In the past 40 years the world made significant improvements in preventing the spread of HIV/AIDS and treating those afflicted with the disease. Education about the disease’s true nature effectively lowered the incidence rate, or the number of new infections each year. International collaborations between scientists boast promising studies pertaining to advanced prevention and treatment options. In turn, these studies garner millions of dollars in research grants to continually propel the search for a cure. This article provides a brief summary about the origin of the disease and recent progress in HIV/AIDS treatment and prevention.
Spreading silently across America and other parts of the world in the late 1970’s and early ’80s, human immunodeficiency virus (HIV) and its advanced form called acquired immunodeficiency syndrome (AIDS), claimed the lives of millions of people worldwide before finally being identified by the medical community. Scientists around the world concur that the virus originated in a species of chimpanzee located in West Africa. The primate version of HIV is referred to as simian immunodeficiency virus, or SIV. Over time, a mutant form of SIV evolved into a strain capable of transmitting across species, specifically from primate to human. Genetic analysis of blood samples led scientists to conclude that the first few cases of HIV originated from a single SIV strain around early 1930. Although not officially documented, the cross-species transmission likely occurred in humans who hunted and ate chimpanzees, coming into contact with the virus via contaminated blood.1 During this time European powers, specifically the French and Belgians, exasperated the spread of the virus while plundering Africa for the continent’s natural resources like rubber and ivory. The colonizers forced many natives to work for them and collect the resources. Once harvested, these resources needed to be transported to the coast in order to be exported so the Europeans coerced local tribes into build railways. Over the course of this campaign the foreigners would transport natives hundreds of kilometers from their homes. European medical professionals would continuously administer series of vaccines to protect their work force, yet they did so with unsterilized needles. In some cases a few hundred people would receive injections with just a handful of syringes. Due to the fact that these needles were handmade, thus expensive, doctors reused needles and essentially offered the virus its most efficient method of transmission, blood transfusion. Although well intentioned, vaccine campaigns for other illnesses offered copious possibilities for transferring contaminated blood from one person to another. In one instance, French doctors injected 80,000 workers with a sleeping sickness vaccine, using only six needles total. Working under inhumane conditions, the malnourished laborers could not support an optimal immune system performance, even before HIV infiltrated their bodies. Additionally, it was not rare for workers to visit prostitutes in the labor camps and engage in unprotected intercourse, further spreading the unknown disease. The virus likely originated in Africa but European colonization efforts proved to be the ideal catalyst in setting up HIV to be one of the most lethal pandemics in human history.2
On June 5th, 1981, the U.S. Centers for Disease Control and Prevention (CDC) intended to publish the unusual incidence of Pneumocystis carinii pneumonia (PCP), a rare lung infection that afflicted five homosexual and previously healthy young men in Los Angeles. Several other opportunistic infections presented in their bodies, leading physicians to presume that each patient's entire central immune system was suppressed or compromised, rather than the issue being confined to a single organ or specific body function. By the end of the week, two of the five men died before the CDC published the report.3 A few days later, multiple accounts of PCP, Kaposi’s Sarcoma (a rare and particularly aggressive cancer), and other atypical infections that would not normally debilitate healthy young men, were reported. The reports found that these outbreaks occurred in groups located in close proximity to each other.3 A disabled immune system can result from any number of health factors such as genetics, environmental toxins, cancers, or infectious diseases, thus, a debilitated immune system offers little help to scientists who hope to identify the disease-causing agent. The lack of any signature symptoms presented a unique obstacle in identifying and containing the spread of the unknown pathogen (i.e., any disease causing microorganisms). The only immunological indication suggesting that the elusive underlying disease in question was present was the fact that “absolute lymphocyte counts, T-cell counts, and lymphocyte proliferation were depressed and that humoral immunity was intact”.4
The demographic of people considered high-risk individuals (i.e., those more likely to contract the disease) consisted of homosexual men, African American men, drug users, or those who identified as all three. The diseased individuals predominantly appeared in clusters in California and New York.5 This clustering of atypical cancers and opportunistic infections (or diseases that do not normally surpass a healthy individual’s defense mechanisms) further supported the hypothesis that the responsible pathogen targeted the entire immune systems of a particular high risk demographic, rather than a specific sub-function or unit of the immune system itself.
