The treatment options of AIDS patients in the U.S. have steadily improved since the disease become a public health crisis that transcended race, gender and sexual orientation. The testing is better. The drugs are better. In short, the chances for HIV-positive men and women to live longer and healthier are better.
Maybe that's why a case of a 49-year-old woman who presented to a Rhode Island hospital with four months of cognitive and behavioral changes is so frustrating to Dr. Edward J. Wing, professor and chairman of medicine at the Warren Alpert Medical School of Brown University in Providence, R.I.
The woman, a widow with one son, smoked but did not use intravenous drugs or practice unsafe sex. Her white blood cell and platelet count were low. Her CD4 count, which indicates the strength of a person's immune system and should be in the range of 500 to 1,500 cells per cubic millimeter of blood in a healthy adult, was 5. With advanced AIDS, the patient was started on antiretroviral therapy and discharged to a nursing home. Six weeks after her HIV diagnosis, she was dead.
"She died because the system didn't diagnose her," Dr. Wing said during the annual Zucker Lecture on April 10 at Uris Auditorium. The Donald Zucker Visiting Professorship, supported by the generous gift from Donald Zucker, brings a leading expert in the field of infectious diseases to give the annual lecture at Medicine Grand Rounds.
An infectious disease specialist who has spent a great deal of his career studying AIDS on a national and global scale, Dr. Wing updated the audience on the treatment of AIDS in Providence, R.I., and Eldoret, Kenya, where Brown University physicians and medical students work in collaboration with the staff at the Moi Teaching & Referral Hospital.
While both regions are making great strides in treating the virus, both face unique challenges in treating its infected populations.
In Providence, where new drugs and HIV tests that yield results in as little as 20 minutes are proving to be effective tools, obstacles still exist in prevailing attitudes about who should be tested for HIV.
Dr. Wing has a simple answer to that question: everyone.
"Anybody who walks into a physician's office should be offered HIV testing," he said. "Unless you were in the nunnery for the last 30 years, you are at risk and should be tested." High-risk persons, he added, should be screened annually.
For those who have tested positive, new drugs are being introduced to fight even the most resistant strains of HIV. Enfuvirtide, which requires twice daily injections, and Maraviroc prevent the HIV virus from getting into a healthy cell.
"The prognosis if you have HIV is good," Dr. Wing said. "It's not normal, but it's much better than it has been and I predict that it will continue to improve."
However, that prognosis is contingent not only on access to the medication, but also strict compliance to the dosage schedules. In a country like the resource-poor and politically unstable Kenya, AIDS patients there have no shortage of obstacles preventing them from staying on their medication.
"They might have to walk 10 miles to the clinic," Dr. Wing said. "And they might not have food, which is more important to them than the medication."
At the Moi Teaching & Referral Hospital, Dr. Wing said as many as three patients to a bed is the norm, and tuberculosis and malaria are rampant. About half of the patients there are HIV positive and it has a daily mortality rate of 10 percent.
But even with 1.3 million of Kenya's 32 million people living with AIDS, there have been signs of progress. The patients who are able are very compliant. And although inadequate nutrition prevents the weight gain associated with successful antiretroviral treatments, CD4 counts are rising.
"The patients in Eldoret really do get excellent care," Dr. Wing said.