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Commentary: HIV Infection: Are We Doing Our Homework?
Comentario: Infección por el VIH: ¿hacemos los deberes?
V. Thomas Muleta
a Centro de Salud Camp Redó, Server de Salut de les Illes Balears, Grupo Infección VIH/Sida de la semFYC, Illes Balears, Spain
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    "textoCompleto" => "<p class="elsevierStylePara">In Spain and throughout the world&#44; the human immunodeficiency virus &#40;HIV&#41; and AIDS epidemic constitute a serious public health problem&#46; The epidemic&#44; now in its third decade&#44; can be divided into three different stages&#46; During the 1980s HIV spread rapidly&#46; In Spain the main route of transmission was through intravenous drug use&#46; Heterosexual mother-to-child transmission also occurred&#44; whereas homosexual transmission between gay men was less notable&#46; During this period mortality from AIDS became the leading cause of potential years of life lost&#46; In the early 1990s prevention programs became more active&#44; especially those aimed at the groups most vulnerable to HIV infection&#46; Seroprevalence began to decline among intravenous drug users &#40;IVDU&#41;&#44; homosexual persons and female sex workers&#46; Mid-way through the 1990s&#44; with nearly 7000 cases of AIDS diagnosed and more than 5000 deaths annually&#44; highly active antiretroviral treatment with protease inhibitors was introduced&#44; and the incidence of AIDS and its mortality both decreased markedly&#46;</p><p class="elsevierStylePara">Current estimates place the number of persons with HIV infection between 110 000 and 150 000&#44; nearly one fourth of whom are unaware that they are infected&#46; We can surmise that between 50&#37; and 60&#37; have contracted the disease through injection drug use&#44; and 20&#37; to 30&#37; through risk behaviors for heterosexual transmission&#46; Risk behaviors for homosexual transmission account for 15&#37; to 25&#37; of all current infections&#46;</p><p class="elsevierStylePara">Current epidemiological data for HIV infection and AIDS<span class="elsevierStyleSup">1</span> indicate that the epidemic is waning&#44; the number of new cases of HIV infection having decreased by almost 60&#37; since the start of the 1990s&#46; However&#44; the rate of decrease in the incidence of new cases of AIDS diagnosed in Spain has leveled off&#46;</p><p class="elsevierStylePara">Among IVDU&#44; seroprevalence and the number of new HIV infections have decreased&#46; In contrast&#44; sexual transmission has become more frequent&#44; especially among heterosexual persons and in women&#46; &#40;Seroprevalence among homosexual persons has decreased&#46;&#41; Sex partners of persons with HIV infection&#44; especially partners of IVDU&#44; have shown the most worrying trends&#46; Among female sex workers seroprevalence remains below 2&#37;&#46;</p><p class="elsevierStylePara">Progression from HIV infection to AIDS is declining&#44; but the interval between infection and diagnosis of HIV infection&#44; when the virus can be transmitted to other persons and the carrier cannot benefit from antiretroviral treatment&#44; needs to be drastically shortened&#46; This would affect the incidence of AIDS and mortality from the epidemic&#46; Efforts are also needed to improve the course of the epidemic in homosexual persons and partners of persons with HIV infection&#46;</p><p class="elsevierStylePara">Further important challenges are to foment adherence to treatment&#44; and to avoid the appearance of resistance to antiretroviral drugs and adverse events that make withdrawal of treatment necessary&#46;</p><p class="elsevierStylePara">The 2001-2005 Multisectorial Plan for HIV infection and AIDS in Spain<span class="elsevierStyleSup">2</span> has set clear goals and defined specific indicators for prevention&#44; which is envisioned as part of the wider system of health care in order to enhance coordination between prevention and care&#46; The general population includes persons who are at low risk for HIV infection and who seek care frequently for other reasons unrelated with HIV&#44; e&#46;g&#46;&#44; for primary care or gynecological consultations&#46; Opportunities for new infections arise among persons in frequent or close contact with those who are HIV infected&#44; persons who engage in risk behaviors&#44; persons who are in habitual or occasional contact with centers that provide care for drug addicts&#44; persons with sexually transmitted diseases&#44; persons with sporadic sexual contacts&#44; and female sex workers&#46; The multisectorial plan therefore also foresees the use of preventive measures in centers for sexually transmitted diseases&#44; and recommends sentinel surveillance for HIV infection to monitor the disease in selected populations that are targets for preventive interventions &#40;IVDU&#44; female sex workers&#44; etc&#41;&#46;</p><p class="elsevierStylePara">It is within this context that we should consider the study by the EPI-VIH Group&#44; a research group with solid experience in HIV epidemiology&#46;<span class="elsevierStyleSup">3</span> We should perhaps note that persons who use alternative centers that provide anonymous&#44; voluntary HIV testing form a group whose risk profile