September 14th, 2017

HIV prognosis and spread—plus ça change, plus c’est la même chose

It’s been my impression that advances in antiviral drugs in recent years have transformed the treatment of HIV/AIDS, once a death sentence. But I wondered how accurate that perception of mine was.

I got curious and looked it up, and it turns out it’s even better than I’d thought:

HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world. Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes. Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype. After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and 19 months. HAART and appropriate prevention of opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 20–50 years. This is between two thirds and nearly that of the general population. If treatment is started late in the infection, prognosis is not as good: for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~10–40 years. Half of infants born with HIV die before two years of age without treatment

Before all this happened, about 30 million people had died worldwide since AIDS burst on the scene. I remember when the disease raced though the dance world and killed many of its leading lights. Horrible.

So we don’t hear anywhere near as much about HIV or AIDS as we used to. And this all makes me wonder whether rates of infection have gone up or down or stayed the same, now that treatments are available.

The answer is “all of the above.” The situation is complex; you can find a lot of statistics here and some more here. A few of the most salient facts: diagnoses have gone down in most populations but stayed relatively stable in the gay population (accounting for about 2/3 of new diagnoses), particularly the black and Hispanic gay population. Among white gay and bisexual men, incidence has decreased, but among Hispanic gay and bisexual men it has risen, while rates have been relatively stable among gay black men.

If you look at the chart here, you can see that HIV is concentrated in certain areas of the country. Half the cases are in the South, for example.

A map (from 2016)—with lifetime incidence rates—can be found here:

You can see from the map that the incidence of HIV infection in Washington DC is a whopping 1 in 13. That’s extraordinary. States such as Louisiana, Georgia, Florida, New York, and Maryland are all around the 50-70 mark, with Texas at 81.

This is shocking and disturbing. Why are rates still so high despite antiviral drugs that can not only help the patient but can markedly reduce the chance of transmission of the virus from that patient to others? Some clues to what’s going on can be found here

…[L]ooking across the spectrum from HIV diagnosis to viral suppression reveals missed opportunities for addressing the epidemic. According to the Centers for Disease Control and Prevention (CDC), while many people with HIV are diagnosed (87%), far fewer are retained in medical care (56.5% of those diagnosed) and fewer still are virally suppressed (55% of those diagnosed). Viral suppression is greater among those who are in medical care.

Because HIV can be transmitted long before it is symptomatic, that figure for the infected-but-undiagnosed (13%) is part of the transmission pattern. People think they are safe when they are not, and practicing preventive measures is often jettisoned where sex is concerned (in the heterosexual arena, that same phenomenon leads to high rates of unwanted pregnancy despite the high availability of many varieties of effective birth control). I would guess that the falling death rates for AIDS might have a part in this feeling of false safety, as well.

And why are so many people who are diagnosed not being treated with antiviral medication, almost half? There are some clues here (although the study was done in Australia, the psychology might be similar). A lot of people feel that the drugs make them more aware that they have HIV, and as long as they’re not feeling bad physically (yet) they don’t want that reminder. That seems problematic to me if they are sexually active with an uninfected person, because antiviral drugs could markedly reduce the chances of their transmitting the disease.

Here’s a Canadian study:

Nearly 20 years after ART became available, therapy is much simpler (often once a day and there are entire regimens available in one pill), safer and more effective. However, there are still HIV-positive people who do not wish to start therapy, though there are many benefits to starting early. At the level of the individual, early use of ART can reduce the amount of HIV in the body. This reduction in HIV helps relieve ongoing damage to the immune system, brain, heart, lungs, kidneys and other vital organs and systems. At the level of thousands of people in a city or region (what researchers call “population level”), taking ART every day exactly as directed and getting regular checkups for sexually transmitted infections helps to greatly reduce the future risk for spreading HIV. This is an important benefit for the community.

