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HIV Treatment Extends Life Expectancy

ResearchBlogging.org

People with HIV are living longer on the latest anti-retroviral therapy. This is something any infectious disease specialist knows from their own clinical experience – but it’s reassuring (I would even argue necessary) to have objective data to support experience. A study published in the latest issue of Lancet provides this objective data. (Lancet. 2008 Jul 26;372(9635):293-9.)

The press release from Bristol University, academic home of the lead author, says:

Professor Jonathan Sterne of Bristol University’s Department of Social Medicine and Professor Robert Hogg of British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University, Vancouver, Canada and colleagues from The Antiretroviral Therapy Cohort Collaboration (ART-CC) compared changes in mortality and life expectancy among HIV-positive individuals on cART.

This collaboration of 14 studies in Europe and North America analysed 18,587, 13,914, and 10,584 patients who started cART in 1996-99, 2000-02, and 2003-05 respectively.

A total of 2,056 patients died during the study period, with mortality decreasing from 16.3 deaths per 1000 person-years to in 1996-99 to 10.0 in 2003-05 – a drop of around 40 per cent.

Potential life years lost per 1000 person-years also decreased over the same time, from 366 to 189 — a fall of 48 per cent. Life expectancy increased from 36.1 years in 1996-99 to 49.4 years in 2003-05, an increase of more than 13 years.

That’s very impressive – both the study and the data. Large collaborative studies are inherently more powerful and reliable than studies conducted at a single location by a single team. Methodological errors and statistical flukes tend to average out in larger studies with multiple centers.

Also – survival is a very hard (meaning objective and concrete) outcome, which is why it is preferred as a primary outcome measure whenever possible. Again this adds to reliability, more so than subjective symptoms dependent upon patient reporting.

The size of the result is also impressive, making it unlikely that small unanticipated confounding factors are responsible for the measured effect. Small effect sizes, even when highly statistically significant, are always suspect because it is difficult to account for everything that could potentially cause a small effect. Large effect sizes require a significant factor that is harder (but not impossible) to miss.

The weakness of the study is that it is a retrospective study, not a controlled prospective study. This opens the door for confounding factors. The authors accounted for known factors by stratifying subjects – making sure that known variables, such as age and sex, were accounted for. But unanticipated factors can always skew the results.

There are several important bottom-line implications of this study. The first is that the current cocktail of combination anti-retrovial therapy (cART) works. It correlated with decreased mortality every way it was measured. A newly diagnosed 20 year old can expect to live 49 years on current therapy. This is not a normal life expectancy, which is closer to 60 years from age 20, but it’s very good considering that in the 1980′s, prior to available treatments, life expectancy was about 12 years from time of infection.

While current treatments are very good, there is still room for improvement.

The data also show that the benefits of treatment diminish if they are delayed. Those with early treatment survived longer than those who started later. It is estimated that about 1/3 of people with HIV do not know it, and therefore are not being treated. The data therefore support continued efforts at public awareness to ensure early diagnosis and treatment.

As those with HIV are living longer we are also discovering new complications of chronic HIV infection, such as organ damage and cancer. Essentially, people with HIV are now surviving long enough to get more complications from long term HIV infection. Recognition of the later effects of HIV is prompting reevaluation of treatment recommendations and research. With continued research we will therefore likely improve survival further.

Being optimistic it is therefore likely that a newly diagnosed young HIV patient today will live long enough on current treatments to benefit from future treatments not yet developed. A normal life expectancy may therefore already be within reach, assuming continued research efforts.

HIV Denial

This study also has great significance for the pseudoscientific denial that HIV is the cause of AIDS. Back in the late 1980′s and early 1990′s, prior to the development of the protease inhibitors and anti-retroviral drugs that make up the current cART, one of the main points of the HIV deniers was that treating HIV did not prolong survival with AIDS. For example, Peter Duesberg said in an interview:

“I could understand them saying I am so horrible and irresponsible if they were showing any results with their theory, but so far they haven’t saved a single life. After ten years there is still no vaccine, and the only therapy is AZT, which is, in my view, making people sicker.”

If the HIV theory of AIDS is correct, deniers argued, then why are HIV treatments not prolonging survival. Even in the early 1990′s the claim was not accurate, but treatments were only mildly effective. Now the efficacy of anti-HIV treatments for AIDS are undeniable. Interestingly, even though they once used this as an argument against the HIV theory, deniers are not willing to admit that increased survival is now an argument for the HIV theory.

