The Conspicuous Gap Between HIV Care and HIV Public Health

John G. Bartlett, MD

Disclosures

June 20, 2016

The Status of HIV Care

The resources for HIV care are extraordinarily good, especially for an incurable chronic viral infection that involves every organ system. But the amazing progress since 1996 with the birth of anti-HIV treatment has now brought hope for what Hillary Clinton promised at the 2012 International AIDS Society annual meeting: "an AIDS-free generation."

Why Aren't Our Plentiful Resources Enough?

HIV/AIDS was essentially an untreatable disease until 1996, when Dr Roy Gulick, in a stunning presentation, reported the results of the Merck 035 trial, which used "triple therapy" with indinavir, zidovudine, and lamivudine.[1] It seemed clear then that we were well on the way to conquering this major modern plague. The subsequent progress was fast and impressive. Twenty years later, we have a virtually perfect HIV test, 28 antiretroviral agents that can reduce viral levels to undetectable in nearly all patients, and highly effective HIV prevention methods (antiretroviral therapy [ART] and pre-exposure prophylaxis [PrEP]). Longevity for those with HIV infection in developed countries approaches normal (71-73 years).

Yet, a humbling concern is that, although loaded with extraordinary gains, the past 20 years have been a big disappointment from a public health perspective. During that time, we have continued to see approximately 50,000 new HIV infections every year, and 155,000 HIV-positive persons in the United States are unaware of their infection. PrEP works well in trials, but implementation of this strategy has performed poorly, and attempts for a vaccine or cure continue to frustrate. This situation is unlikely to change in the foreseeable future without a major change in strategy.

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