Human immunodeficiency virus (HIV) is a virus that spreads from person to person through certain types of bodily fluids such as blood, semen, pre-seminal fluid (pre-cum), rectal fluids, vaginal fluids, and breast milk (see Transmission section). Viruses, by nature, are not considered “alive” because they lack the ability to reproduce without the aid of a host cell. Thus, the virus targets the immune system’s CD4 cells as their host. CD4 cells, also known as T-cells and T-helper cells, are lymphocytes (white blood cells). Their main function is to alert the immune system once they detect invaders like bacteria or viruses so that the body can mount a defensive response. These T-cells, or T-helper cells, coordinate cellular components of the immune system. Once a pathogen is detected, CD4 cells mobilize the immune response mechanism of the body.6 HIV is a particularly difficult pathogen to fight because its mechanism of action is to target and compromise the very body cells responsible for detecting infections such as HIV/AIDS.6 Once HIV is inside a CD4 cell it hijacks its natural reproductive machinery and uses it to replicate viral DNA instead of the cellular DNA that it should be making, all the while eluding detection by hiding inside the very cells responsible for detecting the virus. As HIV infiltrates, replicates, and destroys the CD4 cells, opportunistic infections gain considerable advantage in the fight against the immune system. This process is similar to a battle in which the pathogen destroys all communicating and organizing abilities of the immune system.6
In the beginning, HIV remains dormant and hidden within the CD4 cells. After a quiet period of 10 to 15 years, during which the virus replicates inside the white blood cells, kills these essential cells, and remains undetected by the immune system, the body finally becomes incapable of fighting off minor diseases like pneumonia, fungal infections, and weak cancers. At this point, a physician would diagnose a patient with fully acquired immunodeficiency syndrome, or AIDS. HIV does not directly kill the host, but rather weakens the host’s immune system to the point where a minor cold poses a lethal threat.6, 16
Symptoms of HIV vary from person to person. Depending the advancement of the infection, the immune system of the individual, and other nutritional or environmental factors, people tend to remain asymptomatic and unaware that their bodies are harboring the lethal virus. The first stage of HIV infection is acute HIV infection. There are very subtle, and usually not easily identifiable, symptoms associated with this period in the infection. This, in combination with a spike in viral load (the amount of HIV present in the host’s body), makes the acute HIV infection stage the most infectious period of the illness. This period begins anywhere from 2 to 4 weeks after a person is infected with HIV. Some symptoms that occasionally surface share common features to those that accompany the flu. These symptoms may be anything from a sore throat to a fever or a rash. 6
AIDS produces far more severe symptoms. Swollen lymph nodes, diarrhea, and weight loss commonly accompany the onset of AIDS. Eventually, if overlooked, these symptoms develop into tuberculosis, lymphoma cancers, Kaposi’s sarcoma, and many more.
Stigma and Discrimination
The primary population that initially succumbed to the mysterious disease the homosexual community; they had already endured stigmatization and ostracism due to their sexual orientation. This discrimination, or homophobia, combined with mass hysteria following the quick spread of an obscure and lethal pathogen, proved detrimental in the effort to persuade the public to fund research and treat the at-risk demographic in a compassionate and humane manner. Over twenty years after the start of the epidemic, discrimination and inequity still impeded the movement to encourage education, decrease the occurrence of new cases, and persuade diseased individuals to pursue treatment. In 2013, a study by Stangl et al. suggested that both refraining from HIV testing and not informing partners of an infection strongly correlate to the HIV/homosexual stigma and greatly hindered the medical community’s prevention efforts.7
Iconic Victims and Awareness
The first wave of heterosexual people who refrained from drug usage, yet still contracted the infection, shocked the world and lent their names sympathy and fame. Although unquestionably tragic, their hardships and celebrity status threw considerable weight behind the movement giving it the momentum it needed to spread accurate education about the disease.