Prominent denier Christine Maggiore on her website Alive and Well, wrote:

Government officials, AIDS organizations and the media unanimously agree that the recent decline in AIDS cases and deaths is an unprecedented occurrence due to a new combination of drugs that include protease inhibitors, chemicals said to block the replication of HIV. However, a careful look behind the headlines reveals that there is no medical evidence to support these popular claims about the protease inhibitor “combo cocktails.”

She then argues that increased survival is due solely to expanding the diagnostic criteria so that more mild cases qualify as AIDS. This is a real concern in any epidemiological data, such as the current study. But the criticism is not fair and accurate because changing diagnostic patterns is a known and often controlled for factor. For example, in the current study the methods indicate that populations were stratified by baseline CD4 count. The CD4 cells are those T-cells that are primarily affected by HIV infection, and CD4 count is widely used as an estimate of disease severity. This ensures that populations with similar severity are being compared, so that prolonged survival is likely to be due to treatment, rather than just changes in diagnostic behavior.

Maggiore also makes the rather dubious argument that decreases in AIDS cases preceded the introduction of modern treatments by several years. But treatment is not primarily about preventing new cases, but prolonging survival of existing cases. It can decrease viral load and therefore reduce the risk of spread – but it does not eliminate it. Most cases are spread from those who do not yet know they are HIV positive, before they would be treated, in any case. The changes in the rate of spread of HIV has to do with changing behavior, not treatment.

Maggiore and other HIV deniers are desperate to cast doubt on this now undeniable fact that treatments targeting HIV significantly prolong survival with HIV and AIDS. This is a major prediction of the HIV theory, and its confirmation is another nail in the coffin of HIV denial.

Posted in: Clinical Trials, Public Health

Leave a Comment (30) ↓

30 thoughts on “HIV Treatment Extends Life Expectancy

  1. gbarendt says:

    So what is the statistical trick to come up with that sort of number given that we can’t actually see how a 20 year old started on antiretrovirals today will be doing in 50 years?

  2. Joe says:

    People with HIV still have a shortened life expectancy (as you wrote). Is that because of the other complications (organ damage, cancer) or does resistance to the drugs often lead to full, untreatable AIDS? I know there are methods for combating resistance; I am wondering if a point is often reached where nothing more can be done.

    As I imagine it, deniers such as Maggiore do not want to accept that they have a problem that requires major changes in lifestyle. But, what is it with Duesberg? As each new piece of evidence discredited his arguments (and, he only had argument, no data) he became more shrill in his rationalizations. As his arguments progressed, I felt bad for him.

  3. DavidCT says:

    I have heard the argument that the improved survival we are seeing, is a result of the virus becoming attenuated as it is repeatedly passed through the population. The argument was then made that the improved survival is due primarily to a weakened virus not more effective treatment.

    This claim does not deny HIV as a cause, but is more in the “drugs don’t really work” camp. I would be interested in any thoughts you might have about that claim.

  4. David Gorski says:

    So what is the statistical trick to come up with that sort of number given that we can’t actually see how a 20 year old started on antiretrovirals today will be doing in 50 years?

    There’s no “trick” involved. Rather, it’s well worked out mathematical models that have been used and validated by the life insurance industry for many decades to estimate life expectancy.

  5. gbarendt says:

    Sorry, I realized upon re-reading my comment that it sounded like I was a denialist and using “trick” in the negative sense. I’m not. I ask because I’m actually genuinely interested in learning more about the math behind this sort of work and can’t get to the paper.

  6. pec says:

    “it’s well worked out mathematical models that have been used and validated by the life insurance industry for many decades to estimate life expectancy.”

    Yeah but the life insurance industry estimates life expectancy based on variables that are already quite well understood — smoker or not, male or female, etc.

    But how the new HIV drugs effect life expectancy is what they were trying to find out in this study. So you would have to be able to estimate the effect of the drugs in order to use the model to come up with the estimate!

    It would be nice if we could actually read the methods and results for this research, rather than blindly trusting those “well worked out mathematical models.”

  7. jwittner says:

    From Alive and Well:

    …that the virus somehow disables the body’s defense system that protects against opportunistic illness.

    Somehow? Am I confused or don’t we know pretty well how HIV attacks and kills CD4+ T cells?

    Do the HIV deniers have any valid alternative hypotheses to HIV? I couldn’t find any clear alternatives on the Alive and Well site, despite its subtitle of “Aids Alternatives.”