differs from that of users ot other types of health care center&#46;</p><p class="elsevierStylePara">The number of diagnoses of HIV infection decreased from 1058 in 1992-1993 to 304 in 2000-2001&#44; and this trend was seen for all exposure categories except female sex workers&#46; The decrease was greatest among IVDU&#46; Similarly&#44; the prevalence of HIV infection decreased from 14&#37; to 2&#37;&#44; a trend seen for all types of transmission&#46;</p><p class="elsevierStylePara">The decrease in IVDU may reflect a shift to other routes of administration and the results of risk-reduction programs offering needle exchange and methadone maintenance&#46; These factors also contribute to the decrease in the number of new diagnoses of HIV infection&#46;</p><p class="elsevierStylePara">Men who engage in homosexual or bisexual relations represent a much larger group of users at alternative centers than at other centers&#46; The number of these users has remained more or less unchanged&#44; and the prevalence of HIV infection in this group has decreased&#44; particularly during the early years of the epidemic&#46; The slowed rate of decrease in recent years&#44; however&#44; seems to indicate that some risk behaviors remain common in this group&#46;</p><p class="elsevierStylePara">Among female sex workers the demand for counseling and HIV testing has increased&#44; along with the prevalence<br></br> of HIV infection&#46;</p><p class="elsevierStylePara">Although high-risk sexual practices are the most frequent reason for requesting HIV testing&#44; the prevalence of HIV infection in this group of users has decreased&#44; while the sex ratio in these users has approached one&#46;</p><p class="elsevierStylePara">What measures should be considered for the future&#63; For the present it appears that we are not diagnosing HIV infection in a timely manner&#58; one third of the persons who develop AIDS did not know they were HIV infected&#46;<span class="elsevierStyleSup">4</span> These are important deficiencies in the early diagnosis of HIV infection&#44; and are particularly worrisome for individuals who do not clearly consider themselves as persons who engage in risk behaviors&#46; Improvements in prevention and the effectiveness of antiretroviral treatment will depend on whether such deficiencies are corrected&#46;</p><p class="elsevierStylePara">Sources of information also await consolidation and improvement&#46; For example&#44; greater coordination should be sought with epidemiological surveillance services that record new HIV infections &#40;as in the regions of Asturias&#44; Navarra&#44; La Rioja and the Balearic Islands&#41;<span class="elsevierStyleSup">5</span>&#46; These services make it possible to obtain information on the characteristics of persons with HIV infection in a timely manner&#46; Such information is fundamental for planning preventive interventions and controlling HIV&#44; and in responding to the health and social needs of persons who are currently infected&#46; Progress is also needed in monitoring HIV infection in specific populations for which preventive activities are targeted &#40;e&#46;g&#46;&#44; IVDU&#44; homosexual persons&#44; male and female sex workers&#41;&#46;</p><p class="elsevierStylePara">Primary care services should play a larger role and be more closely involved in health promotion&#44; especially in efforts aimed at patients who are not infected and have no known risk factors&#46; A greater role for primary care in prevention is also desirable because the continuity and frequency of clinical contacts with large numbers of persons in the community offer a superb opportunity to disseminate information about prevention and to reinforce health-promoting behaviors&#46;</p><p class="elsevierStylePara">Prevention is not an easy task&#44; as there is no explicit demand for preventive interventions&#46; For IVDU&#44; such measures comprise strategies to reduce risk&#46; To prevent mother-to-child-transmission&#44; HIV testing for sexually active women is advisable&#46; Occupational prevention requires efforts to reduce needlestick injuries&#46; Once the general population becomes more knowledgeable about HIV infection&#44; these practices will become long-term health- promoting habits&#46;</p><p class="elsevierStylePara">To make further progress in our knowledge about and control of the HIV epidemic&#44; we must make prevention our main goal&#44; place prevention within the sphere of health care&#44; and integrate preventive and health care measures more fully&#46; Primary care should play a more active role in these efforts<span class="elsevierStyleSup">6</span>&#46;</p><p class="elsevierStylePara">Key Points</p><p class="elsevierStylePara">&#42; Although the epidemic is remitting&#44; HIV infection and AIDS still constitute a serious public health problem&#46;</p><p class="elsevierStylePara">&#42; A substantial number of persons who develop AIDS are unaware that they are HIV infected&#46;</p><p class="elsevierStylePara">&#42; Alternative centers fulfill the needs of specific groups within the general population&#46;</p><p class="elsevierStylePara"> &#42; Primary care has a fundamental role to play in the early diagnosis of HIV infection&#46;</p>"
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