HIV Policy: The Path Forward—A Joint Position Paper of the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians
Year: 2009
Type: article
Abstract: The American College of Physicians (ACP) and the Infectious Diseases Society of America (IDSA) have jointly published 3 policy statements on AIDS, the first in 1986 [1], the second in 1988 [2], and the third in 1994 [3]. In 2001, the IDSA created the HIV Medicine Association (HIVMA), and this updated policy paper is a collaboration between the ACP and the HIVMA of the IDSA. Since the last statement, many new developments call for the need to reexamine and update our policies relating to HIV infection. First, there have been major advances in treatment for HIV infection that have transformed HIV/AIDS from a terminal illness to a chronic disease for many of those who have access to potent therapies and expert medical care [4]. Second, there has been a profound expansion and intensification of the global HIV pandemic, particularly in sub-Saharan Africa, coupled with significant US leadership and resources aimed at providing prevention and care services to affected populations in developing countries. Third, the concerns that were prevalent in the mid-1990s regarding the possibility of HIV transmission in health care settings have ultimately proven to be unfounded as the result of the adoption of universal precautions in those settings. In this article, we emphasize the public health and clinical imperatives for earlier identification of persons with HIV infection; the urgent need to expand access to state-of-the-art HIV care and treatment for infected individuals; the need for access to comprehensive prevention and education for those living with and those at risk for HIV infection; and the need for stronger national leadership to respond to the HIV epidemic in the United States and in the developing world. In December 2008, the ACP and HIVMA released a guidance statement on screening for HIV infection in health care settings that recommended that clinicians adopt routine screening for HIV infection and encourage patients to be tested. Also included in the guidance statement is a recommendation that clinicians determine the need for additional screening on an individual basis. Since the first AIDS cases were reported in 1981, ∼1.7 million people have become infected with HIV in the United States [5]. Of these individuals, >550,000 have died, and nearly 1.2 million people are estimated to be living with the disease today [6, 7]. Of these, 415,000 are estimated to be living with AIDS, and 417,000 are estimated to be living with HIV infection. Another 252,000–312,000 people are estimated to be living with HIV infection or AIDS in the United States and to be unaware of their status. In August 2008, the Centers for Disease Control and Prevention (CDC) revised the annual HIV infection incidence rate to 56,300 cases per year and asserted that this number has remained stable for more than a decade [8]. In 2006, the largest estimated proportion of HIV/AIDS diagnoses in the United States were among men who have sex with men [9], and a majority of those women who contracted HIV infection did so through heterosexual contact [10]. HIV/AIDS continues to disproportionately impact racial and ethnic minorities, who now account for 65% of new AIDS cases [6]. During the mid-to-late 1990s, advances in treatment slowed the progression of HIV infection to AIDS and dramatically reduced the number of deaths among people living with AIDS. Regionally, the South has had the greatest numbers of people estimated to be living with AIDS, AIDS deaths, and new AIDS diagnoses, followed by the Northeast, West, and Midwest [5, 6]. The number of pediatric AIDS cases has decreased considerably in the United States, with only 38 cases diagnosed in 2006 (a considerable decrease from the ∼745 cases diagnosed in 1995) [11]. Among children and adolescents, teenaged girls and minorities have been particularly affected. Similar to the adult population, children and adolescents have experienced a dramatic decrease in morbidity and mortality due to HIV infection in the United States since the advent of combination antiretroviral therapy [12, 13]. Although the United States has seen a drastic decrease in the number of AIDS-related deaths since the early 1990s, AIDS remains a global epidemic and affects an estimated 33 million people worldwide. The Joint United Nations Programme on HIV/AIDS has estimated that, in 2007, 2.7 million persons were newly infected with HIV, and there were 2 million AIDS-related deaths globally. Sub-Saharan Africa continues to be the region most affected by the AIDS pandemic and accounted for 67% of all people living with HIV infection and 75% of AIDS-related deaths in 2007. Although women represent 50% of people living with HIV infection globally, they account for nearly 60% of infections in sub-Saharan Africa, where transmission is primarily through heterosexual contact. Nearly 90% of the 2 million children <15 years of age living with HIV infection worldwide are in sub-Saharan Africa, and >90% of the 270,000 