Landmark Developments in Infectious Diseases

A 20-Year Look-Back: Two Steps Forward, One Step Back

Ingrid G. Hein

Disclosures

October 20, 2015

In This Article

From Fatal to Treatable

In the past 20 years, researchers have proven that it is possible to turn fatal diseases into chronic, manageable conditions, or eradicate them entirely. It would be hard to find another field of medicine where there has been so much drama in the past two decades," says John Bartlett. "The dramatics of the field are just extraordinary. In other fields, you don't get rid of diseases."

HIV

In the past two decades, HIV treatment has changed dramatically, and the discoveries made during that time have opened new avenues for treatment.

"The experience of the past 20 years has been remarkable in medicine. We have gone from a disease that was inevitably fatal to one that is treatable with a single once-daily combination pill. HIV is almost always manageable if diagnosed early enough and treated effectively," says Dr William G. Powderly, director of the Institute for Public Health and past chair of the HIV Medicine Association. He adds, "We're lucky that HIV is a fairly simple virus."

Twenty years ago, patients with HIV infection had to take several pills every 4 to 6 hours—a total of 30 pills daily. "They needed a tremendous amount of adherence. Not taking drugs on a regular schedule allowed the virus to break through," Powderly remembers.

The 11th International Conference on AIDS in Vancouver in 1996 marked the year that everything changed in HIV treatment. Dr David Ho, from the Aaron Diamond AIDS Research Center in New York, New York, and Dr George Shaw, from the University of Alabama at Birmingham School of Medicine, presented viral dynamics data showing that a person with HIV produced 10 billion virus particles a day, making it clear that the disease required antiviral treatment.[11,12,13] This led to the emergence of highly active antiretroviral therapy and the release of two major HIV drugs: ritonavir and indinavir.

The research that changed AIDS treatment forever was a study led by Dr Roy M. Gulick, who also presented his findings at the Vancouver AIDS conference and later published in the New England Journal of Medicine.[14]

John Bartlett was in attendance at the conference and remembers the "aha" moment vividly. "It was a slam dunk. We went into the Vancouver meeting thinking that every AIDS patient was going to die, and came out knowing that they would survive—an incredible moment in medicine."

"The change was like night and day," William Powderly agrees. "We saw dramatic improvement right across the board. People who were expected to die gained weight and recovered. It was a remarkable time."

Bartlett says that HIV wasn't conquered by research alone, and points to the President's Emergency Plan for AIDS Relief (PEPFAR), announced by President Bush in the 2003 State of the Union address, as having helped tremendously in the global fight against HIV. As of September 2014, PEPFAR has been supporting life-saving antiretroviral treatment for 7.7 million men, women, and children living with HIV, and provided testing and counselling for more than 56.7 million people.[15] "It's made HIV manageable in parts of the world where it was so devastating. PEPFAR is a godsend to most of the world."

In the past 20 years, the outcomes for HIV have been extraordinary and unanticipated in the field, Bartlett believes. He notes, "We have been good at antibacterial treatment since Fleming, but never good with treating viral infections. This successful venture into viral infections was relatively new and obviously has been extraordinarily successful, thus opening the door to this new field."

Recognizing that HIV was a worldwide epidemic led to increased awareness campaigns, and relief funding to help other countries control AIDS. Today, 15 million people are receiving antiviral treatment for HIV daily.

"Now we just need to produce a vaccine," Powderly says, "and find a cure."

Bartlett says that success in the treatment of HIV set the stage and inspired researchers to find a cure for hepatitis C, another profoundly important viral infection that has become treatable in the past 20 years.

Hepatitis C Virus

An estimated 2.7 million people in the United States are chronic carriers of the hepatitis C virus, according to the CDC.[16] Worldwide, 130-150 million are infected.[17] Not everyone shows signs, but the disease profoundly affects the liver, causing inflammation and liver scarring, leading to cirrhosis.

Successful hepatitis C treatment is recent. "We passed the goal line about 3 years ago. Now everyone with hepatitis C can be cured," says Bartlett.

Today, hepatitis C infection can be treated with a once-a-day pill for 12 weeks, changing the outlook of this disease dramatically.[18] Still, the initially high costs have limited access to these drugs for some patients. A recent study revealed that nearly 1 in 4 patients is initially denied access to treatment.[19]

Bartlett says that hepatitis C deserves more attention. "The disease was initially associated with injection drug use—but many other populations are at risk as well." The rate of perinatal vertical transmission of hepatitis C is 5.8%.[20]

"It's a common disease," says Bartlett, which is why many pharmaceutical companies and researchers leapt at the chance to develop drugs for the disease. Hepatitis C drugs are now pouring onto the market.

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