    These are the people that give skepticism a bad name by representing it as something it is not.

    I just threw up a little in my mouth.

  8. pec says:

    “Patients treated later in the course of their infection, with lower CD4+ cell counts (below 100 cells per μl blood at initiation of cART), had shorter life expectancy, at 32.4 years, compared with 50.4 years in patients treated at earlier stages with higher CD4 loads (above 200 cells per μl).”

    They probably forgot to think about lead-time bias.

  9. teeps29 says:

    Pec seems less trollish today, but please ignore the major logic hole in that last post and remember this advice: Don’t Feed The Troll.

  10. Mark Crislip says:

    It has been an amazing 25 years. AIDS started as a disease when I was an intern and the hospitals used to be filled with young men dying rapidly of oportunistic infections due to some unknown immunodeficinecy.

    Now?

    I have seen one aids death this century and complications of AIDS are so rare residents can never see PJP or other OI’s during a three year training program.

    All thanks to the advanced understanding of the disease from chiro… I mean accupu… i mean homeo…. I mean…. reik….

  11. Fifi says:

    Mark – It has been both an amazing and horrific 25 (almost 30) years. Two of my best friends were diagnosed with AIDS in the mid-80s (incidentally, one was a woman, even then AIDS wasn’t purely a homosexual issue – she contracted it from a hemophiliac boyfriend back before the blood supply was properly tested in Canada). It was still the early years for treatment. Both were told they’d be dead within the year (standard at the time). Both lived another decade thankfully. Only one friend from back then who was HIV+ is still living (also a woman). Back then, the suffering was made all the more profound by both public and institutional homophobia and general fear, prejudice and misinformation. Remember, back in the 80s there were still medical professionals who justified their homophobia on “scientific” grounds and wouldn’t treat people living with AIDS. Thankfully things have changed, the hysteria has died down (unfortunately with an attendant lack of caution regarding safe sex) and treatments are better. People are still getting sick and dying but they’re also living longer. There’s still a long way to go, no one should be patting themselves on the back yet, but we have come a very very long way from the days of hate, fear, ignorance and suffering that marked the 80s and early 90s.

  12. David Gorski says:

    It has been an amazing 25 years. AIDS started as a disease when I was an intern and the hospitals used to be filled with young men dying rapidly of oportunistic infections due to some unknown immunodeficinecy.

    Indeed.

    I was a medical student in the 1980s, and I remember actually wondering if I wanted to be a doctor, much less a surgeon, mainly because of fear of exposure to HIV-containing blood. Young men were dying horrible deaths from opportunistic infections, and AZT was only starting to be used. At the time, we didn’t know how high the risk was from accidental needlesticks, and every surgeon gets needlesticks from time to time.

    How times have changed–thanks to scientific medicine. Not woo. Not HIV/AIDS denialists, who cannot provide a useful (or even testable) alternative hypothesis for HIV pathogenesis. Science.

  13. Fifi says:

    I mean no personal offense Dr Gorski – and I am not suggesting this is true of you – but the homophobia and mistreatment of people living with AIDS by some medical professionals continued long after the evidence came in regarding risks. I’m not trying to chastise you for being afraid – there was an atmosphere of hysteria around AIDS and back in the 80s overt homophobia (institutional and personal) was pretty normal. We really have come a long way on many fronts since the 80s.

    Yes, medical science has stopped treating being Queer like a disease (for the most part) – partly because science has finally overcome the societal/religious prejudices that informed scientific/medical and public opinions about sexuality and gender. Part of what underlies these changes is social activism and education – it wasn’t just science and certainly there was some ignorance being perpetuated by the scientific community about homosexuality. Woo tends to be quite homophobic itself a lot of the time – as are most major world religions (which is where science’s original homophobia originated, in religious morality) and it certainly did nothing to contribute to the understanding of being homosexual, lesbian, bisexual or transgender and acceptance of natural human difference/diversity.

    Sorry to get sociopolitical but the history of AIDS is innately sociopolitical even on the level of science. That said, AIDS denialists are often working a decidedly homophobic agenda and the big steps science and scientists have taken – despite the resistance and fear of some of their own – shows that good scientists will let go of misled theories once they have been shown to be wrong (even, at times, if it means admitting their personal prejudices are founded in ignorance not the incorrect science they were using to justify them).

  14. ama says:

    First, please take my apologies for putting in a long text in German.