deaths due to AIDS among children in 2007 were in Africa [14]. More than a decade ago, combination antiretroviral therapy was widely introduced in the United States and Europe, constituting a medical breakthrough that revolutionized the treatment of HIV infection in the developed world. The approval of the first protease inhibitors in late 1995 and early 1996 shifted medication strategies from monotherapy to combination therapy with at least 2 different drug classes, and standardized combination antiretroviral therapy came to be regarded as the best clinical practice in treating HIV/AIDS. The effective suppression of HIV through combination antiretroviral therapy resulted in an 80% decrease in AIDS-related mortality in the United States and in dramatic reductions in the prevalence of the debilitating opportunistic infections that had been commonly associated with an AIDS diagnosis. It has been estimated that combination antiretroviral therapy has saved 3 million life-years [4]. For women with HIV infection, the availability of combination antiretroviral therapy has meant that they may become pregnant and have children at virtually no risk to the baby if there is appropriate administration of HIV treatment during pregnancy and delivery and postnatal treatment for the infant [15, 16]. Furthermore, in a recent study [17], pregnancy was not associated with an increased risk for disease progression in women who received combination antiretroviral therapy and were not severely immunosuppressed. Such observations highlight the remarkable impact of antiretroviral treatment and contribute to the evidence in support of the right of women with HIV infection to bear children. There are now 32 US Food and Drug Administration–approved antiviral medications in 5 major drug classes [18]. More recently, therapeutic breakthroughs have come in the form of new classes of drugs with new methods of action against HIV infection, as well as more potent medications in existing classes, including combination products. For the patient, the toxicity and adverse effects of many of the newer medications are reduced, compared with those of older drugs, and the pill burden has also been substantially reduced, which promotes better adherence to drug regimens. Nonetheless, the development of drug resistance has become a serious problem for long-term survivors of HIV infection, and a significant percentage of individuals with newly diagnosed infection have contracted virus that is resistant to at least 1 major class of HIV medication. Drug resistance testing and medication changes in response to the development of infection with drug-resistant virus are an integral part of HIV care and treatment. In addition to drug resistance, many patients who receive antiviral treatment experience toxicities associated with the long-term use of certain HIV drugs, including metabolic changes, such as abnormal fat distribution, abnormal lipid and glucose metabolism, and bone loss [19]. Finally, increases in longevity have meant that many persons who are living with HIV infection and are now middle aged are vulnerable to chronic conditions that are associated with aging, some of which are exacerbated by the presence of HIV infection. In developing countries, access to combination antiretroviral therapy is still a challenge, and when it is available, most individuals have access to only 1 drug regimen. A proliferation of generic medications and deep discounts by pharmaceutical companies have dramatically reduced the cost of first-line regimens, but second-line therapies and common diagnostic tools are still prohibitively expensive for many developing countries and are not widely available in the public sector, where most people receive their care. Opportunistic infections in HIV-infected patients are common in developing countries, with tuberculosis being the leading cause of death among patients with HIV infection in sub-Saharan Africa and in much of the developing world [20]. HIV disease in the United States increasingly and disproportionately affects low-income and minority populations that are less likely to have reliable access to care and that face many other life challenges in addition to HIV infection, including addiction and mental illness, as well as poverty, violence, homophobia, and racism. Early and reliable access to care is critical to successful treatment of HIV disease, but it is not well supported by the fragmented US health care system. Moreover, nearly 40% of newly diagnosed infections occur in persons who are already severely immunosuppressed, which makes their treatment more costly and less effective [21]. Recent studies have estimated the annual cost of care for a person with a CD4+ cell count >350 cells/µL to be $13,885, compared with $36,533 for an individual with a CD4+ cell count <50 cells/µL [22]. Treatment advances have resulted in a shift in medical resource utilization for patients with HIV infection from the hospital to the outpatient setting. Early in the epidemic, many HIV physicians were drawn to HIV medicine as interns and residents when they cared for