Kathryn Anastos, MD Comments On the Future of HIV/AIDS Research
Kathryn Anastos, MD: Medical Director, Lincoln Medical and Mental Health Center, Bronx, NY; Principal Investigator, Bronx/NYC consortium, Women's Interagency HIV Study
It is critically important that we expand the research activities in HIV and AIDS to include more women and individuals of color, who now represent 67% of newly diagnosed AIDS cases, 62% of individuals living with AIDS, and 69% of newly reported HIV infections. In the United States, the highest rates of AIDS incidence, HIV prevalence and HIV-related mortality are in black women and men.
There is a growing body of evidence that there are gender and ethnic differences in the laboratory markers we use to advise patients as to disease progression and when to begin HAART. Several investigators have shown that individuals of color and women have lower viral loads than men at early and moderate stages of disease, and a recent study reported that women developed AIDS at a much lower viral load than men: 17,149 copies/ml in women compared to 77,800 copies/ml in men. Other investigators have found that women progress to AIDS or death at higher T-cell counts than men.
These findings are disturbing: most of the HIV infected individuals in the US are women or people of color, and we are lacking adequate information about the prognostic value of our major markers for disease progression. However, because treatment is so effective, and everyone with HIV infection should have access to treatment, the most important question is whether there are differences by gender or race in response to treatment with HAART. While it is clear that HAART is effective in women and people of color, we have not defined the best time for starting therapy, which may be at lower viral loads than the current guidelines suggest. There do exist cohort studies of HIV-positive women which will help us answer these questions for women. However, there is no large enough group being studied to yield these answers for men of color. This needs to be rectified either by enrollment of men of color into clinical trials or by establishment of a cohort study of men of color.
The research needs for women and men of color also include defining the toxic effects of HAART: diabetes mellitus, insulin resistance, osteoporosis and possibly hypertension. These conditions are already more prevalent and cause more health problems (heart attacks, strokes) in women and in communities of color. Thus, it is extremely important that we investigate these side effects of HAART in the communities with the highest rates of HIV infection and already high rates of diabetes and hypertension, the major risk factors for cardiovascular disease, which is the leading cause of death for women and men of color over the age of 45 years.
The ability to delay or prevent HIV disease progression is one of the greatest public health achievements ever. There are precious few chronic diseases in which we are as successful with treatment: 80% decrease in the rates of AIDS and death since 1995. Our treatment regimens are becoming simpler and more tolerable. However, those communities bearing the greatest burden of disease are also those for whom we have the least information regarding the best treatment. While we continue to improve access to treatment for these groups, we also need to improve markedly their access to research programs, so that we advance our scientific understanding of their response to treatment, both in terms of disease progression and rates of side effects.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication CRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.