Medical Editor: Leslie J. Schoenfield, M.D., Ph.D.
I am frequently asked why, despite major educational campaigns and the development of new therapies, Americans continue to be contracting HIV and dying from AIDS. In fact, in association with the availability of more effective antiretroviral therapy, a sharp decline did occur in AIDS deaths between 1995 and 1997. The current estimate is that there are approximately 15-20,000 AIDS deaths per year, down from 40-50,000. However, the estimated rate of new HIV infections in the United States has not declined and has remained stable at approximately 40,000 per year.
Let us consider the HIV problem as a continuous sequence (continuum) from the initial HIV infection, to clinical progression with symptoms and AIDS, and finally to death. This approach enables us to address each potentially significant factor individually. First of all, the nature of the HIV epidemic has changed. For example, increasing numbers of people are being infected who do not perceive themselves to be at risk, such as heterosexual women. In addition, there is evidence that even gay men, particularly younger individuals, are putting themselves at increasing risk.
Why would these gay men put themselves at increased risk? Actually, many factors may be contributing to this major setback in our efforts to control HIV. For one thing, there is the inappropriate perception that therapy is so good that getting infected is no longer a "big deal." For another, many individuals are putting themselves at risk because they suffer from depression, drug and alcohol abuse, or sexual addiction. While education has been the mainstay of HIV prevention, these observations illustrate that there are indeed underlying, basic problems. Moreover, these fundamental problems need to be better identified and addressed if there is to be a decrease in the overall infection rate.
With no decline in the rate of new HIV infections and an initial decline in AIDS deaths, increasing numbers of HIV-infected individuals are to be expected. Of course, this increase would expand the population that can then transmit HIV to others. At the same time, it also would increase the number of individuals that can eventually progress to AIDS and death.
Moreover, many of the factors associated with new HIV infections, outlined above, are associated with a reluctance to get tested and diagnosed, and to enter into treatment. Furthermore, even if those individuals who are infected enter into treatment, factors such as depression, illicit drugs, and alcohol abuse often limit their ability to strictly follow their medication regimens. This poor adherence then promotes the development of resistance by the HIV to the medications (drug resistance), which, in turn, increases the risk of progression to symptoms and death.
Finally, the issues discussed above may in part explain why there has been a leveling off or even a slight increase in AIDS-related deaths. Thus, many individuals are dealing with issues that prevent them from getting into care, or when entered into care, being successful with their treatment. In addition, people who do not perceive themselves to be at risk are less likely to get tested for HIV. Consequently, these people often first find out they have HIV when they are having symptoms from AIDS. As a matter of fact, many people I care for who have HIV disease and symptoms or who have died from AIDS during the last few years are coming to the hospital without having ever been tested for HIV.
Only a better understanding of the reasons for these trends in HIV disease will enable us to approach the underlying basic problems. Hopefully, studies that address all of these issues will ultimately lead to changes in our national HIV prevention efforts. These changes should then reduce the number of new HIV infections, cases of AIDS, and AIDS-related deaths. In the interim, education and encouraging people to get tested remain a good start.