Editor's Note
Unfolding Story
Antiretroviral therapy has changed HIV infection from an incurable, fatal disease to a still incurable, but survivable condition.
Every disease has a biography. The story may start with a hasty declaration such as John Snow’s “Aha!” at the Broad Street pump as he introduced cholera to the world. But most diseases arrive in fits and starts as medicine stumbles toward a working model complete with a pathophysiology and a name. The tale frequently has false starts: Chapters get written only to be torn up when new information is uncovered and characters enter the plot only to leave when they no longer fit the storyline.
AIDS has such a story. Smoldering as a mysterious wasting disease in Africa in the 1970s, AIDS surfaced in the United States in 1981 with a description of immunocompromised gay men who were contracting opportunistic infections. After a peculiar interlude when it was described as a disease of homosexuals, heroin addicts, and Haitians, identification of the route of transmission and finally the causative organism guided the recommendations for prevention and the search for treatment. For years, exhortations about safe sex and needle exchanges seemed mere whispers in the storm as the epidemic exploded and a diagnosis of HIV infection meant a death sentence. It seemed that medicine was fighting a losing battle and the final scene in this story was to be a grim one.
This month’s Minnesota Medicine explores more recent chapters in the AIDS biography. Antiretroviral therapy has changed HIV infection from an incurable, fatal disease to a still incurable, but survivable condition for those who have access to these expensive medications. The care of geriatric HIV patients, inconceivable years ago, now has become a problem of success that physicians must tackle (p. 45 and p. 50). And the truly radical notion of normal life spans for HIV patients is even bruited about in the AIDS literature.
Yet these successes are only part of the AIDS story. Lulled by the promise of available treatment, the number of people practicing safe sex in at-risk populations has dwindled, and the previously stable or declining incidence rate in sexually transmitted HIV in the United States has started to climb (p. 40). The disease inferno in Africa and other parts of the Third World burns incessantly (p. 38). And the virus continues to resist true eradication or an effective vaccine.
So the story of AIDS is still being written. Virologists struggle to keep up with the ever-changing costumes of the HIV organism with an eye to devising treatment and concocting a vaccine that will provide a modicum of protection (p. 22). Public health officials are revising and reinvigorating campaigns to change dangerous behaviors. And clinicians and drug companies are refining treatment regimens that have given years of life to people with HIV and disease-free life to infants of HIV-infected mothers.
Years ago, in the midst of the seemingly unstoppable AIDS epidemic that threatened to consume all the resources medical practice and society had to throw at it, then-state epidemiologist Michael Osterholm, Ph.D., said in a talk to our medical staff that medicine and society would be judged in the future by how well we addressed AIDS. The final verdict is still out and the last chapters have yet to be written, but the AIDS story in 2009 has glints of hope not imagined in those dark times.
Charles R. Meyer, M.D., editor in chief Dr. Meyer can be reached at cmeyer1@fairview.org.