Spread To The Western Hemisphere
Further isolated occurrences of this infection may have been emerging as early as 1966. The virus eventually entered gay male communities in large United States cities, where a combination of casual, multi-partner sexual activity and relatively high transmission rates associated with anal intercourse allowed it to spread explosively enough to finally be noticed.
Because of the long incubation period of HIV before symptoms of AIDS appear, and because of the initially low incidence, HIV was not noticed at first. By the time the first reported cases of AIDS were found in large United States cities, the prevalence of HIV infection in some communities had passed 5%. Worldwide, HIV infection has spread from urban to rural areas, and has appeared in regions such as China and India.
Hiv Treatments: A History Of Scientific Advance
The introduction of antiviral medications used in combination is among the most important advances in the history of HIV/AIDS treatment. By using more than one drug at a time, combination therapy is able to “pin down” HIV from more than one angle, so that even if one drug fails, another can continue to suppress viral replication. But this advance was a long time in the making, following a historical course from “no therapy” to “monotherapy” and now to “combination therapy.” This book excerpt provides a historical overview of advances in the monitoring of treatment progress and the emergence of combination therapy.
The Evolution Of Hiv Treatment
The arrival of the AIDS epidemic in Canada and other countries was scary on so many levels. We watched in shock as previously healthy young men became ill and were robbed of their vitality and eventually their lives. In the early 80s, scientists had few answers to many of the questions that people and the media posed about AIDS. Perhaps most chillingly, the new disease primarily affected groups that were despised by our broader society, and for years authorities largely turned their backs to the growing epidemic. Neglected by the state, many people with HIV felt a deep sense of a betrayal, abandonment and isolation. This resulted in anger and incited AIDS activists to mobilize and create a plan to deal with the epidemic.
Things began to change but only very slowly. In 1983 French scientist Françoise Barré-Sinoussi discovered HIV and in 1985 the first HIV test became commercially available. But the number of people who died from AIDS kept growing.
Then, in 1996 at the International AIDS Conference in Vancouver, everything changed for the better. Researchers announced some stunning results: For the first time, people who had been deathly ill with AIDS had seen their health improve thanks to a combination of at least three anti-HIV drugs. The drugs were from at least two different classes the newest one was called protease inhibitors. For the first time in the history of AIDS treatment, we heard reports of peoples CD4 counts rising and staying up.
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Have You Been Able To Stop The Spread Of Infection
Yes and no, says Dr. Villanueva. In the past five to eight years, the number of newly documented infections has decreased. But we’re looking nationally at a level of almost 38,000 new infections per year, which is a lot.
A major approach to prevention is the use of PrEP or pre-exposure prophylaxis. This approach is based on administering drugs used to treat HIV to people who do not have HIVbut who are at a high risk for itin an effort to prevent them from contracting the virus. Different formulations are being made available, including long-acting injectables and a vaginal ring for women, and this worldwide effort is extremely important, says Dr. Villanueva.
There have been other pockets of success. Mothers-to-be who had HIV used to transmit the virus to their infants when they gave birth, says Dr. Villanueva. But a landmark trial that Yale participated in showed that giving mothers an antiretroviral medication called azidothymidine during the third trimester and delivery resulted in a marked decrease in the mother-to-newborn transmission rate in the U.S. That treatment was introduced as a standard of care here in Connecticut, with only one new case of perinatal transmission since 2008, Dr. Villanueva says.
How Do Hiv Medicines Work
HIV attacks and destroys the infection-fighting CD4 cells of the immune system. Loss of CD4 cells makes it hard for the body to fight off infections and certain HIV-related cancers.
HIV medicines prevent HIV from multiplying , which reduces the amount of HIV in the body . Having less HIV in the body gives the immune system a chance to recover and produce more CD4 cells. Even though there is still some HIV in the body, the immune system is strong enough to fight off infections and certain HIV-related cancers.
By reducing the amount of HIV in the body, HIV medicines also reduce the risk of HIV transmission. A main goal of HIV treatment is to reduce a persons viral load to an undetectable level. An undetectable viral load means that the level of HIV in the blood is too low to be detected by a viral load test. People with HIV who maintain an undetectable viral load have effectively no risk of transmitting HIV to their HIV-negative partners through sex.
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A Time Before Treatment
HIV treatment is something that was on everyones minds in the 1980s, confusion was rife and there was very little known about the virus. Sydney Star Observer first published a piece on the disease in 1981, reporting a new disease affecting gay men in the US describing a range of illnesses and infections.
The first diagnosis of AIDS in Australia wasnt for another year in St Vincents Hospital Sydney, and the formation of the AIDS Action Committee again not until another year later in 1983. At this time the gay community struggled to communicate what little was known about the virus to one another as they struggled with a much more adverse Health system.
A Lifetime Of Treatment
In the United States today, most people living with HIV can afford medicine, through insurance and programs like the AIDS Drug Assistance Program , but these benefits vary widely by state.
These medications are redefining what it means to live a healthy life with HIV. Today, people living with HIV are going to college, working, volunteering, getting married and having children. They are not only having children, they also have grandchildren. According to the CDC, one-quarter of people living with HIV in the United States are 55 or older.