    Second, I hope that those of you who understand German, will help in fighting against the author, Bert Ehgartner.

    Bert Ehgartner is a former editor with surfmed.at

    http://med.blogger.de/stories/1072863/

    [*QUOTE*]
    ——————————————
    Lob der Krankheit
    Randbemerkungen zur Medizin
    Navigation
    Startseite
    Themen

    Blogger.de Startseite

    Suche

    Werbung
    Freitag, 14. März 2008
    AIDS unterm Glassturz
    malamud, 10:56h
    Vergangenes Jahr habe ich einen Artikel zur AIDS-Problematik geschrieben, der in den Leserbriefen und Stellungnahmen komplett verrissen wurde. Der Tenor lautete: Skandalös! Unverantwortlich! Unseriös!
    Alice Wimmer von UNAIDS-Pakistan schrieb sogar, dass „der Beitrag durch seinen unausgewogenen Tenor weltweite Anstrengungen unterminiert.“

    Hier zum Nachlesen der Artikel:
    http://www.news.at/profil/index.html?/articles/0721/560/174173.shtml

    Beim Interview mit einer moslemischen Frau und zweifachen Mutter in einer Blechhütte im Slum Mukuru, Nairobi.

    Und hier eine Stellungnahme, die ich dazu auf http://www.sciblog.at/ veröffentlicht habe:

    Im Kern gings in dem Artikel um drei Thesen:
    • Das häufig von AIDS-Organisationen prophezeite Überschwappen der Epidemie auf die heterosexuelle Bevölkerung findet (in den Industrieländern) nicht statt und wird auch nie stattfinden.
    • Die AIDS-Katastrophe in Afrika und Asien wird (z.B. von US-amerikanischen fundamentalen Glaubensgruppen) zur Missionierung der Entwicklungsländer mit moralischen Botschaften (Treue! Enthaltsamkeit!) missbraucht. AIDS als flammendes Schwert der neuen Kreuzritter.
    • Die Versorgung von Abermillionen Patienten mit antiretroviralen Medikamenten ist zweifellos ein gutes Geschäft für die Hersteller dieser Präparate und beschäftigt unzählige Mitarbeiter diverser Hilfsorganisationen. Mit Sicherheit ist die pure Medikamentenabgabe aber nicht dazu geeignet, die gesundheitlichen Probleme von Menschen nachhaltig zu verbessern, die unter katastrophalen hygienischen und sozialen Bedingungen z.B. in den Slums der Großstädte Afrikas oder Asiens hausen. Zudem sind die Nebenwirkungen der HAART Drugs enorm und in ihren Langzeit-Konsequenzen nicht wissenschaftlich erforscht. Gerade unter Dritte-Welt-Verhältnissen ohne ausreichendes Monitoring (viral load, CD4 T-cell counts, etc.) und bei problematischer Compliance erscheint die Ansicht extrem blauäugig, dass diese Drugs in der Dauertherapie „jedenfalls mehr nützen als schaden“.

    In den meisten Bereichen der Medizin könnte man über diese Thematik offen und vorurteilsfrei diskutieren. Bei AIDS geht das nicht.
    Da schwappt gleich die Empörung hoch.
    Alle Medien fühlen eine selbstverständliche Verpflichtung zur Aufklärung im Dienste der guten Sache. Und zwar – mit folgender stets gleich bleibenden Grundmessage:

    „AIDS ist eine fürchterliche Krankheit, die schon Millionen Todesopfer gefordert hat. Viel Positives wurde schon geleistet aber eine Menge ist noch zu tun. Deshalb braucht es weiterhin die strikte
    1) Vermeidung von Risikoverhalten und
    2) noch mehr Geld für Aidshilfe, Medikamente und Wissenschaft“

    Unausgesprochen, aber geradezu selbstverständlich gilt die Pflicht, die nicht so tollen Aspekte dieser „weltweiten Kampagne“ auszublenden. Und gerade wir Wissenschaftsjournalisten, denke ich, lassen uns hier manchmal allzu leicht einspannen.

    Ich weiß schon, dass wir es hier mit einem seltsamen Konglomerat zu tun haben, wo die wüstesten Thesen kursieren und man sich rasch in seltsamer Gefolgschaft befindet, wenn man öffentlich eine kritische Haltung vertritt: mit Leuten, die die Existenz von HIV komplett abstreiten bis zu Verschwörungsfreaks, die AIDS als gesteuerte Kampagne der CIA darstellen.

