The Evolution of HIV by Zhibin Dai

This post focuses on the two articles from the New England Journal of Medicine, “AIDS – Past and Present” and “AIDS in America — Forgotten but Not Gone.” The former discusses – from a medical standpoint – the evolution of understanding and treating HIV, while the latter focuses on the current state of the disease in the United States, particularly the disproportionate prevalence of HIV among poor and minority groups in major urban areas such as Washington, D.C. and New York City.

The biggest take-away from “Past and Present” for me were the myriad ways in which HIV impacted medicine. Although it’s tapered off in recent years as public consciousness of HIV – what it is, how it’s contracted, how to avoid contracting it – has grown and stabilized, and treatments for it have made HIV a somewhat treatable disease, HIV figured prominently in the public consciousness during the 1980s and 1990s. And it was prominent probably because of two factors: 1) the confusion about the disease (essentially its “newness”) and 2) how deadly it was. But one consequence of these unfortunate factors was that it created great public urgency – for both researchers and medical practitioners – to quickly try and understand HIV and develop methods to combat it.

In roughly 15-20 years, greater understanding about HIV transformed it from a brutal and quickly fatal disease to one that is treatable and manageable. Gottlieb writes, “Twenty years after the first reported cases, we know more about HIV than we do about most other human pathogens. This achievement exemplifies the way in which an investment in basic research can change the natural history of a fatal illness.” This point illustrates the need for greater investment in research, for HIV as well as other diseases. More research is socially beneficial because improving understanding about diseases can lead to more medically successful – and cost effective – medical care.

Further, more investment into research – particularly among developed nations – can significantly benefit developing nations, such as those in Africa struggling to combat HIV because they can receive many of the benefits of research without having to incur the costs (provided that access to the benefits is adequate).

The challenge of combating HIV also led to broad-based improvements across the medical community. It led to the development of universal precautions in handling blood; treating patients with HIV also challenged physicians to be more thoughtful and empathetic in their practice of medicine, benefitting not just HIV patients, but other patients as well.

“AIDS in America” points out that although the percentage of Americans with HIV is relatively low – particularly compared to many sub-Saharan nations, HIV prevalence is actually very high in the United States in small, discrete locales and among specific social and racial groups. But what is surprising and disappointing about the state of HIV in America is not its geographic and socio-economic distribution, it’s the number of people inflicted with it. But let’s discuss both issues.

With respect to HIV’s distribution in America, the fact that HIV is largely confined to individuals who live in poverty, are poorly educated, and have limited access to health care can be viewed positively because it shows that not being poor, getting a good education and having good access and high quality health care significantly limits the chances an individual will contract HIV. If you take a step back, this is a sign of huge progress. The HIV epidemic now largely ceases to be a problem for most Americans; it’s now primarily confined to the most marginalized members of society. This is incredibly problematic because they have limited political power, but it’s also an opportunity because combating HIV can be integrated into broader social policy aimed towards helping the less fortunate.

Thus, the fact that HIV infection rates have failed to decline in the last decade suggests two possible issues: 1) the symptoms of HIV – poverty, lack of education and health care – are not being adequately or successfully addressed, and 2) strategies to combat HIV may be outdated and need to evolve to confront the changing context of HIV in America. Clearly both issues need to be addressed, but going forward, the goal of reducing HIV incidence in the U.S. may hinge on whether HIV-specific interventions can be integrated into broader initiatives to improve social-economic conditions among the nation’s poor, and then whether those broader initiatives can achieve the attention and funding necessary to be successful.


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