Yet even with effective treatment, HIV is now a risk factor for cardiovascular disease, cancer, kidney disease and bone diseases like osteoporosis. That proper treatment can suppress the virus means that we can see the secondary illnesses that HIV can cause.
Though the exact reasons why this happens are unknown, it appears a combination of factors including HIV medication use and increased inflammation from the infection itself raise risks. And of course, so do health habits such as smoking, substance use, inactivity and a poor diet.
That means people with HIV may need to take medication to manage these other conditions in addition to their HIV medication. That means more pills, which can be complicated for patients to manage. And new medications can also cause new side effects. Patients and doctors need to keep an eye out for new symptoms and medication side effects.
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The Global Distribution Of Deaths From Hiv/aids
In some countries HIV/AIDS is the cause of more than a quarter of all deaths
Globally, 1.7% of deaths were caused by HIV/AIDS in 2017.
This share is high, but masks the wide variations in the toll of HIV/AIDS across the world. In some countries, this share was much higher.In the interactive map we see the share of deaths which resulted from HIV/AIDS across the world. Across most regions the share was low: across Europe, for example, it accounted for less than 0.1% of deaths.
But across some countries focused primarily in Southern Sub-Saharan Africa the share is very high. More than 1-in-4 of deaths in South Africa and Botswana were caused by HIV/AIDS in 2017. The share was also very high across Mozambique Namibia Zambia Kenya and Congo .
Death rates are high across Sub-Saharan Africa
The large health burden of HIV/AIDS across Sub-Saharan Africa is also reflected in death rates. Death rates measure the number of deaths from HIV/AIDS per 100,000 individuals in a country or region.
In the interactive map we see the distribution of death rates across the world. Most countries have a rate of less than 10 deaths per 100,000 often much lower, below 5 per 100,000. Across Europe the death rate is less than one per 100,000.
Across Sub-Saharan Africa the rates are much higher. Most countries in the South of the region had rates greater than 100 per 100,000. In South Africa and Mozambique, it was over 200 per 100,000.
The Global Hiv/aids Epidemic
HIV, the virus that causes AIDS, is one of the worlds most serious public health challenges. But there is a global commitment to stopping new HIV infections and ensuring that everyone with HIV has access to HIV treatment.
According to UNAIDS:
Number of People with HIVThere were approximately 37.6 million people across the globe with HIV in 2020. Of these, 35.9 million were adults and 1.7 million were children .
New HIV InfectionsAn estimated 1.5 million individuals worldwide acquired HIV in 2020, marking a 30% decline in new HIV infections since 2010. Of these new HIV infections:
- 1.3 million were among adults
- 160,000 were among children
HIV TestingApproximately 84% of people with HIV globally knew their HIV status in 2020. The remaining 16% still need access to HIV testing services. HIV testing is an essential gateway to HIV prevention, treatment, care and support services.
HIV Treatment AccessAs of the end of 2020, 27.4 million people with HIV were accessing antiretroviral therapy globally. That means 10.2 million people are still waiting. HIV treatment access is key to the global effort to end AIDS as a public health threat. People with HIV who are aware of their status, take ART daily as prescribed, and get and keep an undetectable viral load can live long, healthy lives and have effectively no risk of sexually transmitting HIV to their HIV-negative partners.
- 84% knew their HIV status
- 73% were accessing ART
- 66% were virally suppressed
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Nucleoside Reverse Transcriptase Inhibitors
These drugs interrupt the virus from duplicating, which may slow the spread of HIV in the body. They include:
- Abacavir
- Zalcitabine
- Zidovudine
Combinations of NRTIs make it possible to take lower doses and maintain effectiveness. These drugs include Combivir , Trizivir , Epzicom and Truvada . We expect more combination drugs to be available in the future.
Antiretroviral Drug Discovery And Development
For more than three decades, NIAID has fostered and promoted development of antiretroviral therapies that have transformed HIV infection from an almost uniformly fatal infection into a manageable chronic condition. In the 1980s, the average life expectancy following an AIDS diagnosis was approximately one year. Today, with combination antiretroviral drug treatments started early in the course of HIV infection, people living with HIV can expect a near-normal lifespan. Watch NIAID Director Anthony S. Fauci, M.D., reflect on advances in HIV treatment.
NIAID plays a role in many stages of the antiretroviral drug discovery and development process. The search for new drugs remains a priority due to the development of resistance against existing drugs and the unwanted side effects associated with some current drugs. NIAID supports basic research to identify novel strategies to prevent HIV from taking hold and replicating in the body, as well as preclinical research to formulate antiretroviral drugs that can be tested in people.
NIAID also helps advance clinical drug development. NIAID today supports the largest networks of HIV therapeutic clinical trial units in the world, including the AIDS Clinical Trials Group , the International Network for Strategic Initiatives in Global HIV Trials , and the International Maternal Pediatric Adolescent AIDS Clinical Trials network. Learn more about pediatric HIV treatment research.
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The Aids Epidemic Arises
Though HIV arrived in the United States around 1970, it didnt come to the publics attention until the early 1980s.
