How the Times Have Changed: HIV/AIDS
This Editorial is a personal reflection on an article from the Consultant archives.
Shobha Swaminathan, MD
Rutgers New Jersey Medical School
Swaminathan S. How the times have changed: HIV/AIDS. Consultant. Published online April 1, 2020.
When reading the 1985 article about HIV diagnostics and treatment, I was struck by how difficult and hopeless of a process it was for both patients and their physicians. Back then, there was no treatment for HIV or AIDS; the only option doctors could offer patients was supportive care. Today, patients with HIV have a close-to-normal life expectancy, provided they remain in care and continue their treatments. The biggest change I see compared with the 1980s outlook is the shift from desperation and fear to optimism and hope. It is a 180° turn, which was influenced by several factors.
First, we now have medications that control HIV very well. We went from having no medications for HIV to having more than 30 medications, administered orally daily. And while right now we are marveling at one pill a day—which is a huge improvement from the time patients took a dozen medications daily—there are more medications undergoing clinical trials that might simplify treatment further. Researchers are developing new therapeutics that could be administered less frequently. Future medications also aim to give patients a choice between pills, injections, and infusions that can be given once a week or every few weeks. Furthermore, a recently validated approach called U=U, which stands for Undetectable Equals Untransmittable,1 confirms that individuals with undetectable levels of HIV in their blood cannot pass the infection to others.
Second, recent scientific advances in infection prevention has allowed patients to have full lives. Pre-exposure prophylaxis (PrEP) helps ward off new infections. Persons vulnerable to acquiring HIV infection can take a pill every day to significantly reduce their HIV risk.
Lastly, since 1985, the HIV community’s activism has helped destigmatize the condition and afforded patients greater access to resources. We have come a long way since one of the early advocates, Indiana teenager Ryan White, had to fight for his right to attend school with other children. Ryan had hemophilia, a rare disorder in which one’s blood does not clot. He acquired HIV infection via blood transfusion and was denied access to his school. Shortly after he died in 1990, the US Congress passed the Ryan White Comprehensive AIDS Resources Emergency Act2 to allocate funds to provide care for people with HIV.
The 1985 article used a stigmatizing term “homosexual behavior,” which has been denounced since then. Instead, we have recognized that other populations are also vulnerable to acquiring HIV infections. That broadened focus helped ensure that all HIV patients could access medical care regardless of how they acquired the infection.
There is one area where much work is still needed. We have not made a dent in preventing new infections, particular among young men who have sex with men between ages 13 and 34 years and transgender people. In the United States, gay and bisexual men account for two-thirds of new HIV diagnoses, despite representing only 4% of the population. While PrEP helps prevent new cases, it must be taken daily as a pill, which is a challenge for patients who face financial issues or those without stable housing. We need a better alternative. A successful HIV vaccine has eluded the scientific community for a long time, but now we are about to start one promising HIV vaccine trial. Mosaico3 is a phase 3 clinical trial for a vaccine that, if found to be safe and effective, could provide HIV immunity after only a few shots. The Clinical Research Center at Rutgers New Jersey Medical School (NJMS) hopes to enroll 50 to 100 volunteers for this trial.
While we are working toward creating the vaccine, I continue seeing patients in my practice at NJMS. I have been here for 16 years, so I have gotten to know many patients and their families really well. And I am glad that today I can give them better news than I could 16 years ago and certainly better than I would have in the 1980s. Today my patients can have close-to-normal life expectancy, have great jobs and thriving careers, meaningful relationships, get married, travel, and have children—essentially enjoy a full life—as long as they stay in medical care. We have come a long way, and while we still have work to do, patients’ futures are no longer a steady, unavoidable decline. They are now full of optimism and hope.
Shobha Swaminathan, MD, is an associate professor of medicine in the Division of Infectious Diseases and clinical research site leader in the NIH-funded Clinical Trials Unit at Rutgers New Jersey Medical School in Newark, New Jersey. She also is medical director of Infectious Diseases Practice at University Hospital in Newark, New Jersey.
- Wheeler JT. Suspected AIDS: An approach that helps patients, whatever the diagnosis. Consultant. 1985:102-116. https://www.consultant360.com/exclusive/infectious-diseases/suspected-aids-approach-helps-patients-whatever-diagnosis.
- Prevention Access Campaign. Undetectable = Untransmittable. Accessed April 1, 2020. https://www.preventionaccess.org/.
- Health Resources & Services Administration. Ryan White HIV/AIDS Program Legislation. Updated February 2019. Accessed April 1, 2020. https://hab.hrsa.gov/about-ryan-white-hivaids-program/ryan-white-hivaids-program-legislation.
- Global Advocacy for HIV Prevention. HPX3002/HVTN 706: Mosaico. Updated February 3, 2020. Accessed April 1, 2020. https://www.avac.org/trial/hpx-3002-hvtn-706-mosaico.