    Dennoch kann das nicht bedeuten, dass eine Wissenschafts-Sparte automatisch unterm Glassturz steht, egal was sie zustande bringt. Eine Science-Community, die es sich in einem schier unendlichen Wasserbett aus Förderungen bequem gemacht hat und seit 25 Jahren emsig an einem einzigen Virus herum forscht. Sie haben HIV nun brav in alle Einzelteile zerlegt und jeder Mechanismus und Submechanismus seiner Existenz ist auf Sabotiertauglichkeit geprüft worden.
    Doch was haben wir als Resultat?

    Eine Therapie, die zwar die HIV-bedingte Sterblichkeit seit Einführung der HAART zur Mitte der 90er Jahre deutlich reduzieren konnte, dabei gleichzeitig aber so belastend auf den Organismus wirkt, dass dieser Vorteil durch eine höhere Herz- und Krebs-bedingte Mortalität wieder verloren geht. Dass „HAART and the Heart“ eine ungesunde Mischung ist, warnen die Mediziner schon seit Jahren. Und es ist jetzt schon absehbar, dass die gesundheitliche Belastung durch die Nebenwirkungen der Therapie von Jahr zu Jahr weiter ansteigt.
    Aktuelle Analysen siehe z.B. hier:
    http://www.annals.org/cgi/content/abstract/145/6/397
    oder hier:
    http://www.thelancet.com/journals/lancet/article/PIIS0140673606691526/abstract

    Heute bietet HIV/AIDS ein Krankheitsbild, als wäre es von einem genialen Superschurken in den Gruselphantasiekabinetts der bösen Pharmamultis entworfen worden:
    • Keine Heilung ist möglich, jeder Patient bleibt bis ans Lebensende in dauerhafte Abhängigkeit von teuren Medikamenten
    • Diese Medikamente werden ständig resistent, damit ergibt sich die Notwendigkeit begleitender Neuentwicklung unter Abkassieren der Forschungsetats – neue Medikamente werden wegen der Dringlichkeit meist „fast-track“ zugelassen.
    • Der tödliche Ruf der Krankheit erlaubt die riskantesten Therapien, Therapiefehler fallen wegen der enormen Mortalität kaum auf
    • Die objektive Prüfung der Therapien über randomisierte placebokontrollierte Studien ist nicht möglich, weil Placebogruppen ethisch nicht verantwortbar wären und auch von keiner Ethikkommission bewilligt würden
    • Es gibt bei AIDS keine Tradition, keine Naturheilmittel oder überlieferten Hausrezepte. Nicht mal fachferne Mediziner können in der HIV/AIDS-Science wirklich mitreden, weil im Lauf der Jahre ein ungeheuer komplexes Thesengebäude mit eigenem Fachvokabular, eigenen Diagnostika und hochkomplizierter Therapie-Schemata entstanden ist. Das erspart Einmischung von außen – die Community bleibt unter sich.

    Kein Wunder, wenn so was die Verschwörungstheorien zum Erblühen bringt.

    Insgesamt ist das Krankheitsbild HIV/AIDS so etwas wie die Apotheose der Monokausalität: DAS Supervirus ist an allem schuld. Es ist derart gefinkelt und bösartig, dass die klügsten Forscherhirne es nicht zu fassen vermögen. „Das einzige, was man diesem Virus bisher noch nicht nachgesagt hat, ist, dass es singt “, formulierte es einmal ein Wissenschaftler.
    Und vor lauter Fokus auf das Virus sieht die Wissenschaft nicht mehr was links und rechts davon vor sich geht.
    Ist es nicht gerade die Pflicht von uns Fachjournalisten, gegenzusteuern, wenn den Wissenschaftlern die Begeisterung über ihren isolierten Forschungsgegenstand durchzugehen droht und darzustellen, dass ein Phänomen in der Medizin selten durch einen einzigen Parameter erklärt wird – außer wenn uns ein lockerer Dachziegel auf den Kopf fällt?

    Wer kann denn wirklich schlüssig erklären, warum sich HIV plötzlich anders verhält – je nachdem, ob sich die Viren in Europa oder in Afrika befinden? Wieso sind hier nach wie vor die bekannten Risikogruppen (promiske Homosexuelle und IV-Drogensüchtige) dort aber die Normalbevölkerung betroffen? Vor allem wenn sie unter desaströsen Bedingungen lebt?

