World AIDS Day is Thursday, 35 years after the disease was first identified in the United States.
Fresno County saw its first cases two years later in 1983. Now, approximately 1.2 million Americans have HIV. Another 40,000 are diagnosed each year. One of 8 infected persons does not yet know it. As for Fresno County, there are about 700 persons with HIV and 1,100 have progressed to AIDS.
Transmission risks for HIV remain unchanged from those that were quickly identified in 1981. Shared needles and unprotected sex remain the leading causes. Occupational exposure remains rare, and casual contact from daily interaction in a school or a household is still perfectly safe.
Since the dire early years of the epidemic, however, we have seen many successes. Treatment of pregnant women reduced mother-to-child transmission from a 25 percent chance to less than 1 percent. Universal screening of pregnant women has nearly eliminated the disease in young children.
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HIV has changed from a death sentence to a chronic disease. Many years ago, diabetes also led quickly to death. With the arrival of insulin, patients who took this new medicine stayed healthy and productive. Today people with HIV who get care and take their medicines lead full and long lives.
The awful infections that affected people in the early years of the epidemic are rare, affecting only those who cannot take medication well or those who don’t know of their infection.
Prevention remains a challenge. HIV still cannot be cured. We have known for decades now that abstinence and condom use reduce risk dramatically. Treatment programs for injection drug users reduce transmission from needles that may be shared.
A new strategy in prevention is giving HIV medicines to the uninfected. For years we have given HIV medications to health care workers exposed to HIV after a needle stick. More recently we have seen this strategy be effective after sexual exposure.
Now we see clear benefits for those who are uninfected but at ongoing risk, to take medication on an ongoing basis. Pre-exposure prophylaxis, or PrEP, greatly reduces transmission risk, especially when paired with effective partner treatment and barrier protection. Anyone having unprotected sex with multiple partners and partners of someone already HIV-positive are natural candidates for PrEP.
Complicating prevention efforts, frequently people do not feel that they are at risk of getting or giving HIV. Fully 13 percent of those who have HIV do not know it. When people learn of their infection it changes their behaviors. Acknowledging this, the Centers for Disease Control and Prevention recommends that every adult get checked for HIV at least once. Don’t be surprised when your physician suggests an HIV test. It is not a value judgment; in 2016 it is simply good medicine. Those with ongoing risks should be checked repeatedly.
Getting people tested and treated is a public health measure. People who know their status reduce their risk behaviors. People who know their status can access life-saving treatments. Those who get treatment have less virus present so they are less likely to pass it on. Besides helping the individual, successful treatment reduces the risk of transmission to others.
An obstacle to testing is the stigma that some people still apply to the disease. Anyone who knows that they will be ostracized from their family or their community for having HIV will avoid finding out. These delays allow the immune system to weaken even more. Many people at risk remain hidden because of their injection drug use or homosexuality. A casual remark denigrating these groups can make a loved one even less likely to seek the testing and care that they need. Acceptance allows everyone to safely seek care.
The last three decades have seen despair turn to hope. Routine testing will bring care to more people who need it. If your doctor offers you testing, accept it! If she doesn’t ask about it, ask her about it. If you are at risk, ask about prevention.
There is no cure on the near horizon but when the day comes, we want as many people as possible alive to get it. Thursday is World AIDS Day. It is still very relevant today, but we can hope someday it will only be a reminder of past challenges.
Roger Mortimer, M.D., is a clinical professor at University of California, San Francisco – Fresno.