patients with HIV infection in urban hospitals. Today, medical residents are far less likely to be exposed to a large number of patients with HIV infection during their training. In addition to this lost opportunity for engagement, HIV medicine now requires expertise in primary and specialty care, in addition to expertise in managing HIV disease. The expanded knowledge base is necessary to manage the serious coexisting conditions that people with HIV are developing as they live longer, such as diabetes, cardiovascular disease, chronic and disease, and and In addition to an medical knowledge HIV medicine requires a to in a that is and with a disease that affects low-income and of these have for medical and for an HIV The availability of experienced HIV clinicians is critical to access to of the HIV and there are already concerns clinical in many of the United that only as the of and who the of HIV medicine in the early of the epidemic to be to that an number of HIV clinicians to be available to care for the numbers of HIV-infected individuals who are in need of care. It is particularly to support minority physicians who are in HIV medicine to access and treatment for the and which are disproportionately affected by the disease The HIV epidemic not be by treatment but prevention to far treatment on new HIV infections they occur among our patients and on patients with HIV/AIDS much earlier in the disease care physicians may be in a to people with HIV/AIDS early during the infection of people with HIV infection experience to those associated with other such as or [18]. with HIV infection are Nearly 50% of new HIV infections be to people who the virus during the infection the number of patients who receive a during the HIV infection to with treatment earlier and an in the number of new infections in the For many in the United States, a of HIV infection still a significant and to that access to health and health care to the of clinical among people with and in people not care their illness has to the at which it is late for to from treatment that and associated with HIV infection are particularly among certain such as The associated with HIV infection is by the and already experienced by many of the education and are with leadership from and medical at the and on HIV transmission and it be be and and support for proven prevention tools is not only to but also to the associated with the that people at increased risk for HIV infection. such as health care for people with HIV/AIDS the with and with such as the HIV/AIDS Treatment access to HIV care the United are critical and still necessary to the impact of the still in many the United patients with HIV/AIDS to that they experience from health care including physicians are supported by HIV medical who have reported challenges medical services of the HIV for their It is that we a policy from our policy health care and have an to all including those with with and care and treatment. and to support routine HIV testing for pregnant and through and by supported health care and of for a for HIV In December 2008, the ACP and HIVMA released a guidance statement on screening for HIV infection in health care settings that recommended that clinicians adopt routine screening for HIV infection and encourage patients to be tested. The statement recommended that clinicians determine the need for additional screening on an individual basis. In 2006, the updated for HIV testing in health care settings to routine HIV and supported health care have been to support routine HIV screening through and HIV testing be as a and be by the Centers for and to routine HIV screening to their HIV screening also be and supported with resources through other such as health the of and the of as well as in the of health care HIV infection remains a serious among adolescents and particularly among men who have sex with of increases in new HIV infection diagnoses among this HIV-infected adolescents have the health care but those who receive a at a medical are more likely to HIV care in a are more likely to to be for HIV infection if it is recommended by a There are a number of that to to screening and particularly in the of support in and that to or an of an HIV health and in public leadership including access to comprehensive sex education for children and adolescents, availability of and education their and availability of and drug treatment to the risk of HIV More than years the first cases of AIDS were reported in the United States, we a the that individuals at risk for HIV infection and that these Physicians bear a to persons in public leadership to the HIV be as well as the that have been to or drug use education an on and that not HIV, as well as those that For more than a the has to for education in public that on than on providing and use as part of a comprehensive sex education to be studies that have that such are in and in some to that may to or including HIV infection Furthermore, that have been to be effective in HIV transmission among drug including and or and drug treatment be by and and be widely available drug use