December 1 is World AIDS Day.
First observed in 1988, it's a time to reflect on efforts to contain the virus and to express support for those who have been affected by it. Since 1984, more than 35 million people have died from AIDS-related illness worldwide, and about 38 million are currently living with HIV, according to UNAIDS.
To learn more, I spoke recently with two Stanford Medicine researchers. Eran Bendavid, MD, an associate professor of medicine, researches the political and environmental factors affecting population health, especially in developing countries; and Philip Grant, MD, an assistant professor of medicine, focuses on antiretroviral therapy and long-term complications for patients with HIV.
What are the most important things you'd want the general public to know and understand about HIV/AIDS as we head into 2020?
Bendavid: Despite all that we've learned about HIV and the improvements in prevention and antiretroviral medications, the number of people living with HIV in most countries is either stable or in some places, like Eastern Europe, rising. There are a few areas in which we have made a lot of progress -- for example, we've managed to greatly reduce mother-to-child HIV transmission. But among high-risk adult populations like drug injectors and MSM [men who have sex with men], HIV seems to be here to stay. Three quarters of all currently-infected people and new cases in the world are in sub-Saharan Africa, where it remains the number one cause of death among adults. The incidence in the United States hasn't really budged in the past 10, 15 years. There's been a lot of excitement about "the end of AIDS," but I'd want people to know that HIV is not going away.
Grant: I'd want people to understand how preventable it is. We have these great preventative treatments like PrEP , which almost eliminate new transmissions; but only about one quarter of people in these high-risk populations are on PrEP. If you're fully suppressed, you can't transmit the virus sexually. If the people at the highest risk were getting tested frequently, and then got treated once diagnosed, that would be enough to seriously reduce transmission of the disease.
Could you describe your work on HIV/AIDS?
Bendavid: One of the key issues in achieving reasonable HIV control is that we don't understand why people keep getting infected, and who these people are. So we're doing two things to understand that better: using big-data analysis to characterize HIV risk factors, and creating 'hotspots' to understand where exactly in the world these new infections are happening.
The other effort is trying to do evaluations of existing HIV programs. The biggest program we're evaluating is an organization called PEPFAR. This started out as the President's Emergency Plan for AIDS Relief. There's no longer an 'emergency,' but it remains a broadly well-received and well-liked organization on both sides of the American political divide.
Grant: One of my focuses is on the long-term complications of HIV and its therapy. In general, people with HIV now have the same life expectancy as other people, but they're suffering from higher rates of bone disease, cardiovascular disease and cognitive impairment. There have been attempts to integrate almost geriatric services for people with HIV, since they're experiencing health problems that older people typically have.
What are your hopes for the future of HIV/AIDS treatment?
Bendavid: There are several vaccines that are currently being tried. Even an imperfect or partially-effective vaccine that only reduces the risk of infection by 30 or 40% -- which is most likely what we'll come up with -- would be huge. That's the kind of intervention we're hoping for in the biomedical world.
Grant: I'm optimistic about the fact that when HIV became a public health emergency in the '80s, the gay men who were affected were really marginalized. There's still work to be done in minority communities, but there's been so much progress in reducing that stigma, which is critical to treatment and prevention. I'm also generally hopeful about the move towards getting people in high-risk communities to get tested and take PreP. The new therapies we have are so simple and so well-tolerated. These days, it's all about prevention, and a major component of that is getting people tested.
Photo by Andy McCarthy