Those who did not fall in the aforestated at-risk demographic still suffered the effects of the HIV/AIDS stigma, such as the case of Ryan White. In 1985, the teenager from Indiana received a blood transfusion to treat his hemophilia, a genetic disease that impleads the body’s ability to form blood clots. He contracted the initial infection from a blood transfusion contaminated with HIV. The public school’s administration banned him from the campus because other students and parents feared the spread of the disease, despite the fact that it was a medical mistake that led to his sickness and there was available scientific knowledge that the pathogen could not spread without the transfer of the previously stated bodily fluids. This type of transfer is not typical of normal contact between people, especially those in middle school. After months of receiving seventh-grade class lessons over the telephone, he won the legal battle for the right to attend school.8 Ryan White died at the age of 18.
Elton John, a homosexual and beloved celebrity, attended Ryan White’s own funeral to raise awareness that anyone can suffer from HIV/AIDS. Unlike a significant portion of the population at that time, the crippling disease did not discriminate between potential victims. Elton John was not the only celebrity to use his iconic status in an effort to dampen the spread of the disease.
Earvin (“Magic') Johnson
In 1991, Earvin (“Magic”) Johnson publicly stated that he contracted HIV. He retired from basketball, the sport that made him famous, in order to teach the youth about the stark nature of the virus.9
Soon after Magic Johnson’s announced retirement, Freddie Mercury (the lead singer of the rock band Queen), publicly disclosed that he suffered from AIDS. Mercury died the very next day.10 His unexpected death shocked the young population of the UK, and the awareness that followed spread worldwide.
Risky Behavior and Prevention
Engaging in certain “risky behaviors” increase the chances of contracting HIV when exposed to the virus. In this case risky behavior refers to sharing needs during drug administration or engaging in unprotected sex.11 Forms of prevention that decrease the chances of contracting the disease include using a condom correctly and refraining from drug usage. Even if the drugs are administered with clean needles, or do not require injections at all, like alcohol, they still impair judgment and increase the chances that condoms are not used or are used incorrectly.
Despite the initial stigmatization of the disease, which was largely due to the fact that the majority of cases predominantly afflicted those who identified as homosexuals, it is now understood that HIV/AIDS transmits from person to person one of several ways.
In 1983, the CDC received reports of two separate cases concerning females involved in relationships with their male counterparts who suffered from AIDS. These females exemplified widespread immunological deficits. This indicated for the first time that the disease could spread via heterosexual intercourse.12
Mother to Child
The pathogen may also pass from mother to child at any point during pregnancy or childbirth. HIV transmission can occur through breastfeeding or during delivery. Without any medical intervention, there is a 15% to 45% chance that the baby will contract HIV. However, with medical attention and antiviral drug treatment, that rate can be reduced to less than 5%.13
Blood Transfusion Needle Sharing, Types of Intercourse
Other methods vary in transmission rates, ranging from an estimated 9,250 out of 10,000 rate (or per act probability of acquiring HIV from an infected source) for contaminated blood transfusions, to 63 out of 10,000 rate of exposures for needle sharing during drug administration.14 In regards to sexual intercourse, the rates of transmission vary depending on whether it is anal, vaginal, or oral intercourse and whether the person involved in the sexual act is the receptive (penetrated by the penis) or insertive (penetrates the other with his penis) partner. Typically, the receptive partner during anal intercourse is in the most at risk category with a 138 out of 10,000 rate of exposure. These risks continue to add up quickly if the act is repeated many times.14 These risks can be minimized if condoms are used correctly.
Fortunately, the efforts to develop better and more effective methods for preventing the spread of the virus increased in the last two decades. The push to prevent the spread of the disease is driven, in part, by the threat HIV/AIDS poses to public health. HIV testing is important in regards to both treatment and prevention. Determining one's HIV infection status allows a patient to begin drug therapies as soon as possible to improve and extend quality of life as well as reduce the chances that the virus is spread to other people. At a minimum, this testing should be done yearly by people who are sexually active, and even more frequently (every 3-6 months) in groups that include homosexual and bisexual men. This is because certain sexual activities, like anal sex, expose them to a higher risk of acquiring HIV or other sexually transmitted infections (STIs).