still for a significant number of new HIV for drug treatment in the public including as well as and be The US for HIV prevention through the to aimed at populations at and at with access to care, as well as to In year 2008, the received million for HIV/AIDS prevention There have been no increases in HIV prevention for in a number of is the that the number of new infections in the US has remained for a decade at 56,300 infections per Although the has developed new to HIV transmission a new on prevention for to minority populations that are disproportionately with new and to HIV testing routine and more widely available in medical to be In addition to these new HIV prevention are for a of including prevention and policy and including testing by and and that increased to support a comprehensive to the incidence and prevalence of HIV infection is Physicians and other health care patients all that at risk for HIV infection and other Physicians who patients with HIV infection their patients that contribute to HIV infection to and drug use Physicians are in a to the of their patients and have a to and on HIV infection and other infections their clinical with patients an of the of the transmission of HIV infection and other that result in HIV transmission and those that the of a result for HIV and for risk including the of Physicians of their and adult patients and and other drug The need to to transmission of infection be with all of HIV infection status. Although some studies have that there is a decrease in knowledge of HIV infection this has not been for all studies have reported that the decrease in may which that HIV infection prevention for individuals who are HIV to be their people living with HIV/AIDS in the United States have access to HIV care by or in with individuals who are in providing care for HIV/AIDS. and other health care are to and care to patients with HIV infection or to for to an HIV resources be to the of newly patients in the health care setting. for HIV care be to a The the and of the HIV clinical and diagnostic methods have the HIV/AIDS from a terminal to a chronic illness for many clinical of HIV infection has become more US Food and Drug Administration–approved antiviral medications are available in 5 major drug classes and are in combination drug regimens. also knowledge the to drug resistance and be to drug toxicities and manage The and such as the HIV antiretroviral are updated Since the early of the AIDS epidemic in the United States, studies have health for those patients who are by clinicians who have of patients with HIV infection and more experience in treating HIV disease Physicians who in HIV care and treatment come from the of primary care medicine and physicians who HIV care today were introduced to HIV/AIDS during their in major during the early of the HIV disease has from the hospital to the outpatient physicians are exposed to HIV medicine during their and study of medical residents from medical that of practice residents and of medicine residents or to care for patients with HIV infection Moreover, for HIV care and treatment is In a by HIVMA of by the HIV/AIDS of reported HIV clinicians and the 2 challenges to as of HIV clinicians and are particularly to more minority physicians to HIV of US physicians as and as is an that requires serious problem is not to HIV care, but to medicine as has been by the of Medicine and many policies and are to support minority physicians in HIV the significant impact on minority and the for patients who are with their for patients in and for patients with HIV infection of the large in HIV care and treatment and the to HIV testing in health care settings we call on the to the and of the HIV clinical and The US with to access to care for all patients with HIV/AIDS in the United States by a that comprehensive medical care and drugs to all low-income persons with HIV infection, as recommended by the a for the Treatment of 2006 and that to expand to low-income persons with HIV infection such individuals experience progression to AIDS. In year 2008, support for HIV care and treatment was with of these for the of and for HIV care and treatment is not to all persons living with HIV infection in the United States, and the availability of care and services from to In the a study of the and delivery of HIV care and treatment for low-income and individuals with HIV disease. a that nearly 50% of individuals with HIV infection have no access or access to HIV care and that the of from was access to HIV care The recommended a to all low-income persons with HIV infection access to a of primary care evidence from HIV the that they are to the medical of their patients has to the Treatment of 2006 or to that of low-income persons with HIV infection in addition to a persons be part of a of be a years of or a HIV infection is not an and most persons with HIV/AIDS not they are as a result of AIDS The last have to to as the Early Treatment for HIV that and encourage through to to and adolescents with HIV infection they experience progression to AIDS In the of universal access to health care