That Crockett is alive today is also reflected in Nik Wada’s data sifting. Post-1996, public health experts say a variety of factors, including new and less toxic medications, faster diagnosis and better clinical management, had greatly lowered the number of HIV deaths directly related to AIDS. Wada’s numbers showed that it had become a statistical tossup as to whether HIV-positive men in the MACS would die from AIDS or non-AIDS related causes. As a result, using his same baseline of 35-year-old infected men, the median age of death from all causes had jumped to more than 57 years of age. A 2009 CDC study confirms this lifespan increase. Looking at HIV surveillance data from 25 states, researchers estimated that as of 2005, people with HIV could now expect to live more than 22 years after diagnosis, and some experts feel the average survival time is even longer.
From a public health perspective, that extended timeline has essentially redefined an epidemic. While people are still getting infected—the CDC’s latest numbers state that more than 56,000 Americans contracted HIV in 2006—“the availability of medications has changed HIV from an acute infectious disease with a high mortality rate to one that behaves like a chronic disease that people can live with,” says epidemiologist Lisa Jacobson, ScD ’95, MS ’86, principal investigator for the MACS Data and Analytical Coordinating Center at the Bloomberg School.
Jacobson is by no means alone in her assessment of HIV management as it is practiced in America, where access to antiretroviral drugs is predictably far greater than in developing countries still ravaged by the disease. All of the more than a dozen Johns Hopkins public health and clinical faculty interviewed for this story, as well as several of their patients who have survived AIDS well into their AARP years, used the phrase “chronic disease” to characterize HIV infection.
But chronic diseases by their very nature cover a wide spectrum of severity. Even within a given chronic disease such as multiple sclerosis, progression and impact on daily life can vary greatly.
Which is why study of the aging HIV population is so important. As HIV-infected people reach their golden years, a host of questions has arisen—including how well will they age, and whether the virus long residing in their bodies makes them more prone to earlier onset of diseases that claim the elderly. “The question is not so much whether you will live as long as your (uninfected) brother but whether you will have more medical problems as an older person than your brother,” says Joel Gallant, MD, MPH, associate director of the Johns Hopkins AIDS Service.
To answer this means delving into a multifaceted puzzle that, on one end, teases apart the lifestyle risk factors particular to certain HIV-infected subgroups. For example, smokers may develop lung cancer or IV drug users may become infected with hepatitis C. HIV and its treatments may negatively affect both. On the puzzle’s other end is investigating HIV’s impact on the aging process itself, and whether the infection, even in a medically suppressed state, promotes premature aging of the immune system. And in between is the ever-moving target of how the timing of the beginning of antiretroviral treatment affects long-term outcomes.
The insights already gleaned have been both surprising and controversial, setting off a vociferous debate among public health researchers as to what recommendations, if any, the data currently support vis-à-vis changing the standards of care for aging HIV patients… patients who fervently hope their best years are still ahead of them.
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