By Ronald O. Valdiserri
The year 2011 marks the thirtieth anniversary of the first case reports in the United States of what we now know to be end-stage HIV disease. This chronological milestone provides an opportunity to reflect upon the changing context of the American HIV/AIDS epidemic. Using two seminal documents as a framework, the 1986 Institute of Medicine Report, “Confronting AIDS,” and the 2010 National HIV/AIDS Strategy, this descriptive analysis details our accomplishments in addressing the domestic U.S. epidemic and outlines what remains to be done on the long road to eradication of HIV disease.
The past three decades have witnessed tremendous biomedical and behavioral advances in preventing, diagnosing, and treating HIV disease. However, to fully realize the promise of these scientific advances, such that we achieve the vision of the National HIV/AIDS Strategy, we must develop effective strategies to surmount a number of salient challenges, including: unbalanced combinations of prevention interventions; programs that are not of adequate scale to achieve population-level results; systems of service delivery that do not function in an integrated fashion; and social and economic structures that increase the vulnerability of populations who are at risk for or living with HIV disease.
As both the lay (Healy & Maugh, 2011) and scientific (Dieffenbach & Fauci, 2011) press have noted, June 5th of this year, marked the thirtieth anniversary of the first case reports of what we now know to be endstage HIV (human immunodeficiency virus) infection (CDC, 1981), otherwise known as AIDS, the acquired immune deficiency syndrome. Given the broad and profound impact that this epidemic has had on families, communities, systems of care, social norms, and our collective scientific enterprise, there are many ways that one might make note of this milestone.
First and foremost, it is an occasion for solemnity and commemoration. Since those first five cases were reported in early June 1981, nearly 600,000 men, women, and children have died in the United States as a result of HIV disease (CDC, 2011a), and Ronald O. Valdiserri, MD, MPH, is Deputy Assistant Secretary for Health, Infectious Diseases, Director. Globally, an estimated 30 million people have died of HIV-related causes (UNAIDS, 2010). With profound sadness, we recognize that HIV has brought premature death to millions—and that behind every one of these mind-numbing numbers are families, partners, spouses, co-workers, and neighbors who have been permanently affected by the loss of someone held dear (Valdiserri, 1994).
Even in the face of this astonishing mortality, there are reasons to mark this thirtieth anniversary with hopeful expectation. In the industrialized nations of the world, including the U.S., survival following an HIV diagnosis has improved considerably with the advent of highly active anti-retroviral therapy (HAART) in the mid 1990s. Between 1995 and 1998, AIDS deaths decreased 63% in the United States (CDC, 2011b). Analysis of surveillance data from 25 U.S. states found that the average life expectancy after HIV diagnosis increased from 10.5 to 22.5 years between 1996 and 2005 (Harrison, Song, & Zhang, 2010). But it’s not only in the treatment realm where we have seen remarkable advances in knowledge.
Prevention science has, likewise, logged very impressive gains in the past three decades. In the United States, routine HIV screening of women during pregnancy and prompt antiretroviral treatment for those found infected has resulted in a 92% decline in perinatal HIV transmission (Fowler, Gable, Lampe, Etima, & Owor, 2010). Scientifically rigorous studies of behavioral interventions, targeting both homosexuals and heterosexuals, have shown efficacy in reducing sexual risk behaviors and promoting condom use (Darbes, Crepaz, Lyles, Kennedy, & Rutherford, 2008; Herbst, Beeker, et al., 2007; Johnson, Scott-Sheldon, HuedoMedina, & Carey, 2011; Johnsonet al., 2008). Among drug users who inject opioids, domestic and international observational studies show that treatment with opioid agonists are effective in reducing injection drug use and are associated with lower rates of HIV prevalence and incidence (Hartel & Schoenbaum, 1998; Sullivan, Metzger, Fudala, & Fiellin, 2005). And for injection drug users who are unable or unwilling to curtail drug use, access to sterile injection equipment, as a component of a comprehensive package of prevention services, has been shown to reduce risky injection behaviors and in some studies has been associated with reduced HIV transmission among injection drug users (Palmateer et al., 2001).
Results from several noteworthy prevention trials have been published in the past decade. A randomized controlled trial of over 3,000 men conducted in South Africa between 2002 and 2004 demonstrated that men who had been circumcised were 60% less likely to become infected with HIV compared to a delayed circumcision, that is, control, group (Auvert et al., 2005). In 2009, Rerks-Ngarm and his colleagues reported the results from the first HIV vaccine trial that showed any degree of efficacy (Rerks-Ngarm, 2009). Although the results were relatively modestat 31%, researchers are conducting follow-up case-controlled studies to try and identify one or more immunologic correlates of protection (Dieffenbach & Fauci, 2011). Two ground-breaking studies demonstrating the efficacy of antiretrovirals in the prevention of new HIV infections were published in 2010. Quarraisha Abdool Karim and her colleagues were able to demonstrate that a 1% tenofovir gel inserted intra-vaginally before and after sexual intercourse reduced HIV acquisition by an estimated 39%, compared to a placebo gel—and its use was not associated with any increase in adverse events (Abdool Karim et al., 2010). Later that same year, Robert Grant and members of the iPrEx Study Team reported a 44% reduction in the incidence of HIV among men and transgendered women who have sex with men who took daily pre-exposure prophylaxis with a combination of two antiretroviral medications as part of a comprehensive package of prevention services (Grant et al., THIRTY YEARS OF AIDS IN AMERICA 4812010).
The most recent prevention breakthrough, described by Cohen and his colleagues, is the first randomized clinical trial to show that treating an HIV-infected individual can reduce the risk of sexual transmission of HIV to an uninfected partner (Cohen, 2011). Recent advances notwithstanding, we must acknowledge that we have not yet achieved the vision of the U.S. National HIV/AIDS Strategy which strives to make our nation:a place where HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socioeconomic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.