"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.
On June 5, 1981, Michael Gottlieb, MD, of the University of California Los Angeles, and colleagues reported on a cluster of five cases of Pneumocystis carinii pneumonia in previously healthy men who had sex with men (MSM). This was the first report in the medical literature of the condition later known as acquired immune deficiency syndrome (AIDS). In 1986, researchers adopted the name for the so-called "AIDS virus" that was the precursor to this series of opportunistic infections: human immunodeficiency virus (HIV).
HIV is a retrovirus, which allows it to integrate itself into and thus alter the host cell's DNA, as well as replicate quickly. The virus is mainly transmitted through direct contact with bodily fluids, such as blood, semen, or vaginal or rectal fluids, of an individual with a detectable HIV viral load, although it can also be transmitted through breast milk to an infant born to a mother with HIV.
Because HIV attacks the immune system, patients often present with viral symptoms, such as fever or a flu-like condition, generally 2-4 weeks following exposure. However, some patients may remain asymptomatic.
Diagnosis is confirmed through one of three testing options:
- Antibody tests, which detect HIV IgM or IgG antibodies
- Antigen/antibody tests, which detect both HIV antibodies and the HIV p24 antigen
- Nucleic acid tests, which detect HIV RNA
There are also two self-testing options available, which allow the patient to either test their own saliva or collect a blood sample through a finger stick and mail it to a lab for results. Both tests are antibody tests.
In the event of a negative test, CDC recommends that patients be tested again outside of the "testing window" (or period of time where antibodies could be detectable) to confirm the result. Once a positive test is confirmed, the patient should be started on antiretroviral therapy (ART), and counseled on strategies to prevent transmission.
Evolving Epidemiology, Improved Survival
While the epidemiology for HIV has remained the same in many ways, it has changed in others. One of the most striking differences is the mortality rate. From 1981 to 1990, CDC data indicated that over 100,000 people died of HIV/AIDS, with a third of those deaths occurring in 1990 alone. In 1989, HIV/AIDS was the second-leading cause of death among men ages 25-44. In 1995, CDC estimated the age-adjusted death rate for HIV reached 16.2 per 100,000 in the U.S.
Yet in 2019, the age-adjusted death rate had dropped to 1.4 per 100,000, and 2.1 per 100,000 among men. Fewer people died of HIV in 2019 than heart disease, cancer, chronic liver disease, Alzheimer's and unintentional death.
While CDC reported a 17% decline in HIV diagnoses in 2020 versus 2019, the agency cautioned that this was attributable to the COVID pandemic and "likely due to disruptions in clinical care services, patient hesitancy in accessing clinical services, and shortages in HIV testing reagents/materials," and that data from that year should be interpreted with caution.
Thanks to advances in treatment and prevention, the prognosis of HIV has dramatically improved, allowing people to live with rather than die from HIV/AIDS.
According to the CDC, most HIV infections continue to be among MSM. Since 2015, MSM have accounted for about two-thirds of new diagnoses. From 1981 to 1990, CDC estimated that 59% of deaths attributed to HIV/AIDS were among MSM.
Growing Racial and Regional Divide
However, the racial/ethnic divide in HIV diagnoses has widened considerably. In 1989, HIV/AIDS accounted for the deaths of slightly more non-Hispanic Black men versus non-Hispanic white men ages 25-44 (16% vs 14%, respectively). But while adjusted death rates from HIV declined from 2009 to 2019, CDC reported that rates of death from HIV were four times higher in non-Hispanic Black individuals compared with all other racial/ethnic groups (5.9 per 100,000 vs 1.4 per 100,000 in Hispanic individuals and 0.6 per 100,000 in non-Hispanic white individuals).
The same trends were observed for HIV diagnoses, with non-Hispanic Black individuals comprising over 40% of new cases in 2019. CDC hypothesized that these disparities were due to "access to quality sexual health care," including access to HIV prevention, as well as "barriers to health care, racism, stigma, homophobia, and poverty."
According to CDC, new HIV diagnoses in 2019 were mostly among men ages 13 and up, with males accounting for 80% of new cases. Younger adults ages 25-34 comprised the highest rate of new diagnoses among all age groups (35%). Notably, over half of new diagnoses were among people living in the South region of the U.S. Not surprisingly, nearly all diagnoses were among people ages 13 and up (with children under age 13 accounting for only 61 diagnoses in 2019).
Routes of Transmission Mostly Unchanged
Sexual contact continues to be the main route of HIV transmission among both men and women. In 2019, heterosexual contact accounted for over 80% of new HIV diagnoses among females ages 13 and up. Heterosexual contact was also the second most common route of transmission among males ages 13 and up, comprising just under 10% of new diagnoses.
While injection drug use was attributed to 21% of HIV/AIDS deaths in 1989, that number declined over the last few decades. In 2019, CDC estimated that 16% of new diagnoses among females ages 13 and up and 5% of new diagnoses among males ages 13 and up were among people who used injection drugs. There are, however, pockets of the country where this is not the case -- for example, in West Virginia, where the primary HIV transmission mode is injection drug use.
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