This Month in HIV: Top 10 HIV/AIDS Stories of the Past Year
Number nine has some good news!
Number nine is good news, and that has to do with survival with HIV infection. One of the questions I'm often asked after a person learns that he or she is HIV infected is, "How long do I have to live?" The good news is that we know it's on the order of decades. In a really, very well done study that came out of Denmark, we see a really nice estimation of how long people can expect to live using modeling. The researchers were able to accomplish this, because they keep track of every single person with HIV infection in Denmark, and they also have great data on the population as a whole.36
What they were able to show us was that someone who's age 25, the hypothetical 25-year-old you mentioned before, who's HIV infected, can expect to live on the order of 20 or more years with their HIV infection. Now, that is less than for the general population, but I think it's really very encouraging.
When you look at survival for people with HIV infection who were diagnosed more recently, that number goes up to 32 years, and that reflects the use of potent HIV therapy. Just looking at the aggregate over a time period of a decade or two, we see that there are already indications that the longevity number is just going to keep getting bigger and bigger.
What I tell people is, if we say that you have 20 to 30 years of life expectancy from now, just imagine what's going to happen in the next 10, 20, or 30 years -- imagine the advances we're going to see realized, and how that's going to extend your life even further.
I think this is great news. It's encouraging and also, importantly, it puts forth a fixed number that people sometimes just need to be able to grab on to. So if I say to this 25-year-old, we're looking at 32.5 more years of your life, in general, and that things are going to happen that'll be amazing during that time period that'll extend it even further, I hope that's reassuring to that person, that they'll be around for a long time and that they will probably succumb to something other than HIV infection.
So they shouldn't get stuck on the numbers -- shouldn't say 25 plus 32 equals 57. I'm going to be dead at 57 and I should plan for my funeral that year.
I think that's important. [If they did get stuck on the numbers,] I think that would be understandable, but naive [of them]. Remember, these are aggregate numbers that come from thousands of people -- this is not individual. I think we have to understand that for all the research we're talking about.
When we look at studies, they don't tell us what's going to happen to the individual patient, they tell us what'll happen to a group of people. Any individual person has to decide for themselves, is this study a good study? Do I look like the people who were studied? Do I live in Denmark? Do I have a system like they have in Denmark, where there's universal health care?
You can't necessarily apply everything you read from one study to yourself, but this gives us sort of a ballpark figure we can use when thinking about this. We certainly know that it's obsolete to say you have 10 more years to live after you get HIV diagnosed, data we had generated from 15 to 20 years ago in a different world.
"I tell people, 'Chances are that if you do most of what we talk about and take care of yourself, you can get old.'"
I find this reassuring; it kind of does tag that number on along with our perceptions. I tell people, "Chances are that if you do most of what we talk about and take care of yourself, you can get old." I think that this study shows that.
One thing the study also showed, though, and about which we have to be very careful, was that this longevity was truncated, limited, among people who have hepatitis C. We really should try hard to make sure that people understand that and do not become infected with hepatitis C if they don't have hepatitis C right now. It also means that, for people with hepatitis C, we have to really take care to neutralize that problem the best we can by offering them treatment.
On to number 10.
Number 10. This follows a similar sort of line, and that's trying to understand what are the risks as people live longer with HIV infection. We've talked a little already about cardiovascular disease, and it makes sense that, as people live longer with their HIV infection and do not succumb to HIV-related diseases, well ? everyone's gotta die of something. None of us are immortal. If you're an HIV-negative person living in the United States or Europe, you're probably going to die of cardiovascular disease or cancer. What we really want to understand is whether there is a greater risk of cancer due to the HIV infection. Is there a greater risk of cardiovascular disease due to the HIV infection itself? We want to know whether this is not just a normal process.
There was a very nice and interesting study published in The Lancet that looked at this in a very creative way.37 What they were able to do was look at different published studies of cancer rates among people with HIV infection, and they compared it to another group of people who also suffer from problems with their immune system, and that's organ transplant recipients. These are people who take medicines that reduce their immune system function so that their body doesn't reject that organ.