In 1981, the Centers for Disease Control and Prevention published a report about five previously healthy homosexual men becoming infected with Pneumocystis pneumonia, which is caused by the normally harmless fungus Pneumocystis jirovecii. This type of pneumonia, the CDC noted, almost never affects people with uncompromised immune systems.
The following year, The New York Times published an alarming article about the new immune system disorder, which, by that time, had affected 335 people, killing 136 of them. Because the disease appeared to affect mostly homosexual men, officials initially called it gay-related immune deficiency, or GRID.
Though the CDC discovered all major routes of the diseases transmissionas well as that female partners of AIDS-positive men could be infectedin 1983, the public considered AIDS a gay disease. It was even called the gay plague for many years after.
In September of 1982, the CDC used the term AIDS to describe the disease for the first time. By the end of the year, AIDS cases were also reported in a number of European countries.
Nucleoside/nucleotide Reverse Transcriptase Inhibitors
NRTIs keep cells containing HIV from making copies of themselves by interrupting the reconstruction of the viruss DNA chain when it uses the enzyme reverse transcriptase. NRTIs include:
- abacavir
- lamivudine
- emtricitabine
- zidovudine
- tenofovir disoproxil fumarate
- tenofovir alafenamide fumarate
Zidovudine is also known as azidothymidine or AZT, and it was the first drug approved by the FDA to treat HIV. These days, its more likely to be used as post-exposure prophylaxis for newborns with HIV-positive mothers than as a treatment for HIV-positive adults.
Tenofovir alafenamide fumarate is used in multiple combination pills for HIV. As a stand-alone drug, its only received tentative approval to treat HIV. The stand-alone drug has been FDA-approved to treat chronic hepatitis B infection. Other NRTIs may also be used to treat hepatitis B.
Combination NRTIs include:
- lamivudine and tenofovir disoproxil fumarate
- emtricitabine and tenofovir disoproxil fumarate
- emtricitabine and tenofovir alafenamide fumarate
In addition to being used to treat HIV, Descovy and Truvada may also be used as part of a pre-exposure prophylaxis regimen.
As of 2019, the U.S. Preventive Services Task Force recommends a PrEP regimen for all people without HIV who are at increased risk of contracting HIV.
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What Needs To Happen
The challenges in the years ahead are clear: we need to reach the 25% of people who have HIV and dont know and support them to test and link to treatment. We need to increase access to prevention to condoms, to voluntary medical male circumcision, to harm reduction and to PrEP. We need to prioritize HIV services for vulnerable and hard-to-reach groups such as people in prisons, people who inject drugs, men having sex with men, transgender people and sex workers. These key populations continue to be left behind, not benefiting from the huge advances in HIV testing, prevention and treatment made over the past 30 years says Dr Baggaley.
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Symptoms Of Hiv Infection
Some people may not develop any symptoms after contracting HIV and could remain undiagnosed until the symptoms of AIDS appear. This could be up to 10 years later.
However, 50% or more of people living with HIV may develop mild flu-like symptoms within 2 to 4 weeks. Early symptoms may include:
- chills
- muscle aches
- swollen glands
The symptoms of HIV infection may last from a few days to weeks. They may go away on their own.
Misdiagnosis of early HIV infection is common. If you think you have HIV, speak with your health care provider about being tested.
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From Monotherapy To Combination Therapy
In 1986 the U.S. Food and Drug Administration approved the first antiviral drug zidovudine for use in preventing HIV replication by inhibiting the activity of the reverse transcriptase enzyme. AZT is part of a class of drugs formally known as nucleoside analog reverse transcriptase inhibitors. After 1991, several other nucleoside analogs were added to the anti-HIV arsenal, as were a new class of anti-HIV drugs called the non-nucleoside analog reverse transcriptase inhibitors which work in similar ways to the nucleoside analogs but which are more quickly activated once inside the bloodstream. Next to be developed were the class of antiviral drugs known as protease inhibitors, which were distinctly different from the reverse transcriptase inhibitors in that they do not seek to prevent infection of a host cell, but rather to prevent an already infected cell from producing more copies of HIV.
Despite this proliferation of drug options, the standard antiviral therapy for HIV-infected individuals between 1986 and 1995 for the most part remained “monotherapy” or treatment with a single drug. Such drugs appeared to be partly efficacious, although there was a great variation in effectiveness among individuals.
New Class Of Antiretrovirals
In 1995, the FDA approved saquinavir, the first in a different anti-HIV drug class called protease inhibitors. Like NRTIs, protease inhibitors stop the virus from copying itself, but at a different stage during the infection.
A year later came yet another class of antiretrovirals, called non-nucleoside reverse transcriptase inhibitor , including nevirapine . Similar to AZT, NNRTIs shut down HIV by targeting the enzymes it needs to multiply.
These drugs paved the way to a new era of combination therapy for HIV/AIDS. Doctors began prescribing saquinavir plus AZT or other antiretrovirals. This combination therapy was dubbed highly active antiretroviral therapy . That approach became the new standard of care for HIV in 1996. HAART greatly lengthened the life span of people with AIDS.
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