Only one out of every five “sexually active” high school students sought and received one HIV test as of January 19, 2016. Furthermore, in America only half of the young adults who carry HIV are aware that the virus has infiltrated their immune systems. The other half of the young population infected with the virus remains unaware of their status and are capable of unknowingly transmitting it to others. This underscores the importance of frequent testing, which should be done yearly, and with even more frequently for the high-risk demographics formerly mentioned.15
According to the CDC, on February 23, 2016, 90% of recent HIV infections in the U.S. could have been avoided if those individuals who unknowingly carried the virus were tested and quickly provided with ongoing medical treatment.16 In 2015, policy decisions regarding the insurance coverage for HIV testing expanded. This means increased accessibility to HIV testing regardless of whether the insurance carrier is public or private. If insurance is not available, testing can be administered at many health care centers for little or no cost.17
Rapid Diagnostic Tests (RDTs)
Rapid diagnostic tests (RDTs) are able to reveal the presence or absence of HIV antibodies and antigens. The FDA approved the first antigen-antibody RDT in 2010.18 The following tests include some of the current RDTs that are in use today.
Antibodies are the body’s chemical defense mechanism against a pathogen. The antibodies attach to antigens (cell specific receptors) on certain types of affected cells, so their presence indicates whether a person is infected. The human body usually takes about 28 days to produce antibodies and mount an attack on the pathogens. During this four-week period, antibody levels remain below a detectable level and thus this period of inactivity (the window period) is the most infectious stage (known as acute HIV infection) of the virus.
Antigen tests allow for quicker results due to the fact that they screen for virus infected cells before the immune system mounts a response and produces antibodies. Fortunately, the majority of these diagnostic tools are able to provide results within 24 hours of administration to promote early medical intervention.19 Detectable levels of antibodies take anywhere from four to eight weeks to produce results after the initial infection, whereas antigen tests take up to two weeks.
Legal Rights in Regards to Testing
The medical community acknowledges a person's right to decline HIV testing. Forced testing transgresses medical practice ethics and human rights regardless of whether the person forcing the test is a physician, family member, or authority figure. The World Health Organization (WHO) insists on adhering to the five C’s: informed Consent, Confidentiality, Counseling, Correct test results, and Connection.
Name reporting is when an individual’s name is sent to the state if they test positive for HIV/AIDS. However, a new development to ensure the privacy of individuals tested for HIV was recently enacted in all states and territories. Now, anonymous HIV testing sites exist where staff does not collect this information.20 The number of positive tests as well as those deemed atypical are sent to the CDC, but names and other identifying information are not reported to the CDC. Only clinical and basic demographic information is sent.
Types of Tests
Numerous testing methods are available to people who think they may have been exposed to HIV and are at risk of contracting the disease. The tests vary in accuracy, administration method, and time required to receive results.
- Conventional blood tests administered by a licensed healthcare practitioner require a blood sample that is sent to a lab to be tested. Results may take anywhere from under an hour to several days depending on the lab and health services.
- Conventional oral fluid tests involve a swab of the inside the mouth to be tested in a lab. Results take from a few days to two weeks.
- Currently, the only FDA-approved conventional oral fluid test is Avioq, which is used in combination with OraSure, the only FDA-approved device for collection of oral fluid.
- Rapid Tests involve samples collected at a lab by a health care provider. Results may take less than ten minutes. A negative test is reliable and requires no further action. A positive tests calls for further, more accurate tests to confirm the person is infected with HIV.
- Urine tests involve a sample collected by a healthcare practitioner, which is then sent to a lab for screening. Calypte remains the only HIV urine test approved by the FDA. Results take a few days to a few weeks.21
- Home tests involve a device that pricks the finger and collects drops of blood on a card that is sensitive to the presence of the virus. This sample is sent to a test lab to be interpreted. Results may take as little as three days.
In July 2012, the FDA approved the first at home rapid oral fluid test, OraQuick In-Home HIV Test. Results take as little as 20 minutes. These testing devices are available in drug stores and online.22
Post Exposure Prophylaxis (PEP)
The existence of a treatment that offers prevention against initial infections used to be a well-kept secret. Known as post-exposure prophylaxis (PEP or the HIV morning-after pill), this treatment involves a month-long regimen of antiretroviral medicines (ART) after potential exposure to HIV in order to prevent acquiring an infection. PEP works by stopping the virus from multiplying inside cells. Infected cells typically die quickly. Without reproduction, the virus is halted from infecting new cells. It should only be used in emergencies. The FDA approved this treatment, which is commercially available and often covered by insurance (though it can cost an uninsured person around $1,000). The Centers for Disease Control recommended in 2005 that PEP be administered on a case-by-case basis to all patients within 72 hours of high-risk exposure and that this be followed by subsequent testing and counseling. PEP does not guarantee prevention of HIV infections. Variables such as not adhering to the prescribed dosage, drug resistant strains of HIV, and tremendous amounts of viral load at the initial exposure determine the efficacy of PEP.
