Treating HIV disease: back to the patient?

Abstract

HIV disease has dramatically changed in the last two decades from a progressive, lethal disease to a chronic manageable condition. These changes are due to the availability of potent antiretroviral combination therapy, which also have the potential to contribute significantly to the control of the epidemic. Among persons living with HIV, incidence of immunosuppression-related opportunistic illnesses has clearly decreased, while an increase was observed in the prevalence of age-related noncommunicable comorbidities, including cardiovascular, metabolic, renal, bone and hepatic disease, due to chronic inflammatory state and to an overall aging of the population of persons with HIV. It has been predicted that by 2030 more than 80% of older persons with HIV will have at least one comorbidity, compared to 19% of non HIV-infected persons, and that one fourth of these persons will have three or more comorbidities. Among persons with HIV, the prevalence of frailty is increasing. Choice of therapeutic approach to HIV disease should take into account, in addition to the ability of drug combination to suppress viral replication, the potential for long term adherence to treatment, the lack of long term toxicity, the possibility to fully restore immune function and prevent immune activation, thus reducing the risk of chronic inflammation related disease. In addition the overall impact of treatment on patients' well-being must be considered, and patients related outcomes should be used to measure this impact.