The end of AIDS: HIV infection as a chronic disease

Abstract

The success of antiretroviral therapy has led some people to now ask whether the end of AIDS is possible. For patients who are motivated to take therapy and who have access to lifelong treatment, AIDS-related illnesses are no longer the primary threat, but a new set of HIV-associated complications have emerged, resulting in a novel chronic disease that for many will span several decades of life. Treatment does not fully restore immune health; as a result, several inflammation-associated or immunodeficiency complications such as cardiovascular disease and cancer are increasing in importance. Cumulative toxic effects from exposure to antiretroviral drugs for decades can cause clinically-relevant metabolic disturbances and end-organ damage. Concerns are growing that the multimorbidity associated with HIV disease could affect healthy ageing and overwhelm some health-care systems, particularly those in resource-limited regions that have yet to develop a chronic care model fully. In view of the problems inherent in the treatment and care for patients with a chronic disease that might persist for several decades, a global effort to identify a cure is now underway.

Figure 1. HIV Infection as a Chronic Disease

Antiretroviral therapy has transformed HIV infection from a progressive, typically fatal infection to a chronic disease that persists for many decades. A typical young adult who acquires HIV is expected to be on therapy for up to 50 years. Cumulative exposure to antiretroviral drugs and/or chronic inflammation is expected to have profound effects on health and aging. Novel health care delivery systems are needed to provide optimal management of treatment and the many co-morbidities associated with HIV disease.

Figure 2. Causes and consequences of chronic inflammation during antiretroviral treatment

Causes and Consequences of HIV-associated Inflammation. Despite effective antiretroviral therapy, many if not most HIV-infected adults have evidence of persistent inflammation and immune dysfunction. Root causes of inflammation include ongoing HIV production, high levels of other co-pathogens, irreversible damage to immunoregulatory system, and translocation of microbial products across damaged mucosal surfaces. This inflammatory environment causes end-organ damage through several potential pathways.