    Wem nützt die nahezu vollständige Fokussierung von Wissenschaft, Politik und Hilfsorganisationen auf die Medikamenten-Therapie wirklich?

    Läuft nicht gewaltig etwas schief, wenn die UN unter dem Einfluss der HIV-AIDS Experten die weltweite Empfehlung rausgeben, dass HIV-positive Mütter ihre Säuglinge nicht stillen sollen, um sie vor den bösen Viren zu schützen.
    Und dann zeigt sich in gleich drei aktuellen Studien – dass die Babys ein doppelt so hohes Sterberisiko haben, wenn sie nach dieser Richtlinie mit Flaschennahrung gefüttert werden.
    Und dass sogar das Risiko, dass sie HIV-positiv sind um ein Vielfaches höher ist, wenn sie NICHT gestillt werden.
    http://www.thelancet.com/journals/lancet/article/PIIS0140673607602839/fulltext

    Wie ist es möglich, dass eine Wissenschaft so daneben haut und ihr eigenes Fachgebiet so schlecht versteht? Und dann auch noch die Warnungen der Experten ignoriert und damit weiter Menschenleben gefährdet http://www.thelancet.com/journals/lancet/article/PIIS0140673606695147/fulltext
    http://www.thelancet.com/journals/lancet/article/PIIS0140673606695147/comments?action=view&totalComments=1#678

    Aids ist längst ein Milliardengeschäft geworden, in dem es um Vieles geht. Unter anderem auch um das Wohl der Patienten. Doch dieser Aspekt gerät zunehmend in den Hintergrund. Immer stärker wird hingegen der Eindruck, dass auf den großen Aids-Weltkongressen längst schon das Lobbying diverser Interessensverbände im Zentrum steht und weiten Vorrang vor Evidenz basierter Medizin genießt.

    Wir sollten uns dieser Tatsachen bewusst sein und uns nicht fesseln und einlullen lassen, von den immer penetranter werdenden Appellen der AIDS-Lobbyisten zu kritikloser Solidarität.
    ——————————————
    [*/QUOTE*]

    “Lob der Krankheit”, by the way, is “praise of the illness”. I think you can guess the background of that headline, which actually is the title of one of his books, if I remember correctly.

  15. daedalus2u says:

    One side effect of the antiretrovirals is suppression of mitochondria biogenesis. They inhibit mitochondrial DNA replication. Mitochondria turn over every day, so anything that blocks mitochondria DNA synthesis is problematic.

    Quite a few of the characteristic side effects can be mediated through this common pathway, hyperlactatemia, lipodystrophy, chronic fatigue, cachexia, various organ failures, especially organs with high metabolic demand such as liver, kidney and nervous tissue.

    Many of these symptoms are similar to mitochondria depletion from other causes, the most usual is due to low NO. NO is what triggers mitochondria biogenesis.

  16. Joe says:

    Mark,

    Thanks, that answers my question.

  17. David Gorski says:

    I’m not trying to chastise you for being afraid – there was an atmosphere of hysteria around AIDS and back in the 80s overt homophobia (institutional and personal) was pretty normal. We really have come a long way on many fronts since the 80s.

    It had nothing to do with homophobia and everything to do with fear of needlesticks, actually. At the time, it was not an entirely unreasonable fear.

  18. Fifi says:

    Dr Gorski – As I tried to clearly say, I wasn’t accusing you personally of homophobia or saying your fears were totally unfounded. At the time, there was a fear of needle sticks that can be seen as reasonable in the face of the ignorance/unknown about a the disease but there was also a lot of very real homophobia and stigma at play too that continued long after the risks were clear and extended to people who weren’t dealing directly with blood or needles. I was integrally involved with my friends’ treatment (I noticed you only talked about AIDS in terms of men) and have personal experience with a wide variety of healthcare professionals in this matter that is probably quite different than your own. For instance, my father’s reaction was based in homophobia though he justified it for a long time as a reasonable medical danger (long after it was clear that the risks were quite slight). You don’t really believe there was no homophobic elements to the fear of AIDS – both institutional and individual – do you?