Researchers in the European Union and Australia conducted a survey of HIV-positive patients and their doctors about perceived barriers to starting ART. Analysis of the survey results suggest that in the current era barriers to initiating therapy still exist but are different from those of the late 1990s. A primary barrier among HIV-positive people today is that they may not feel sufficiently unwell and they lack serious symptoms that would hasten their entry to treatment. Major reasons by doctors for delaying the initiation of ART include that they perceived some of their patients to be suffering from a degree of depression, that there was active substance use and that patients did not understand the need to adhere to HIV medicines.

It seems as though this is a very difficult population to treat. Particularly the young people (the following data is for the US, not Canada):

Significantly fewer young people with HIV accessed services to maintain viral suppression. The researchers found only 13 percent of HIV patients aged 18 to 24 had achieved viral suppression, though that percent doubled for people aged 35 too 44. Nearly 40 percent of HIV-positive people over age 65 were able to effectively manage their disease with drugs and other health care services.

And then there’s money. I don’t know how often that’s the barrier to taking the drugs, and I haven’t found any statistics on it, but even in Canada payment for the antiviral drug treatment can be a problem. I was surprised to hear that; previously I had been unaware that medication wasn’t necessarily covered there. Some Canadians have private insurance that helps, and each province has a special program to subsidize AIDS drug payments. There is a lot of variation there:

Generally, the publicly funded provincial and territorial drug programs offer coverage for people on social assistance (“welfare”) and for seniors over the age of 65. Some provinces issue cards to show to your pharmacist that prove you are entitled to this type of coverage.

Some provinces and territories offer assistance to cover costs for other citizens who have high drug costs but little or no private insurance. This is often referred to as a catastrophic drug program. The availability of such programs varies among provinces and territories…

In the US, there’s also a wide variety of programs to help people with drug payment (see this). No doubt money is a problem for some, but I have no idea how many. My guess, though, is that a lot of people might qualify for those programs that pay for drugs but are not about to pursue the treatment for a variety of reasons, including denial and/or drug addiction and/or fear.

As I got deeper and deeper into writing this piece, I felt a growing sense of sorrow. Although you can’t compel treatment, nor can you compel people to change their sexual behavior, the consequences for this behavior include a lot of suffering as well as the continuation and spread of a dreadful disease. I also realized as I wrote this post that some of the comments here were probably going to be of the “then let them rot” variety. I don’t feel that way. Not only are innocent lives affected negatively, but the social costs are great.

I don’t have a remedy, but I have compassion. You may not think that’s worth a whole lot, however.

The good news is that AIDS isn’t killing people at anywhere near the old levels, and that it never became a widespread conflagration as was often predicted. Even in Africa, where it has taken its deadliest toll, things have calmed down a bit.

[NOTE: This post had already grown so long that I decided not to get into the Truvada controversy. Maybe another post sometime.]

29 Responses to “HIV prognosis and spread—plus ça change, plus c’est la même chose”

  1. vanderleun Says:

    A difficult subject and a more devious disease. As I’ve mentiojned to friends I was on a trip, decades ago, with one of the first laboratory scientists examining and testing the HIV virus. The most memorable thing he said to me one night around a campfire was that “The Virus is very clever. It mutates around manythings.”

    His point was that one never should get complacent about HIV. Never.

    Lately however gay lifestyles have become depressingly casual about this.

    If you want to be depressed about the inate stupidity of portions of the human race, search under “bug chasers”.

    On second thought, don’t. I’m sorry I did.

  2. Mark30339 Says:

    Great info Neo. Oprah tells us the words of Maya Angelou: When you know better, you do better.

    But this does not translate to HIV reduction in the gay community, it doesn’t translate for avoiding unwanted pregnancy in the straight community, and despite knowing better, large portions of drivers travel too close, too fast, text and disregard turn signals.

    We seem so mired in our own chaos that we can’t be left on our honor to be responsible for even the small behaviors that make a big contribution to bettering our world.