A study published online on June 29, 2015 in the Oxford Journal provided information on a PEP related investigation: Clinical Infectious Diseases was a study that investigated the completion rates for HIV- PEP when taken in a multi-tablet form versus a single tablet form. The study was conducted with one hundred recently HIV-exposed homosexual men in two public sexual health clinics and two hospital emergency departments in Australia. Completion rates with the multi-tablet form of the treatment were low in comparison to a single-table regimen of a drug cocktail consisting of emtricitabine-rilpivirine-tenofover disoproxil fumarate (FTC-RPV-TDF). For more information see Truvada® and Tenofovir under the treatment section of this article. This study showed increased adherence, completion, and safety in the single tablet regimen form.23
A health care center or emergency room can prescribe PEP. If someone thinks they have been exposed to HIV, they should contact either of those resources immediately.
Pre-Exposure Prophylaxis (PrEP)
In order to ensure that PEP is used as a last resort (because of health toxicity and mutations that may produce resistant strains) medical professionals recommend the use of PrEP (i.e., pre-exposure prophylaxis). PrEP is suited for individuals who are frequently exposed to HIV, such as health care workers and people who are HIV-negative but have HIV-positive partners (serodiscordant partners). PrEP is a combination of multiple antiretroviral drugs that, when taken prior to HIV exposure, drastically reduces the rate of transmission according to a study published in The New York Journal of Medicine. In 2011, results from the HPTN 052 trial showed that early initiation of antiretroviral treatment reduced the risk of HIV transmission by 96% among serodiscordant couples.24
In a 32 month long Kaiser Permanente study at the San Francisco Medical Center, the 657 sexually active homosexual men who took PrEP (consisting of the drug Truvada®) recorded no new HIV infections.25 Interestingly, the study also showed a 50% increase in instances of STIs. However, HIV did not fall in that category. There was no control group in the study, so there is no conclusive method to determine if STI rates would have been different in the group without PrEP. Critics of the treatment argue that PrEP, treated in a casual manner, would promote the message that risky sexual behavior is condoned. According to the study, 74% of subjects reported no change in the number of sexual partners they had while participating in the study. Only 11% reported an increase in sexual partners. However, 41% stated that they had decreased their use of condoms. Conversely, 51% stated that their condom use did not change. This data provided a conclusion of mixed results.26 The abundance of disapproval, stigma, and arguments against the drug (critics fear it would promote risky behavior) and surrounding the topic of PrEP appears to mirror those that surrounded birth control when it first entered the political and social scene.
It is vital to talk to a health care provider if someone believes they may be at high risk for acquiring HIV.
After receiving HIV-positive exam results, a patient will likely begin taking a form of antiretroviral therapy (ART) in order to combat the virus’ replication and spread throughout the body. These medications target the reproduction of the virus and stop it from multiplying. Although there is still HIV present in the patient’s body, fewer viruses make it easier for their body’s natural defenses to recover and fight off the pathogens, as well as prevent the spread of HIV. The FDA recommends creating drug cocktails composed of at least three HIV medications from at least two different drug classes. These drugs have been improving steadily since the advent of potent combination therapy in 1996, and now offer new mechanisms of action, improved potency and activity against multi-drug-resistant strains of the virus, dosing convenience, and increased tolerability as compared to early treatment regimens. Instead of having to take twenty pills a day, patients can now achieve similar results from as few as two pills. Although there is no cure for HIV/AIDS, the current goal of antiretroviral therapies is to decrease levels of HIV-related morbidity as well as improve the patient's’ quality of life, restore and preserve immunological function, suppress viral counts to the lowest levels possible, and prevent the transmission of HIV to uninfected persons.