Looking at these two groups, the investigators were able to understand the patterns of cancer, and how much this might be related to immunosuppression.
Most of us think of the immune system as protecting us against germs. The immune system also protects us against cancers. We're just starting to understand that over the last several years. When a cell becomes cancerous, the body responds to it by saying, "You don't look like me, you look foreign." That's the same response the body has when a germ comes into it. It says, "You don't belong here, and we're going to attack you." A healthy immune system will take care of a cancer cell. People develop cancer cells all the time, and the immune system gets rid of them -- you don't even know it!
In people who have problems in their immune system, that protective mechanism is faulty. That's why we do see cancers in people with HIV infection. Two of the first things we saw, Kaposi's sarcoma and non-Hodgkin's lymphoma, are cancers that people developed with HIV infection.
People with solid organ transplants also developed cancers. What the investigators found was that the patterns of increased cancer risk were actually not that dissimilar between HIV-positive patients and those who received transplants. The rates of cancers with an infectious cause -- those are cancers we know are triggered by viruses, such as cancers related to human papillomavirus (HPV); Hodgkin's lymphoma, which can be triggered by Epstein-Barr virus (EBV); or liver cancers caused by hepatitis C or hepatitis B. There were more of those cancers in both groups. The patterns were a little bit different, but not as different as you'd think, suggesting that the immunosuppression that occurs both with HIV and transplants leads to a development of malignancies.
This is important data because it really indicates to us that we cannot tolerate poor immune function among people with HIV infection. If we do, we risk the development of malignancies. This is not the focus of this paper; in fact, it wasn't mentioned, but to me it brings up the issue of when do we treat HIV infection. Do we allow people's T-cell counts to go down so low that we may be placing them at risk for these infections that could lead to cancers? I think this is part of that discussion, and it goes along with also the effect on the brain and central nervous system of having a lower CD4 cell count, and long-term exposure to virus.
Is there a risk of cardiovascular disease that occurs with uncontrolled HIV infection, and is there increased risk of cancer? Those are things we're going to have to try to figure out over time.
I think this is a very important study that puts another dot on the paper; we just have to connect the dots and try to understand the data.
On to the runners up.
There were a few runners up.
One of them was a nightmarish report from St. Petersburg.38 It looked at the HIV prevalence -- how much HIV was present -- in street youth in St. Petersburg, Russia.
For listeners and readers who are in the United States, you might say, "Oh, Russia, who cares?" But I think that this is important because there are some lessons for us as well here, including lessons about how society should take care of its people.
St. Petersburg is a big city, the second-biggest city in Russia. What the researchers found was an alarming amount of HIV among these kids. These are kids who have been basically abandoned; most of these kids are orphans.
The researchers looked at 313 street youth and found 37 percent were HIV infected. These are very young people between the ages of 15 and 19; these are people who are living on the streets, often drug addicted, and often abused. Forty-two percent of the male street youths were found to be HIV infected, and 29 percent of the females. Most didn't know that they were HIV infected. It was just amazing. Two-thirds of those who were double orphans were HIV infected; so it's a huge risk to be an orphan in St. Petersburg, especially a double orphan. Seventy percent of the teens who didn't have a place to live or who had a sexually transmitted disease were HIV infected.
These are numbers that blow away seroprevalence studies of HIV in Africa.39 This is just amazing. This is in a country where there are hospitals, there's medication, there are doctors, there are roads, there is electricity. This is just total neglect of a group of people within a society. There's a cautionary tale here; for the people who live in Russia, this is a wake-up call. If these youths have such high rates -- four out of 10 of these street youths are HIV infected -- then you have to think about what's going on in that society as a whole.
"The rate of HIV infection is climbing so steeply in parts of the former Soviet Union that in a decade or two when we think about HIV, it's going to be in that part of the world."
This is a shocking report; sometimes I just can't stop thinking about these data. When I compare them to other parts of the world, it just blows me away. It's just as important as the data we've gotten from parts of Africa, where we learned that one out of every 20 adults is HIV infected. It's mind-numbing data that goes right along that same category.
