AIDS was first reported by the United States (US) Centers for Disease Control and Prevention (CDC) (1981) as a form of pneumonia, although cases were almost certainly present as early as the 19th century. Since then, we have learned that AIDS is the result of a series of life-threatening infections arising from the HIV virus. In 2023, there were an estimated 1.3 million new infections, with almost 40 million people living with HIV and 630000 deaths attributed to the disease (World Health Organization, 2024). There is currently no cure, but the evolution of treatment has led to a reduction in mortality rates, and improved quality of life.
In 1987, azidothymidine (AZT) was licensed in the US as a treatment for HIV. It was found to inhibit viral replication but came at the expense of some serious side effects, such as liver damage and blood problems (e.g. anaemia, neutropenia). However, the harm was somewhat mitigated by lowering the dose. The next significant breakthrough came with the advent of nucleoside reverse transcriptase inhibitors (NRTIs) such as dideoxycytidine. During the 1990s, multiple studies showed that a combination of AZT with dideoxycytidine vastly improved patient outcomes. Proteas inhibitors arrived on scene in 1995 and non-nucleoside reverse transcriptase inhibitors (NNRTIs) followed in 1996. Combination therapy became the standard treatment method in 1997 and the highly active antiretroviral therapy (HAART) was realised (the practice of combining three or more drugs in the treatment of HIV).
The aim of treatment is to reduce the viral load to an undetectable level and reduce transmission risk, alleviate symptoms, and minimise toxicity. Treatment consists primarily of antiretrovirals, usually in combination and dependant on common comorbidities such as hepatitis B. The UK National Institute for Health and Care Excellence (NICE) recommends commencing treatment with two nucleoside reverse transcriptase inhibitors (NRTI) plus one of the following: an integrase inhibitor, an NNRTI, or a protease inhibitor). Further options are available if the viral load becomes unmanageable such as in patient deterioration or increasing drug resistance. In these cases, CCR5 antagonists, fusion inhibitors, attachment inhibitors or pharmacokinetic enhancers may be incorporated into the regime or even replace existing choices.
Currently, there is no cure for HIV/AIDS. However, there is a reasonable expectation that with the correct combination of drugs, the viral load will be suppressed such that it is not detectable in blood samples. It is reasonable to assume that with ongoing research in antiretroviral therapies, further advances will be made. However, there are also interesting possibilities for alternative methods such as transplantation with stem cells.
World AIDS Day takes place on 1st December 2024. An extended comment with detail on the actions of treatments mentioned will appear in the December issue of International Paramedic Practice at https://www.magonlinelibrary.com/toc/ippr/14/3