David Alain Wohl, M.D. (Courtesy of David Alain Wohl)
Given the slipperiness of time, it is not surprising that 2017 played out like a sequel to 2016. The shock that followed the U.S. presidential and congressional elections uneasily gave way to the edge-of-your-seat state of anxiety that finds us now compulsively checking for the next provocation, untruth, backtrack, and threat. Frankly, many of us are afraid, and we have reason to be. What does or does not happen in Washington, D.C., is very much felt across the country and the globe. For people living with or at risk of HIV, the administration's proposed budget slashes to programs that support HIV prevention and care can be expected to have far-reaching and deadly consequences. We learned that our votes count and are consequential. While many considerations must be weighed when choosing whom to vote for, perhaps an additional one to think about come Election Day is which candidate's victory will lead to the fewest number of people dying.
For those fortunate to continue to have access to HIV care, this past year saw the continued spread of an almost philosophical movement calling for minimal HIV therapies. The push for less medicine to control HIV might be largely born of financial considerations, but it has also resonated among patients and providers seeking simple regimens with minimal risk of long-term toxicity. Along these same lines, long-acting antiretrovirals, which are in essence minimal in composition and dosing frequency (if not cost), are gaining traction with HIV providers who see that more of their patients might opt for the shot once available. Refinements to existing HIV medications and novel new agents continue to be developed and tested as pharmaceutical companies aim for an antiretroviral nirvana.
While incredible strides have been made in engineering molecules that can shut down a fatal contagious virus, much less success has been achieved in designing strategies to address the pathologic effects of poverty, racism, stigma, and an atrophied HIV health care model -- factors that keep people from getting into and remaining in care. A key to overcoming such barriers is to first understand them, and we are just beginning to piece together how the complex and chaotic lives of many people in the U.S. make attending to their HIV secondary, at best. As the forecast calls for cloudy with a slim chance for revolution, innovative approaches, including even financial incentives, are being tested to bring people living with HIV into care.
Simmering issues remain of great importance and consequence to people living with HIV. Younger people are the most vulnerable to new transmissions, but older patients continue to struggle with comorbid conditions that can complicate long-term HIV survivorship. The processes of aging and of living decades with HIV make for a complicated mix, and the relative contributions of the virus and its therapies to the development of conditions that can cause frailty remain unclear. New insights suggest a need to approach cardiovascular disease prevention and treatment among those with HIV not only through lowering lipids and ceasing smoking but also by addressing less commonly appreciated risks, such as bacterial infections, cocaine use, and mental health. Globally, the expansion of antiretroviral availability, particularly older agents with lower barriers to resistance, coupled with the scarcity of plasma HIV RNA and antiretroviral resistance testing in many resource-limited places, has led to an increase in drug resistance that complicates salvage options.
An optimist, I view these as challenges -- but not as a woe-is-me challenge of too tall a mountain or too far a run. Instead, these are the "you-want-a-piece-of-this?" challenges that should motivate us to take action and make things happen. That's what we do in medicine, take action and make things happen, and for those of us who care for people touched by the HIV epidemic, it is our obligation.
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David Alain Wohl, M.D., is a professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC). He is site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill, director of the North Carolina AIDS Education and Training Center (AETC), and co-directs HIV services for the North Carolina state prison system. In 2014, he became co-director of the UNC-Duke Clinical RM Ebola Response Consortium.