35 years after the discovery of HIV

Dr. Rita Rojas, infectologist. Infectology Service Coordinator of the Internal Medicine Unit of the General Hospital of the Plaza de la Salud.
A little history. A strange condition created concern in the 80s 

The joint United Nations program on HIV / AIDS (UNAIDS) has chosen, to commemorate International HIV / AIDS Day (December 1), the slogan “Communities make a difference”, evoking the role we all have in Fight the disease.

A strange condition created concern in the early 1980s in New York City, San Francisco and Los Angeles, in four groups of people: homosexuals, hemophiliacs, heroin addicts, and those who had arrived from Haiti to the United States. . They were called “the 4H Club”.

They described an unusual increase in cases of Kaposi sarcoma and pneumonia due to Pneumocystis carinii. Years later, HIV was identified as the cause and these vulnerable groups were stigmatized

Things have changed a lot since more than 19 years ago that I started my training in Internal Medicine and Infectology. I have treated many affected people and I know that you can live with HIV.

I know people who have been diagnosed for more than 20 years, who have not always had many financial resources, who along with their HIV status have suffered various diseases such as tuberculosis, lymphoma, toxoplasmosis, among others and have overcome them even in cases where They have received chemotherapy. I am witnessing the good news when it comes to life expectancy: at the end of the 80s a person of 20 years with a diagnosis of HIV / AIDS at an advanced stage had a life expectancy of 1 or 2 years, While at present, the expectation is almost that of a person without the condition, thanks to antiretroviral therapy.

Medications have evolved in numbers, amounts of combinations, classes, method of administration ...

At the beginning, Zidovudine (AZT) was supplied, which was the first approved drug; then two combinations were made, after three (Trizivir), therapy was interrupted ("holiday therapy"), then four and finally we have several years supplying combinations of three. The combination of three in one pill was popularized by Magic Johnson, a well-known member of the Basketball Hall of Fame who reported in 1991 that he was suffering from HIV, and is still a rights activist for those who suffer from the same condition.

It has evolved from regimes of 6 to 20 pills, to the “simplified regimen in a tablet”, in which a combination of three types of medicines in a single pill is supplied. The supply of ARVs went from needing refrigeration or food restrictions to having none and being free.

Globally, strategies such as 90-90-90 are developed where 90% of people living with HIV / AIDS are known to know their diagnosis, 90% are receiving ARV medications and 90% are suppressed with viral loads.

Unfortunately, according to Onusida, in 2018 only 79% of the world's population knew their condition and among people who knew their status, only 78% had access to treatment. In the Caribbean, only 55% are taking medication, and of those, only 53% are virally suppressed.

Sexual pre-exposure prophylaxis strategy

It consists of administering antiretroviral drugs (Tenofovir / Entricitabine, trade name Truvada) prior to a sexual relationship in high-risk people (sex workers, men who have sex with other men, transgender, serodiscordant couples (one is positive for HIV and the couple no).

PrEP provides a high level of protection against HIV but does not protect against other sexually transmitted infections (syphilis, HPV, gonorrhea ...) and should be used in combination with the use of condoms.

Another recommendation refers to the practice of circumcision, which has proven to be a protective factor for different STIs, especially HIV, and is therefore highly recommended.

There are two types of prescription, which are "on demand", which is recommended when the person has casual sex, but scheduled (between 2 to 24 hours prior to the relationship, the day of the sexual act and the next day); or "fixed", which consists of receiving treatment every day.

Tenofovir / Entricitabine have been used as ARV therapy with other medications for several years, but in the long term the use of these medications can affect the kidney and bone.

PrEP must be supervised by a doctor who accompanies people with HIV, because prior to the beginning it is necessary to verify that the person is not already affected or that he / she has other STIs or other infections such as hepatitis type B or C.

Despite the fact that in both strategies, pre-sexual prophylaxis (PrEP) or post-sexual or occupational post-exposure ARV medications are used, they are not administered in the same way or for the same time.

Post exposure prophylaxis to the virus can be due to an accident at work, rape, or unprotected sex, and the treatment is offered for 30 days with combinations of three medications, taking into account the type of accident, the inoculum, the patient's serological status with whom it happened, if known. In contrast, PrEP only uses combinations of two medications.

Not all countries carry the PrEP strategy in their programs. The Dominican Republic does, so it is important that an infectologist can offer information on where to get, either publicly or privately, medications.

In addition, periodic review is required to rule out an acute HIV infection, because the treatment strategy would change immediately.

HIV / AIDS in the world and in the Dominican Republic

According to Onusida figures there are around 37.9 million people affected in the world, of which 14.6 million are not yet receiving ARV. Each week, about 6200 young women between 15 and 24 years of age get HIV infection.

From 2005 to 2018, AIDS-related deaths have decreased by 55% due to antiretroviral treatment, which tries to be universal.

1200 people died in 2018 due to AIDS in the country. The prevalence in DR is 0.9% of the population and is equivalent to 70,000 people affected.

In the Dominican Republic we have 76 units for the care of people living with HIV / AIDS distributed throughout the country and laboratory tests are undertaken by the State so that everyone has access to care.
It is required that the Dominican people, patients and health care providers understand that "the community makes a difference" and that it is everyone's business if we want to eradicate the disease by 2030.

To this end, we should encourage the use of condoms, PrEPs in vulnerable communities and indicate more HIV tests in order to diagnose earlier to reduce transmission in our country.


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