  3. Frog Says:

    The highest frequency of HIV is in the South. The majority of blacks are Southern. Also NY(C) and NJ, with large black populations (see Newark, home of Corey Booker). And Washington DC is 50% black.
    Just facts. Demographic facts.
    You do not cite any data about HIV rate in women of all or any races. My impression has been this was rising. More than one sex partner by either hetero party is the obvious explanation. Part of our ongoing secular-induced self-destruction.

  4. DNW Says:

    ” I also realized as I wrote this post that some of the comments here were probably going to be of the “then let them rot” variety.”

    Now that you have gone and said that, probably not.

  5. neo-neocon Says:

    DNW:

    Yes, I was trying to head them off at the pass.

  6. neo-neocon Says:

    Frog:

    The post was getting so long I couldn’t discuss all the interesting things that are to be found in the statistics.

    Regarding the rates in women—no, they are not increasing, according to one of the links I previously gave:

    Between 2005 and 2014, new HIV diagnoses among women decreased 40%…

    …in 2015, Black women accounted for 6 in 10 (60%) of new HIV diagnoses among women; white women accounted for 19% and Latinas accounted for 16%.54 Although there is a disproportionate impact on Black women, new diagnoses among Black women decreased 42% between 2005 and 2014.

  7. DNW Says:

    “We seem so mired in our own chaos that we can’t be left on our honor to be responsible for even the small behaviors …”

    Do you think everyone is like that? No, you most probably don’t.

    To what ostensibly distributive “we” then, does one refer to with such a categorical, or at least unqualified, diagnosis?

    Not a real one.

    Of course the phrasing is intended to be tactful and non-stigmatizing. But the problem is, that however well intended, it is simply not true.

  8. Richard Aubrey Says:

    DNW.. “we” in this usage generally excludes the speaker despite being first person.
    It means “you” [a lot of you, or most of you] but in a polite fashion.
    I just happened to be reading The Divine Conspiracy and this crops up. “We” do this and that. I don’t. My wife doesn’t. My kids don’t. And the author doesn’t.

    I suppose it’s an okay substitute for something like, “a number large enough to concern”
    As long as nobody takes it literally.

  9. Trimegistus Says:

    I call that the “liberal ‘we'” — where by “we” the speaker means “you.”

    As in “we must reduce our carbon emissions” being said by a man who owns multiple houses and travels by private jet.

  10. Israel Says:

    How much does the govt spend on aids?

  11. Mark30339 Says:

    We conservatives are so ready to absolve ourselves from being part of the decline of the whole. As evidence of decline I point to Post-modern nihilism climbing up to be the prevailing measuring stick on value decisions. Not only does the current age consider it cruel to bring children into a world perceived (wrongly) as more troubled than ever, it is beginning to rationalize its abortions as mercy killings. The powerfully lurking hypothesis is that life is not worth the effort, and increasing disregard for the other follows from it. I came of age in the early 80s, so this decline has prospered on my watch — my acts & omissions have contributed to it. Contrary to unwelcome conjecture on my motives, my WE includes me.

  12. Ann Says:

    Drug abuse plays a very large role in all of this — from the NIH:

    Drug abuse and addiction have been inextricably linked with HIV/AIDS since the beginning of the epidemic. While intravenous drug use is well known in this regard, less recognized is the role that drug abuse plays more generally in the spread of HIV by increasing the likelihood of high-risk sex with infected partners. The intoxicating effects of many drugs can alter judgment and inhibition and lead people to engage in impulsive and unsafe behaviors. Also, people who are abusing or addicted to drugs may engage in sexually risky behaviors to obtain drugs or money for drugs. Nearly one-quarter of AIDS cases stem from intravenous drug use, and one in four people living with HIV/AIDS in the period of 2005–2009 reported use of alcohol or drugs to an extent that required treatment.

  13. Yancey Ward Says:

    Given that the virus does mutate pretty readily, it is even more depressing. Right now the drugs work, but will they still be effective a quarter century from now?

