AIDS Day 2011: Dramatic Declines in Opportunistic Illnesses

A recently released HIV/AIDS epidemiology report from the San Francisco Department of Public Health (SF DPH) described a continuing general decline of opportunistic illnesses (OIs) among those newly diagnosed and the aging population of people with AIDS (PWAs).

For AIDS cases in the early years of the epidemic, individuals were frequently diagnosed with CD4 cell counts under 200 and an OI such as Candidiasis, Kaposi's sarcoma, pneumocystis jiroveci pneumonia (PCP), and wasting syndrome.

However, the health officials observe the following positive development:

--In the most recent years, more than 80% of (AIDS) cases were diagnosed by CD4 levels alone.

--This means newly-infected individuals are not as ill when receiving an AIDS diagnosis, giving them better chances of maintaining wellness and a robust immune system.

This 2010 annual report provides background about the history of tracking OIs:

The SF DPH has collected the initial and subsequent occurrence of AIDS opportunistic illnesses since AIDS surveillance began 1981. To our knowledge, the SF DPH is the only health department in the country to have done so. This provides us with a comprehensive understanding of the spectrum of opportunistic illnesses over time.

Possessing decades of collected data gives the epidemiologists data from which an invaluable picture of OI trends emerges. The section for OIs contains much good news regarding the falling frequency of incidences:

--Declines in opportunistic illnesses can be attributed to prophylaxis and improved antiretroviral therapy and to earlier diagnosis of HIV infection.

[A chart illustrating] the incidence rate of eight major opportunistic illnesses between 1993 and 2008... [shows] dramatic declines in the most frequently occurring illnesses. Though more difficult to appreciate, there have also been declines in the less frequently occurring illnesses occurring over this time period.)

The decline in PCP in the early to mid-1990s can be attributed to widespread use of PCP prophylaxis. Declines in Mycobacterium Avium Complex (MAC) are likely due to use of prophylaxis as well, although this is more difficult to observe because of their small numbers.

Improved care, including HAART (highly active antiretroviral therapy), is likely to be responsible for most of the decline.

In other words, AIDS cocktails are directly boosting the immune function of PWAs who are contracting fewer OIs and statistical trends show steady rates or drops, with no OIs on the rise.

The report examined OIs in three time-periods: pre-HAART (1993-1996), early HAART (1996-2000) and late HAART (2001-2010), and the following declines were recorded for the ten most-frequent OIs:

OIs by year..........'93-'96...'96-'00...'01'10

PCP .....................559.........410........343
Kaposi's sarcoma.....226.........155........131
Wasting syndrome....176..........107.......69
Candidiasis ...........113...........91.........81
Recurrent bacterial....77............80.........31
pneumonia
Cryptosporidiosis......74...........35.........16
Pulmonary
tuberculosis.............74...........44.........50
HIV encephalopathy.....60.........37.......28
Cryptococcosis.........56...........35.........51
MAC.....................36...........27.........23

Dr. Grant Colfax, the SF DPH director of HIV and OI prevention, said the numbers are motivations for treatment adherence and regular visits to the doctor. Asked to interpret the data and what lessons the aging PWA population should learn, Colfax said:

--Recognize that aging is part of the natural life process, though there's evidence that HIV (especially untreated) accelerates this process. Stay active, exercise, maintain a strong social network, don't use tobacco and drink only in moderation, if at all.

--Diet and a healthy weight are also important. Eat meat in moderation, lots of fruits and vegetables, avoid processed foods. Get routine checkups, talk to your healthcare provider about any medical concerns.

--Plan for longer-term needs including the possibility of long-term medical care. Write a living will with clear instructions regarding life support.

Colfax's best practices suggestions for PWAs as they age are echoed by Gary Virginia, a Castro neighborhood resident living with AIDS since the late 1980s, who describes himself as "a survivor and thriver."

Virginia says he's maintained wellness through simple health habits, and offers these recommendations:

--It's critical for newly infected and long-term HIV survivors to have regular lab work (every six months minimum) to monitor viral load and CD4/T-cell counts (immune system health). Baseline figures and changes alert your healthcare provider to whether or not you should start or change your HIV medications.

--The newer drugs have fewer side effects and often are more effective and stay in the blood system longer which helps fight drug resistance. Trouble with drug adherence should be discussed because many drugs are now combined to reduce pill count or frequency in taking them.

--Stay current on issues such as chronic GI inflammation in long-term survivors and how that impacts digestion and overall health.

--Many HIV meds can cause dry mouth, which affects dental health, so it's important to stay on top of routine dentist visits and use products to prevent decay. Depression and anxiety should be discussed with one's doctor as well.

--It's not just the traditional OIs associated with HIV that can affect your health.

Both Colfax and Virginia emphasize that OIs are preventable for the most part if you keep a low or an undetectable viral load and a stable CD4 cell count over 200.

The benefits of AIDS medicines are clearly measurable and through the years have directly contributed to people living with HIV infection and averting OIs that once disfigured bodies, ravaged compromised immune systems, and all-too-quickly lead to death and funerals.

What cannot be measured are the years of extended lives, all the holidays and birthdays, the vast numbers political and medical advances and setbacks for the gay and AIDS communities, myriad laughs and tears of modern life, and so many additional facets of living that PWAs have lived to witness and experience.

It is frequently said by public health experts that AIDS trends seen in San Francisco over time are replicated in other American urban areas. Thomas J. Coates of the University of California is one such HIV prevention expert and he maintains that, "what happens in the HIV epidemic usually happens here first."

Many hope those words will apply to OI rates outside of San Francisco.

(The 2010 SF DPH Annual HIV/AIDS Report can be read here:
http://www.sfdph.org/dph/files/reports/RptsHIVAIDS/AnnualReport2010_2.pdf. Data on OIs was extracted from pages 32-34.)