There are several common regimens available to patients which all share comparable success rates, but differ in terms of dosing frequency, pill burden, drug interactions, and potential side effects. Precisely because adherence to the chosen therapy is paramount for its success, the treatment should ultimately be tailored to the needs of the individual patient. A panel of experts convened by the Department of Health and Human Services recommends that all HIV-infected individuals receive antiretroviral therapy, with the precise dosage determined by a CD4 cell count in the individual. If the patient is in the acute-HIV infection stage, is experiencing symptoms inline with AIDS, or is pregnant and has a T-cell count below 350 cells/mL ART therapy is highly recommended. Typically, medical authorities initiate ART in asymptomatic people with a T cell count between 350-500 cells/mL. On occasion, ART may be offered to people with a T cell count greater than 500 cells/mL depending on the circumstances.27
Antiretroviral Treatment Drugs (ART), Highly Active Anti-Retroviral Therapy (HAART)
Antiretroviral drugs (ART) are a subgroup of antiviral drugs. ART drugs work by inhibiting a reverse transcriptase enzyme or protease enzyme. Reverse transcriptase enzymes play a major role in the synthesis DNA from the virus’s ribonucleic acid, or RNA. RNA acts as a messenger for DNA and transports instructions on how to assemble proteins. Protease enzymes also play a role in this mechanism by cutting or breaking down large proteins into smaller protein fragments for reconstruction. Other drugs work by prohibiting the virus from entering the human cell, while alternative drugs inhibit the integration of viral DNA into the human DNA.28 Each of the following medications is intended as treatments, not cures. No cure for HIV/AIDS has been discovered, but there have been many strides in improving quality of life and life expectancy. The main categories of ART drugs used to combat HIV infection are reverse transcriptase inhibitors, protease inhibitors (PIs), entry inhibitors, and HIV integrase inhibitors. The term HAART refers to an HIV therapy regimen consisting of 3 or 4 ART drugs taken in combination.
The following lists pertain to a handful of medications commonly used to combat HIV infection. They are all typically taken in combination with two or more other medications.
- This medication is considered a nucleoside analog reverse transcriptase inhibitor (NRTI). NRTI’s work by disrupting the creation of new, viral, genetic material. A subunit of DNA, a nucleotide, is replaced with a similar compound. However, since the chemical structures of the nucleotide and the compound replacing it are slightly varied, the formation of chemical bonds is disabled. The HIV virus is unable to check for and correct mistakes, subsequently, viral reproduction is halted. A person must weigh 77 pounds or more to take this medication. The following list describes specific features of the drug:
- It is a combination therapy (two medications in one pill; in this case, emtricitabine and tenofovir disoproxil fumarate).
- This medication is always used in combination with several other medications as it is not a complete treatment on its own.
- This medication operates with a particular mechanism. It prevents proliferation of HIV, lowers viral load, and decreases the amount of HIV in the blood (may also increase CD4 cell count if used with other medications).
A study published on March 3rd, 2015 in the Journal of Infectious Diseases shows that Truvada® is less effective in females and that they need to take double the amount that males do to get the same effects.29
- This is a NRTI (and component of Truvada®) used to block the enzyme reverse transcriptase.
- Over 1,900 people with HIV failed to respond to Tenofovir in an international study. On January 28th, 2016, researchers announced that the failure of this key ingredient in HIV medication is indicative of growing drug resistance.30
ZIDOVUDINE (i.e., AZT or RETROVIR)
- AZT aims to slow down and prevent damage to the immune system, thus reducing the risk of developing further illnesses.
- This is a NRTI approved by the U.S. Public Health Service on the grounds that it may be used to prevent mother-to-child transmission of HIV.
- In 2011, Complera® (an all-in-one fixed dose combination tablet) was approved by the FDA, offering yet another option for HIV patients.