  19. Fifi says:

    Dr Gorski – Clearly AIDS had enough of an impact upon you at the time that you considered giving up medicine because of the fear of infection (not just surgery). This seems like a pretty extreme reaction to me – even at the time and based upon the evidence (or lack thereof). I’m not trying to negate your emotions or your experience, or say that you didn’t have a right to be cautious, I’m just sharing my experiences. Obviously you chose to continue in medicine, which no doubt benefited many people and is a good thing (and hopefully brought and brings you much pleasure). It would have been a shame if your fear had prevented your from pursuing your career. I can understand and empathize with your fears (founded or unfounded) – at the time very little was known about the virus and there was a lot of speculation both within the medical community and amongst AIDS activists. Obviously my perspective on AIDS – particularly when we talk about the 80s – is going to be somewhat different than yours since I was dealing with it from the perspective of people I love being told they’d be dead within a year (rather than “we don’t know”), accompanying them to the hospital and caring for them in their last, painful and debilitated year.

  20. Fifi says:

    I’d also like to make it clear that I’m in no way trying to demonize anyone or the entire medical profession. Doctors are people – with all the variety of any other group of people. Doctors can have irrational, fear based responses to things – they’re human. They can also have irrational, compassion based responses to things – they’re human. I met some wonderful compassionate doctors and health care workers during this time, and attitudes generally changed as more became known. I greatly appreciate the research and advances that have been made (I have a friend who’s an AIDS researcher). I just feel it’s important to not gloss over the less pleasant aspects of the past rather than to justify or deny them.

  21. pec says:

    I am not an HIV denier but I’m not a cheerleader for the drug companies either. I have noticed some of you “skeptics” writhing in ecstasy over this study, but I have not seen much skepticism about the convoluted statistics required for this conclusion.

    When controlled experiments are not possible, skepticism is called for — the results of this research may be distorted by over-diagnosis and lead-time bias, for example. Many more patients may have been tested for HIV in the later eras, at an earlier stage of infection.

    We do not know how many HIV cases will progress to AIDS, or how long it might take. We don’t know if later HIV cases are exactly the same as earlier cases, since viruses evolve and change.

    You “skeptics” always point out that anecdotal clinical experiences do not count as scientific evidence. Well you seem to think your clinical experience with AIDS is worth mentioning — HIV was a death sentence in the 1980s but now patients live for many years thanks to drugs.

    I am not saying the drugs don’t work, I really don’t know. But isn’t it possible that some of the effect you attribute to drugs is really over-diagnosis (not all HIV progresses to AIDS) and lead-time bias (HIV is diagnosed earlier)? More people are tested for HIV now than previously, so more cases are diagnosed and they are diagnosed earlier.

  22. David Gorski says:

    We do not know how many HIV cases will progress to AIDS, or how long it might take. We don’t know if later HIV cases are exactly the same as earlier cases, since viruses evolve and change.

    We do know what percentage of cases of untreated HIV will progress to AIDS and about how long it takes. Steve even gave such an estimate in his post.

  23. trrll says:

    You “skeptics” always point out that anecdotal clinical experiences do not count as scientific evidence. Well you seem to think your clinical experience with AIDS is worth mentioning — HIV was a death sentence in the 1980s but now patients live for many years thanks to drugs.

    While the plural of anecdote is not data, the virtually universal perception of medical personnel that it has become much more uncommon to see people dying from acute AIDS offers at least a strong suggestion that something important has changed with respect to the disease. Combine that with statistical evidence such as this report, along with the huge amount of laboratory evidence indicating that the drugs are effective against HIV, and it becomes very difficult for a rational person to doubt that the development of antiretroviral therapy has led to a dramatic improvement in the prognosis of people infected with HIV.

  24. HCN says:

    http://rationalwiki.com/wiki/Scopie%27s_Law

    In any discussion involving science or medicine, citing Whale.to as a credible source loses you the argument immediately …and gets you laughed out of the room.

  25. Deetee says:

    Pec, you asked:

    “When controlled experiments are not possible, skepticism is called for — the results of this research may be distorted by over-diagnosis and lead-time bias, for example. Many more patients may have been tested for HIV in the later eras, at an earlier stage of infection.”

    Perhaps you should tell us exactly what “lead time bias” you see in this study?

    Firstly, the study stratified by CD4 counts.

    Secondly, if that was not enough, any bias regarding initiation of therapy because of starting treatment at an earlier stage of illness would have resulted in a consequently longer survival irrespective of treatment effect.

    Recall the “hit hard, hit early” hypothesis of the late nineties? By the early 2000s, the pendulum had swung away from initiating treatment at around 500 CD4 cells and shifted to around 350, as people still “hit hard”, but waited a bit later in the course of the illness to do so. Any possible lead-time bias around this issue would work in the opposite direction to that you are implying.

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