Very few people think about Russia as similar to sub-Saharan African.
In 25 years, it's going to be all different. Eastern Europe is going to be where people think about HIV. Right now we think about Africa, but the rate of HIV infection is climbing so steeply in parts of the former Soviet Union that in a decade or two when we think about HIV, it's going to be in that part of the world.
Another runner up you had was about aging and HIV.
This is an emerging story, and one I think physicians and clinicians are being led to by their patients.40 People are getting older with HIV infection, and there are questions about how to do that well. There are questions about how to grow older well in general, but especially with HIV infection vis-à-vis everything we've talked about with the increased possible risks of cancer, heart attacks and the like.
A number of studies have looked at this at the biological level, looking at cells and how cells age, and markers of aging and premature aging.39,41-43 The bottom line is that there is a picture emerging that HIV does seem to cause more advanced aging in many people. We have to understand more about this. We have to understand how we can counteract that. There may even be therapies we can develop to do this.
One thing that seems clear is that controlling HIV helps. Again, this is sort of a drumbeat from study to study. Getting control of your HIV -- getting your viral load down and your immune system strong -- that is one of the best things you can do.
Not smoking is another; smoking enhances the risk of many of the things that are associated with aging -- the bad things: the cancers and the cardiovascular disease. People who smoke look older. It's not new news; anyone can understand, you don't have to be a scientist to see the deleterious effects of smoking on the body and how it can facilitate the problems that we think about as we get older.
I think there is something going on here. We're just at the beginning of understanding what's going on biologically. We do know that the immune system ages prematurely in people with HIV, so we should do everything we can to keep that immune system healthy and happy.
The final runner up was about underestimating HIV incidence in the United States. Can you talk a little about why you picked that?
Again, I think this goes along with a theme I tried to develop in picking the top 10 and the runners up, which is not so much trying to present studies that tell us what we already know, or confirm things we thought. I'm trying to look at things that help us understand what the future is going to be like. There's no better way to do that than to look at how many cases of HIV are occurring every year.
The important part of the story is that while the world is reassessing how many people are HIV infected and downgrading their estimates, saying they overestimated,44 here in the United States, we're finding we probably underestimate the number of people acquiring HIV infection.29 This is according to a leak from the CDC that has been reported in the Wall Street Journal about how the CDC is on the verge of adjusting their estimate of how many people are infected -- and increasing it substantially, to indicate that maybe they were off by 10,000 to 15,000 people per year. That would be significant.
I think that this, if it pans out, will be important. It again refers back to some of the questions I had before about: Is this a phenomenon occurring among men who have sex with men? If so, why and what can we do about it? How much is meth use playing into this? How much of this is young men who have sex with men, who don't have a historic memory of losing friends, who are not part of an active advocate community? What's going on here?
There are more questions raised than answers, but most of the data suggest that the increases are going to be largely made up of men who have sex with men, and young ones at that.
I think this is where we have to focus more energy. We don't have a vaccine; we're not going to be able to prevent HIV that way. How do we work to have prevention happen, especially among those who are most likely to acquire the infection? I find this to be a very concerning development, despite all the millions of dollars and all the intelligence and the conferences that have been dedicated to HIV prevention. It's a shame that we're not seeing the decrease that we thought we should be seeing with all this effort. It really tells us that we have to go back to the drawing board and figure out what works, and how to get that to work in different populations.
Wow. Well, an amazing top 10, with runners up. I think I could have asked you questions all day about these studies. Many of them have so many implications. What a great job picking through all this research from 2007!
I hope people take from this mostly hopeful messages. I do think that there are tremendous advances that we've seen, and I do think we'll see these kinds of things happen in the realm of prevention. I do. I think we're at the beginning of that, despite the failures. There were lots of failures when it came to therapeutics, to treatment; we're seeing treatment really mature here. We still have a ways to go; we don't have a cure yet.
Thanks very much.
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