    The compliance differences in age are worrying. Naively one might think that as the less compliant young will eventually become the more compliant older group, this might be overlooking the fact that the older group of today grew up in the age when it was death sentence. The young of today don’t face that pressure the same way.

  14. huxley Says:

    I was shocked to see the South so dark blue in that map. For instance, Georgia has twice the lifetime HIV risk as California?!

    However looking at the chart “Diagnoses of HIV Infection in the US in 2015, by Race/Ethnicity and Region of Residence” from neo’s CDC link, black HIV infections are running roughly triple the rate one would expect based on the black percentage of the population.

    Which means over time HIV/AIDS is becoming predominantly a black disease in the US. Thus we see an HIV map generally corresponding with US black populations.

    Very sad and concerning.

  15. DNW Says:

    “As evidence of decline I point to Post-modern nihilism climbing up to be the prevailing measuring stick on value decisions.

    … the current age consider[s] it cruel to bring children into a world perceived (wrongly) as more troubled than ever,

    … it is beginning to rationalize its abortions as mercy killings.

    The powerfully lurking hypothesis is that life is not worth the effort …

    … increasing disregard for the other follows from it.”

    These are interesting points, and seem to be the kinds of points a traditional conservative would be interested in making.

    In a certain sense, traditional conservatives share an at least partial concern for the welfare of undesired or undesirable others and a feeling of community obligation; differing from progressives obviously in their proposed solution to assisting and mainstreaming these types.

    I personally think that for conservatives this corporate sense of obligation is religiously inculcated and part of a quasi-philosophical worldview that emanates from those religious convictions.

    The difference between libertarians and progressives’ (and I believe most conservatives’ as well) attitudinal stance, as Jonathan Haidt has observed, is that libertarians do not see another’s “need”, as necessarily implying a moral obligation.

    In this limited sense, the libertarian stands apart from both the progressive and the conservative who both appear to believe something should be done for everyone, not just the congenial and virtuous and attractive, but disagree on the morality of methods for doing it.

    Also, the idea – insofar as it can be called an idea rather than an artifact of some dysfunction -that “the game of life” is not worth the cost of the candle, is an idea that was unfamiliar to me until relatively recently. But once I heard it said, I began to notice that numerous people were mentioning it as if it were a familiar problem or consideration to them. Some saw the answer in God, some in “the collective and inclusion” but it included both liberals and religious conservatives.

    When most on this site strenuously disagree with me when I say I would gaze with indifference if Debbie Wasserman Schultz were dragged through the street by the hair by the Jihadists she has effectively abetted they are expressing a kind of principled moral solidarity common to conservatives who see their opponents as broken or lost like-kinds, rather than existentially alien (implied by the progressives’ own progressive metaphysics) moral kinds.

    Progressives do seem to affirm the value of unconditional social solidarity. But I have no clear view of the path of reasoning they use to get there; though I have studied the matter for quite a number of years.

  16. AesopFan Says:

    Ineresting points all the way around, but to address this specifically:
    “Progressives do seem to affirm the value of unconditional social solidarity. But I have no clear view of the path of reasoning they use to get there; though I have studied the matter for quite a number of years.”

    IMO, it is a practical recognition that there is strength in numbers, and that “who is not with us is against us” (that is, how to identify the enemy).

    Not concern for individuals or any kind of salvation, as for principled or religious liberals or conservatives — just power.

  17. TommyJay Says:

    I have read that some in the gay community have unprotected sex with the intent of potentially spreading HIV. The details vary: the thrill of risk taking, a badge of honor, vindictiveness. I don’t know the percentages; it could be negligible, I hope.

    Then there is the gay war against male circumcision and its impact on HIV transmission. I don’t really understand this topic at all, so I’ll stop there.

    A doctor told me about 30 years ago that HIV was going to be THE epidemic issue of our times. But this was before ART therapy. Even if one felt no particular responsibility for other’s problems, this is an epidemic that impacts the future of human civilization that most of us do care about.

