Optimism in the Face of Crisis
Three decades out from the darkest days of the AIDS epidemic's early "plague years" in the 1980s, major improvements in treatment and prevention offer reasons to be optimistic. That includes not only treatment options, but the very real -- albeit, still remote -- possibility of eradication of HIV and AIDS.
Experts warn, however, that optimism should not be taken as a license for complacency. Those with HIV need to remain proactive in their treatment, while those who aren't infected need to remain vigilant. Until a vaccine to prevent HIV or a "magic bullet" to cure AIDS comes along, proactivity and vigilance remain our best hope of turning the tide.
Still, the ongoing work of researchers will continue to result in new and better treatment options.
"Treatment continues to get better and better," Dr. Joel Gallant, chair of the HIV Medicine Association, a society for doctors whose primary practice is in HIV care. "We have three different one-pill-a-day combinations, and we're about to have four. Many people can be treated with one or two pills a day with very few side effects."
Such treatments can not only reduce an HIV-positive individual's viral load to undetectable; they can also significantly reduce the risk of transmission from an infected partner to an uninfected one.
From Death Sentence to ’Manageable’ Condition
Until the mid-’90s and the advent of the protease "cocktail," HIV was a death sentence. Since then, new developments in treatment have transformed it for most people into a manageable chronic condition.
"It’s a totally different prognosis now than it was 10 or 15 years ago," said Jeff Lubsen, a Denver psychotherapist specializing in LGBT mental health who also helped found the Healthcare Guild, a grassroots organization that helps LGBT clients find health providers.
"The medications available now have really increased life expectancy, and the treatments being used to keep viral loads low have made a big difference in keeping folks healthy for a lot longer. People are leading healthier, happier lives."
In fact, by 2015 more than half of all people living with HIV will be over the age of 50 -- a dramatic shift from the early days of the disease, when HIV-positive people measured the length of their prognosis in months, not years (and certainly not decades).
The high level of meds has raised the bar for researchers to the point, Gallant said, that "it’s getting harder and harder to improve on the kinds of treatment we’ve got now. The next big hurdle we have to cross is finding the cure."
An actual cure for HIV would have sounded impossibly naïve only a few years ago. Gallant is optimistic that it will be a reality one day in the future, saying "it’s something that will happen eventually," Added Gallant, "It won’t be anytime soon, but it’s not a pipe dream.
Gallant pointed to "more and more research in that direction." Some of the best scientists in the world at the National Institute of Health and other research institutions dedicating their professional lives to the search for a cure, he added.
Just as exciting as improvements in treatment -- if not more so -- is the progress being made in transmission reduction and outright prevention.
Targeted campaigns that focus on promoting prevention and safer sex in high-risk communities have been effective. "Except in the Midwest, rates of new infections have stabilized, which is really refreshing," Lubsen noted.
Prevention: PrEP & Testing Key
Even more encouraging is the development and FDA approval of Truvada, an HIV treatment that can also be used as "pre-exposure prophylaxis," or PrEP, for those who are HIV-negative and sexually active. A daily PrEP pill of Truvada can be as effective as regular condom usage in preventing HIV transmission, a crucial leap forward for prevention efforts.
PrEP "will have a profound effect on HIV prevention, since taking a daily pill is far different from making a choice about whether or not to use a condom in the heat of the moment," HIV-positive blogger Mark S. King, of MyFabulousDisease.com, said. "Let’s remember that half of gay men report not using condoms consistently, and it has always been that way. We need to provide options that help them avoid infection or transmission."
Gallant, for one, finds it "a little surprising that more gay men aren’t using PrEP. This is a major way of preventing transmission, but it’s not in widespread use yet." He believes this disconnect has happened at least partly "because people aren’t aware of it. Some of the people at highest risk aren’t really connected with the health care system."
Indeed, by now one of the biggest obstacles to HIV prevention is simply that many HIV-negative people, especially younger ones, don’t take the risk of infection seriously enough. "Younger folks are classically at risk," noted Lubsen, "because they weren’t around back when it was a nightmare, when the really bad things were happening. With the fact that we can manage the disease so much better now, some individuals don’t see it as a real risk, so they might not take care of themselves the way they need to."
King also notes that misunderstandings about what kind of sexual behavior carries the risk of infection may be hindering prevention efforts. "As many as two-thirds of new infections happen within committed couples," he said, "so the idea that people getting infected today are ’promiscuous sluts’ is way off base. If anything, they are people seeking intimacy and relationship who get involved with someone whom they unwisely trust, or who doesn’t know their status. Listen up, you lovebirds," he emphatically added, "get tested together!"
If there is any place where we should be least optimistic, it is in the continued lack of access to health care in high-risk communities. As Gallant noted, that has historically been an obstacle to treatment and prevention.
"A lot of people currently at high risk are not connected to health care providers or don’t have insurance," he said. "Hopefully, with the implementation of the Affordable Care Act, more will get insured and hopefully get tested."
Like King, he stressed the importance of getting tested: "Testing is such an important branch point. If you’re positive, you get into care, and if you’re negative it’s an opportunity for preventative intervention."
When people get tested and take steps -- whether condoms or PrEP -- the tide will finally turn in the fight against HIV. "We could really make a big dent in the epidemic if we tested and treated everybody," Gallant said. "We’re a long way from done, but that could really make difference."