The following facts list some of the most recent statistics and discoveries that have been linked to new developments in HIV/AIDS preventions and treatments:
- Depo Provera, an injectable hormonal contraceptive, shows a moderate increased risk (40%) of acquiring HIV.31
- By the end of 2015, 17 million people afflicted with HIV were receiving ART globally.32
- New HIV infections fell by 35%, AIDS related deaths fell by more than a quarter, and 7.8 million lives were saved by the international efforts to prevent the spread of HIV between 2000 and 2015.32
- People living with HIV (PLHIV) and taking ART often interact directly with antiretroviral drugs which are successful at prolonging survival in HIV patients but have also recently been linked to a higher incidence in cardiovascular disease. The study published January 19, 2016 in the International Journal of STD and AIDS showed that across the world a large portion of people living with HIV die from cardiovascular and liver disease as compared to other non-AIDS related deaths.33
- In 2016, the World Health Organization stated that the majority (54%) of people who are considered eligible for treatment were receiving it.32
- On February 25, 2016 at the annual Conference on Retroviruses and Opportunistic Infections (CROI), researchers reported that a man taking the HIV-prevention pill Truvada® contracted HIV—marking him the first reported infection of someone regularly taking the drug.34
Many patients using older suppressive antiretroviral therapy regimes may be considered eligible candidates for regimens simplification. The following provides a list of circumstances where this might take effect: if these patients are receiving treatments that are no longer recommended as preferred, are receiving treatments that were not fully understood in terms of drug interactions at the time, or are being were prescribed a regimen that was approved prior to the availability of newer options that offer easier administration and/or greater tolerability. The primary consideration behind this involves improving the patient’s quality of life, maintaining long-term regimen adherence, avoiding toxicities that may result from long-term use, and reducing the risk of a type of failure in the treatment of HIV called virologic failure. Virologic failure means that the antiretroviral therapy (ART) failed to decrease and maintain a person’s viral load to less than 200 copies/mL. Prospective studies of HIV-infected individuals show that patients with reduced dosage frequency have higher levels of adherence, and that patient satisfaction is higher with regimens that include fewer pills and reduced dosing frequency. Unlike treatments of the past, many offered today require only one daily dose and place no dietary restrictions on the patient. Ideal candidates for such simplification are those who are on their first regimen and lack a history of treatment failure; these patients are less likely to harbor a drug-resistant form of the virus. Generally, there are three major forms of simplification possible:
- Within-Class Substitutions: This offers the advantage of not exposing patients to still unused drug classes, potentially preserving those classes for future treatment. It usually involves using a newer drug, a co-formulated drug, or a formula that has a lower pill burden, lower frequency, or less toxicity.
- Out-of-Class Substitutions: Just as the name implies, this type of regimen simplification involves substitution drugs of a certain type for more effective drugs from a different class.
- Reducing the Number of Active Drugs in a Regimen: This process involves switching a patient from a suppressive treatment plan to one containing fewer active drugs. The major motivation behind this approach stems from drug-related toxicity and lower overall treatment costs.
Different cultures around the world, as well as the international medical community, made strides in the past twenty years towards ending the HIV/AIDS epidemic. A person diagnosed HIV-positive today can leave their health care provider with the assurance that they have nearly the same ability to lead a normal life (ignoring the economic burden of treatment), which contrasts starkly to the gruesome discrimination and lack of available medical treatment options a mere 40 years ago. Furthermore, there has never been more hope for a cure than there is today. On June 10, 2016, the United Nations pledged to end the AIDS epidemic by 2030.35 This marks the first time worldwide, multi-nation, coordinated efforts established and pledged to meet a concrete deadline to end the epidemic. On July 14, 2015, UNAIDS (Joint United Nations Program on HIV/AIDS) announced that one of the targets for the Millennium Development, specifically number six (to combat HIV/AIDS, malaria, and other diseases), reached a bench mark nine months ahead of schedule. That means that the global population accomplished the feat to provide life-saving HIV treatment to 15 million people worldwide. Additionally, on June 30, 2016, WHO announced that Cuba is the first nation to eliminate mother-to-child transmission of both HIV and syphilis. The scientific community (more specifically the National Institute of Health and Partners) confirmed plans to establish an HIV vaccine trial, one that will be the largest of its kind since 2009. The trial will be conducted in South Africa by November 2016 pending regulatory approval.36
Finally, a cure is in sight. On November 30, 2015, the Foundation for AIDS Research (amfAR) publicly announced its intention to create the institute for HIV Cure Research at the University of California, San Francisco. The collaboration of research teams confirmed that their primary mission, funded by a one hundred million dollar investment, is to develop the scientific bases for an HIV cure by the end of 2020.37 Communities are finally acknowledging and supporting the people suffering from the HIV epidemic and discrimination and illness are on the decline. There is still much to be done but the next decade and a half promises continued progress for those in need.
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Last Updated: 29 November 2016.