    “Israel” asks about gov spending on HIV. I recall hearing second hand about a Jon Stewart interview of humanitarian and singer Bono of U2. The question was, who made the biggest humanitarian impact of late? Bono shocked Stewart by saying George W. Bush, because he had pumped billions of $$ of HIV ART therapy into Africa.

    I found this about GW Bush putting our tax dollars to work. The number there is 148 B$, but that a total for domestic and global aid for HIV and malaria. Who knew? I noticed that the date on that doc is Dec. 1, 2008, the depths of the stock market crash.

  18. Ray Says:

    If you really want to be depressed, read this book.
    http://www.healthhazardsofhomosexuality.info/

  19. GRA Says:

    @ Ray: Yea, a good majority of HIV/AIDS in the US are within same-sex sex encounters and then followed by needle usage and unprotected sex within opposite sex encounters, and the drop off % is staggering from the former group compared those that follow.

  20. Terrence Condolini Says:

    it was recently reported that 50% of the gay black men in Atlanta are HIV+. and there you have the reason the south is such an HIV hotspot. another thing not generally known (or reported) is the higher incidence of gayness within the black community, with respect to other races. probably due to higher T levels.

  21. neo-neocon Says:

    Terence Condolini:

    Here are the most recent figures on that. I can’t seem to find the full report, but from the summary I just linked you can see that slightly more black people than white people identify as LGBT (lesbian or gay or bisexual or transgendered). It also says that the rates of LGBT identification are even higher in Hispanics and Asians than in black people.

    And yet HIV rates are not higher in those latter two populations.

    What’s more, the study said that more women than men identified as LGBT in their survey. That would indicate that it’s possible that the higher black figures (or higher Hispanic or higher Asian figures) might reflect higher levels of lesbianism in those groups, rather than higher levels of gay men. The numbers weren’t broken down in such a way that we would know, however. So I don’t see how to come to any conclusions about it vis a vis the incidence of HIV infection.

  22. Terrence Condolini Says:

    ever hear of the term “on the down low”?

    did i miss something or did you completely ignore the 50% infection rate?

  23. neo-neocon Says:

    Terrence Condolini:

    Yes, I think you missed several things.

    My post discusses how the change in HIV rates vary in gay people between ethnic groups, as well as containing links to the fact that blacks are the ethnic groups with the highest rates. You didn’t link to where you found that 50% figure, but since it is similar to figures in articles I already linked to that said that 44% of new HIV diagnoses in the US are in the black population, I wouldn’t be the least bit surprised if that 50% figure was accurate. The high rate of HIV in black people is obvious in the map, and was explicitly discussed in the links. I was focusing on other issues—particularly, recent changes in rates—but the racial distribution is quite obvious and undisputed.

    My point in my comment to you was about a completely different statistic, the percentage of blacks who are gay versus the percentage of whites who are gay. I don’t think that the large and disproportionate prevalence of blacks among HIV-positive people is necessarily explained by the fact that a slightly higher percentage of black people than white people declare themselves to be LGBT, because it’s possible some of those people are lesbians (who are not really a vector for HIV at all), and because the much higher proportion of black people among the HIV-population is much larger than the difference in reported homosexuality among black people. That was what I was getting at.

  24. Frog Says:

    huxley @7:26AM-
    Exactly what I was getting at. HIV infection is predominantly a black phenomenon here in the USA. As Neo pointed out, 60% of new female cases are in blacks.
    It may be a biological selection phenomenon, as, for example, whites do not get sickle cell disease, which in malarial black Africa is associated with relative malaria resistance though at a hellish price. Or, it may be behaviorally linked, though it is hard to imagine that today blacks are more promiscuous than whites or Latinos. They, all American races, are all promiscuous. The upper classes are less so, marry much more often: the last holdout of the nuclear family.
    Hell, I’ve been married 3x and have only had intercourse with 4 women my entire life, a period that spans 55 years! Turned down a bunch, all white, too. My kids are entirely the same: Fidelity.

