World AIDS Day: Major Advances, More Work to Do

By Beverly Sha, MD

I began my medical training in 1986, just a year after HIV, the virus that causes AIDS, was first identified. Already, nearly 25,000 people had died of AIDS in the U.S. alone, and to date more than 650,000 people in just this country have died with an AIDS diagnosis.

In the early part of my career as an infectious disease specialist treating patients with HIV and AIDS, I expected that I would see every person for whom I provided care die. We could prolong their life to some degree, get them through certain infections, but at some point they would progress and die of AIDS.

That’s no longer the case at all. We’ve made extraordinary advances in treating and preventing HIV infection and AIDS in what for medicine is a very short amount of time. As we observe the 30th annual World AIDS Day on Dec. 1, it’s a good time to consider the current state of AIDS prevention and treatment, how far we’ve come, and how much work remains.

Know your status

This year’s theme for World AIDS Day is “Know your status.” In the U.S., guidelines from the federal Centers for Disease Control and Prevention recommend that all sexually active people who are from 13 to 64 years of age get at least one HIV test in their lifetime. Persons at higher risk — gay and bisexual men, transgender women who have sex with men and injection drug users — are candidates for annual testing. 

Currently, approximately 36.7 million people are living with HIV worldwide. In 2016 (the most recent year for which data is available), 1.8 million people worldwide were infected with the virus, according to UNAIDS.

In the United States at the end of 2015, approximately 1.12 million people were estimated to be living with HIV infection, with about 162,500 of them undiagnosed, the CDC reports. In 2016, nearly 40,000 people were newly diagnosed with HIV infection in the U.S. The good news is that this number is lower than the nearly 45,000 people that were infected in 2010, but that number still is too high.

In Chicago, 23,824 people were living with HIV in 2016, and 839 people were diagnosed with the infection that year, according to the Chicago Department of Public Health. We are making progress: That number is the lowest we’ve had in a year since 1990.

Why test?

People at risk for HIV infection should be tested because earlier treatment improves outcomes, and treatment that reduces the presence of HIV to undetectable levels in their blood reduces transmission of the virus. It’s also a way for at-risk people who are HIV negative to learn about PrEP (pre-exposure prophylaxis) –the use of antiviral drugs to prevent HIV infection.

In the mid-1990s, before we had effective antiretroviral therapy, we only were able to add about eight years of life to people who were HIV-infected. There were a lot of people dying and it was a difficult time to be a physician. In 2010, an infected 20-year-old person in the developed world can expect to live another 55 years, nearly a normal lifespan, according to UNAIDS.

When we are able to identify HIV-positive individuals and treat them to bring their HIV down to undetectable levels and maintain undetectable levels, the chance of them transmitting the virus to someone else is zero. A European study followed 888 heterosexual and same-sex male couples, in which one partner was infected but their HIV levels were suppressed for at least six months and the other partner wasn’t infected. They found that after more than 58,000 sex acts without a condom, there was no documented transmission of HIV to the uninfected partner.

Overall, in the United States a person’s risk of HIV infection in his or her lifetime is one in 99, the CDC estimates. However, this risk is not uniformly distributed. HIV is affecting a large part of our community, especially on the West Side of Chicago and among minority populations. Black men are the most affected ethnic group, with a one in 20 lifetime risk of HIV infection, and black and Latino men who have sex with men have a one in two and one in four lifetime risk, respectively. (These estimates come from the CDC.)

People who test HIV negative but are at significant risk for HIV infection should be offered HIV pre-exposure prophylaxis (PrEP). Taking the drug Truvada once daily can reduce the risk of HIV acquisition by more than 90 percent.

Rush is doing its part

Because the West Side communities we serve are at higher risk of HIV infection, Rush has implemented protocols to test for the virus among our patients. Since March of 2015, we’ve had an opt-out HIV testing program in our emergency department based on CDC guidelines. Through this past July, we’ve tested 19,569 people,and 142 of them tested positive, including 47 who were newly diagnosed and 13 with acute HIV (a condition that occurs in the first few weeks after infection and causes flulike symptoms).

Early this year, we expanded our testing program to three primary care clinics, two on our main near West Side campus and one in Lincoln Park which have performed 1,232 tests through October, with two positive results. We plan to expand this program to other clinics in 2019. 

We are also working on an initiative to create an alert to prompt clinicians to consider HIV PrEP in at-risk persons. 

As difficult as it was to live through the early part of the HIV epidemic, it was also incredible to contribute to the advances that have made HIV into a chronic treatable disease and no longer a death sentence. The collaboration between physicians, scientists, patients, and activists was unprecedented and were critical to these advances. I’m proud to have spent my career at Rush, an institution that has been at the forefront of HIV research via our ongoing participation in the NIH-funded AIDS Clinical Trials Group Network since 1987.

Beverly Sha, MD, is an infectious disease specialist at Rush University Medical Center.

Tackling the Neurological Complications of HIV

igor-koralnik-mdBy Igor Koralnik, MD

“I take care of HIV-infected people who have neurological problems and I do research on progressive multifocal leukoencephalopathy.” This is my typical answer to the question:  “What kind of a doctor are you? “Which most often elicits raised eyebrows, puzzled looks and a polite, “Oh, this is so interesting! Now what is it that you are actually doing?”

Most people know that neurologists take care of patients with stroke, seizure, Parkinson’s or Alzheimer’s, but few are aware of the multiple neurological complications of HIV infection. Even fewer have ever heard of progressive multifocal leukoencephalopathy or PML.

So I tell them that I got interested in this area when I was a med student at the beginning of the HIV epidemic. During my first forays on the wards, I saw so many young people coming down with all kinds of neurological diseases of the brain, spinal cord and nerves. Those diseases were either caused directly by HIV, or by other opportunistic infectious agents that took advantage of the patients’ lower immune defense caused by AIDS. This is when I decided to specialize in the neurological complications of HIV, and, by extension, to the care of patients with infections of the nervous system.

The paradox of PML

One of these infectious agents is JC virus, named according to the initials of a patient with PML. After his death, researchers in the U.S. isolated the virus from his brain. JC virus is a fascinating paradox: innocuous in healthy people, it resides in the majority of us as a lifelong infection in the kidneys and gets excreted in the urine without causing any disease; deadly in immunosuppressed individuals, it destroys the white matter of the brain in multiple areas, causing a variety of neurological deficits including paralysis, blindness, language dysfunction and seizures. There is no specific treatment for JC virus. Only half of patients who develop PML survive more than one year.

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