, it is shocking to think of using a single medication in treatment of HIV, which mutates rapidly. Current drug regimens typically include two NRTIs and a third medication from a different medication class. The first protease inhibitor did not become available until 1995. In 1993, there were already multiple case reports of drug resistant strains of HIV to the only available drug, zidovudine, developing after the patient had been on the medication for six months or longer.
Aside from the vast medical advances we have made in the treatment of HIV, it is also worth reflecting how global society has changed since the CDC first recognized HIV in 1981 to the day my principal retired in 1993 to today. In the 1980s, a diagnosis of HIV, a virus well known but not well understood, was a death sentence. The introduction of antiretrovirals provided hope but fear continued to run deep in 1993 and today.
A week ago at the AIDS 2012 conference Hillary Clinton called for an AIDS free generation, an incredibly bold statement that may in fact be feasible if governments, societies, and health-care professionals continue to fight. I think that making a distinction between an "HIV free generation" and "AIDS free generation" is important to make at this moment. Hillary's plan outlined in her speech focused primarily on increasing efforts at prevention of new infection, but separating the idea of an AIDS free generation from that of an HIV free one would indicate that improving the quality of care for our HIV positive patients could prevent AIDS and allow all patients with a positive status the right to a long and healthy life.
AIDS, or Aquired Immune Deficiency Syndrome, occurs when the human immunodeficiency virus has destroyed enough of the immune system that it is no longer able to prevent the patient from contracting infections that healthy individuals would not be subject to. Preventing AIDS would include:
- Improve follow up. Many patients receiving a diagnosis of HIV/AIDS never follow up and therefore are unable to receive treatment which would likely result in the progression of their disease to AIDS.
- Get more patients on treatment: medications are expensive but there are a number of assistance programs available. From a global perspective, many countries reserve treatment for when patients develop AIDS because limited treatment options in certain countries increase the risk of developing resistance or losing control of the epidemic if resistant strains are widespread. The type of intervention for improvement would depend on the country.
- Get more patients to an undetectable viral load on treatment: This means that the medication is working and the patient is taking it like they are supposed to. Unfortunately, HIV hides in certain cells and there is no cure for HIV currently, but having an undetectable viral load allows for the immune system to recover. In a presentation at the conference, it was estimated that about 50% of HIV positive patients (including those not yet tested) had an undetectable viral load versus about 25% of HIV positive patients in the United States.
I was also fortunate enough to attend a profound session moderated by Laurie Garrett, the author of "The Coming Plague", the book that sparked my interest in epidemiology and public health. She began with a quote from the World Health Organization:
"The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries." In other words, how do government, health care structure, social norms and culture influence a person's health?
Also on the panel was Dr. Nono Simelela who ran (runs?) the South Africa AIDS counsel and continues to work closely with the current president. Ms. Garrett set the stage discussing that in a society where 1/3 of the population is HIV positive, people in the society became fatalistic. They saw HIV as unavoidable with death at its heels, and as a result, this fatalism contributed to increased unemployment and further reduced morale.
Dr. Simelela responded saying that it truly is an epidemic of depravation. Aside from looking for funding for HIV programs, South Africa analyzed the gains already made and uses allotted funds to not only move forward, but to ensure that the gains made are not lost. On striving for an AIDS free generation, she discussed the need to get more people involved. It will not work if it is only government officials changing laws, everyone will need to be an educator. Patients may spend a few hours with a health care professional per year if they choose to access the health system, but that does not account for the 5000+ hours spent doing everything else. HIV is an issue that needs to be discussed from different angles. If people are not talking about it in terms of helping things progress, then little will be gained by society.
I could go on for pages over what I saw at the conference and what was said in this session, but I will end with a quote from a member of that panel, Michaela Clayton, who works in Namibia:
We don't defend human rights because people have HIV, we defend human rights because people have human rights.
References:
http://www.kff.org/hivaids/timeline/hivtimeline.cfm
Erice A et al. Primary infection with zidovudine-resistant human immunodeficiency virus type-1. The New England Journal of Medicine 1993; 328:1163-5.
http://www.who.int/social_determinants/en/
Asch DA et al. Automated hovering in health care - watching over the 5000 hours. The New England Journal of Medicine 2012; 367(1):1-3.
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