  25. Terrence Condolini Says:

    oh, that explains the miscommunication. i mixed two thoughts in the same comment. the higher rate of hiv in black gay males contributes greatly to the overall rates of infection in the south. why they have higher rates i cannot say (they also have higher infection rates in the non-gay parts of the black community). the other part, about (slightly) higher rates of gayness in blacks was just a throw in tidbit.

  26. neo-neocon Says:

    Terrence Condolini:

    On the higher rates of HIV among black people:

    While male-to-male sexual contact accounts for the largest share of HIV cases among both Blacks and whites, fewer Blacks are infected this way and heterosexual sex plays a bigger role among Blacks compared with whites. Among Blacks, 58% of new HIV diagnoses in 2015 were attributable to male-to-male sexual contact and 34% were attributable to heterosexual sex; among whites, 72% of new HIV diagnoses in 2015 were attributable to male-to-male sexual contact and 13% were attributable to heterosexual sex. The remainder of HIV diagnoses in each group were attributable to other causes, including injection drug use.
    HIV transmission patterns among Black men vary from those of white men as well. Although both groups are most likely to have been infected through sex with other men, white men are more likely to have been infected this way. Heterosexual transmission accounts for a greater share of new diagnoses among Black men than white men.
    Black women are most likely to have been infected through heterosexual transmission, the most common transmission route for women overall. White women are more likely to have been infected through injection drug use than Black women.

    In addition, higher rates of VD in the black population are part of the picture. There seems to be a higher rate of heterosexual transmission among black people. Is it because of higher rates of concomitant VD or other infections? It might be. I’ve also read that there is a much higher rate of heterosexual transmission in sub-saharan Africa, and of the disease as a whole. This genetic quirk might be part of the reason, and I would imagine a great many American blacks share the mutation:

    Nearly all Africans carry a mutation near the DARC gene that prevents its expression. “It’s a tradeoff,” says Robin Weiss, an HIV researcher at University College London and part of the team that has found the new HIV link. “This genetic factor that has made sub-Saharan Africans resistant to vivax malaria is also making them more susceptible to HIV.”

    There are probably a lot of reasons for the higher rate.

  27. Frog Says:

    “This genetic factor that has made sub-Saharan Africans resistant to vivax malaria is also making them more susceptible to HIV.”
    Related to what I said before, though it was about the sickle cell genetic factor and malaria.
    Ah well.

  28. huxley Says:

    Looking into the HIV statistics online, I notice most state that HIV rates are higher among African American, but you have to burrow deeper or crunch the numbers yourself to get a sense of how much higher those rates are.

    Here are some cold hard numbers from the National Institute of Health in a 2005 article. From my reading the numbers are still this bad.

    African Americans in the United States are disproportionately affected by HIV/AIDS, with the rate of AIDS for African Americans nine times that of Whites.
    […]
    While African Americans make up only 13% of the U.S. population, they represent 39% of all AIDS cases reported in the U.S. through 2002.

    Furthermore, the proportion of AIDS cases accounted for by African Americans has steadily and markedly increased over time: of the more than 42,000 new cases reported in 2002, 50% were African American, an overall rate that was almost 11 times greater than the rate for Whites in that year.

    In the same year, African Americans constituted almost two-thirds of all AIDS cases in women and two-thirds of all pediatric AIDS cases.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388265/

    The article suggests that some of the racial disparity is due to high rates of blacks incarceration in prisons which are STD factories.

    Makes sense to me. People go on about microagressions but the fate of those imprisoned is a horror and one of the true shames of America.

  29. Ymar Sakar Says:

    US black rates are mostly due to the sodomy culture of gang banging and black culture in inner cities. Women are treated as property, and unless they can fight back, they lack any authority or say over the black male.

    Even white males have aggression issues dealing with black males. Women tend to fold since they lack anything, other than firearms, on controlling more powerful males.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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