Whatever Happened to the AIDS Crisis?

Chronic diseases such as end-stage renal disease (ESRD) have now surpassed opportunistic infections as the leading cause of death among HIV-infected patients.
Chronic diseases such as end-stage renal disease (ESRD) have now surpassed opportunistic infections as the leading cause of death among HIV-infected patients.
Recently, researchers reported on a national study comparing outcomes among the entire U.S. cohort of HIV-infected kidney transplant recipients with appropriately matched HIV-negative controls. The study, published online in the Journal of the American Society of Nephrology, found that HIV-infected patients who were not co-infected with hepatitis C virus had 5- and 10-year graft and patient survival rates similar to those of HIV-negative recipients. The researchers noted that chronic diseases such as end-stage renal disease (ESRD) have now surpassed opportunistic infections as the leading cause of death among HIV-infected patients. The study got me thinking about the evolution of HIV disease in the United States and how AIDS has slipped from public view compared with, say, 2 decades ago. 

The Centers for Disease Control and Prevention (CDC) estimates that more than 1.2 million people aged 13 years and older in the United States are living with HIV infection, and the number is increasing. In 2013, an estimated 47,352 people were diagnosed with HIV infection and an estimated 26,688 were diagnosed with AIDS in the United States. HIV/AIDS remains a serious epidemic, yet it gets relatively little coverage in the mainstream media these days, unlike in the past, when AIDS reports appeared almost daily, and, not uncommonly, on newspaper front pages. 

One reason, I suspect, is that the advent of highly active antiretroviral therapy (HAART) in the mid-1990s transformed AIDS from a fatal to a chronic illness, at least in the United States. The incidence of opportunistic infections and virus-related malignancies—the main causes of death among AIDS patients—plummeted. In 1995, around the time of HAART's debut, 50,876 deaths were reported among adults or adolescents diagnosed with AIDS (although these deaths may or may not be related to AIDS), according to the CDC. In 2013, the figure was 13,712. 

The increased life expectancy of HIV-infected patients and the continued growth of the HIV-infected population have implications for nephrologists and urologists, who may now see more and more of these patients presenting with the same renal and other urinary tract problems seen in the general non-HIV-infected population. Nephrologists will likely be managing more HIV-infected dialysis and transplant patients, given that chronic kidney disease is a common complication of HIV disease. 

Although the care of HIV-infected patients may present concerns and challenges, such as the potential danger of HIV transmission, it should give clinicians some satisfaction to know they are tending to the needs of individuals who, prior to HAART, might not have lived long enough to require their professional services.

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