HIV: You're Still the One

Infectious disease physicians often tell those who are diagnosed with HIV in the modern era that they will likely live a normal life span if they are placed on and are adherent to antiretroviral therapy. My career started just as this modern era dawned but I wasn't too far removed from the bad old days of HIV to not have some experience with it. 

As a resident, I recall about a dozen patients with undiagnosed HIV presenting to the hospital with shortness of breath and subsequently diagnosed with Pneumocystis pneumonia. Some of these patients ended up in the ICU and on mechanical ventilator. During my fellowship in infectious disease, by contrast, I think I only saw one relatively mild case of Pneumocystis

A few weeks ago, however, I had the unfortunate opportunity to relive this experience when a patient was admitted to the hospital with a severe pneumonia requiring mechanical ventilation and round-the-clock care in the ICU. This patient was not known to be HIV positive but I soon discovered that the virus and Pneumocystis were responsible for the dire conditions of the patient. 

According to current statistics, 86% of those with HIV know their status leaving 14% unaware of their diagnosis. My patient was one of the 14%. Being aware of one's diagnosis is no guarantee, however, that viral suppression will occur. In fact, 70% of those with HIV in the US have not achieved viral suppression, despite the high potency of antiretroviral therapy indicated other factors are at play. 

Individuals with Pneumocystis pneumonia who require a ventilator have a 60% mortality rate--a startlingly high mortality rate that often necessitates starting anti-HIV therapy in the ICU without counseling, without a genotype, and with no assurance that the patient will be compliant. But, in such situations anything that will help the patient leave the hospital alive is welcomed. 

My patient, thankfully, was one of the 40% that survive but served to remind me that in the midst of Ebola, MERS, and avian influenza, HIV remains an ominous foe.