services for all we support policies that that all low-income persons with HIV/AIDS have access to the of care for HIV disease. The to a for the treatment of HIV infection be the most and to this in the United In the of and we that respond to the in access to HIV care by for the Treatment of 2006 and the Early Treatment for HIV of individuals be to the greatest with the to and to the public care the and of patients living with HIV disease. The of health care who are HIV-infected also be and their HIV not be a in or in the of persons with HIV/AIDS and and HIV/AIDS is still a disease, and public have for individuals, including and In addition to that the of all medical many and have and that are to HIV infection. Physicians their to the of their patients with their to the health and of their or drug use In virtually all of the and of the United States, there are health care to cases of HIV infection to or health also health care in patients their to their and drug use their HIV and in many health the with and and services are and The US to support a comprehensive of the and treatment of HIV infection and AIDS, including aimed at a prevention to HIV the development of antiretroviral and therapeutic and for opportunistic infections and that persons with HIV infection. that the and of prevention and treatment of HIV infection in the US and the associated also be well in the The of is the global in AIDS the largest and most significant public in AIDS in the world. The of the AIDS at the of are a in to and HIV transmission and to better therapies for those who are already to the pandemic in developing countries, and and to the impact of AIDS on minority populations in the United States In years 2007 and 2008, the for AIDS was AIDS has a from our of the of HIV infection to therapeutic developments that have resulted in dramatic in life for infected A more to be Prevention is as is to the development of medications with increased better resistance and less The US to resources to respond to the global pandemic, with a on developing countries. be to prevention such as for distribution, and drug treatment and to antiretroviral treatment and comprehensive medical care and support services for and and to care and services to children who have been as a result of The US also a major to the to HIV, and US and other to and be supported in the of developing countries to the and of new Since the United States has a major in the global AIDS pandemic with the of the for AIDS which a to HIV infection, primarily in countries In addition to providing for and care as well as services for children by AIDS, the United States also to the to HIV, and through 2008, the number of individuals who were antiretroviral therapy in the countries increased from to million supported of the United States and in 2008, which the US global AIDS and in a for HIV, and the US to to global health by the at the recommended in the and and the US support to the to HIV, and with HIV infection be to the United States, and with HIV infection be to or are that the on persons with HIV disease the United States as or with the of the United States and now the of and to to HIV disease from the of of public health and to this practice against and with HIV infection. There has been major in the HIV epidemic, and globally, but significant challenges and a of remains to be support is from the public and for and health services and health care and the leadership in these all by our individual and to of the the world has of has in a has on the of and and has received clinical support or clinical drug from and has as a to and and has received from and has received from the of and of of and and HIV and has as a to and and has from and has received support from and and has as a to and has as a to and has received from the of the of and has in a has as a for United in and is an of other no
Source: Clinical Infectious Diseases
DOI: 10.1086/598169
Authors: Christine Lubinski, Judith Aberg, Arlene D. Bardeguez, Richard Elion, Patricia Emmanuel, Daniel Kuritzkes, Michael Saag, Kathleen E. Squires, Andrea Weddle, Jennifer Rainey, M. Renee Zerehi, J. Fred Ralston, David A. Fleming, David Bronson, Molly Cooke, Charles Cutler, Yul Ejnes, Robert Gluckman, Mark Liebow, Kenneth Musana, Mark E. Mayer, Mark W. Purtle, P. Preston Reynolds, Lavanya Viswanathan, Kevin B. Weiss, Baligh Yehia
Institutions: Infectious Diseases Society of America, Bellevue Hospital Center, New York University, Rutgers New Jersey Medical School, University of Medicine and Dentistry of New Jersey, University of South Florida, Brigham and Women's Hospital, Harvard University, University of Alabama at Birmingham, Thomas Jefferson University Hospital, American College of Physicians, University of Missouri, Cleveland Clinic, University of California, San Francisco, Providence Portland Medical Center, Mayo Clinic, Virginia Commonwealth University, University of Virginia, Uniformed Services University of the Health Sciences, American Board of Medical Specialties, Johns Hopkins University
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2128479250