The Centers for Disease Control and Prevention (CDC) reported at the 17th International AIDS Conference in Mexico City this past summer that the total number of Americans affected yearly by AIDS is about 56,000, some 40 percent more than previous estimates had warranted.

It is a difficult task to judge history when history is still being made. What can we make of AIDS 27 years after it was first classified as a specific disease? Is it a one-time terror that countries and organizations around the world are continually reigning in? Or a brutal epidemic that has revealed but a mote of its fury?

When a single cause is attributed to the deaths of 2 million people in a given year it is hard to discount the severity of such a disease. That was the estimate released by UNAIDS,a multi-party initiative of the United Nations,in a report in late July. But the same report shows that worldwide prevalence and deaths are in decline. From 2001 to 2007, new HIV infections declined from 3 million to 2.7 million. While much of the decline has been seen in Africa,the overall numbers do not dictate with authority that the disease is under control. The UNAIDS report listed eight countries in which new infections are on the rise, including China, Indonesia, Kenya, Mozambique, Papua New Guinea, the Russian Federation, Ukraine and Vietnam.

It turns out, in addition, that in the United States the prevalence of HIV, the virus that causes AIDS,has been miscalculated for some time. The Centers for Disease Control and Prevention (CDC) reported at the 17th International AIDS Conference in Mexico City this past summer that the total number of Americans affected yearly by AIDS is about 56,000,some 40 percent more than previous estimates had warranted.

As understanding of pathology and effective medicines improve,more and more people are living with the disease — some 33 million world- wide.In the United States,the mortality rate of AIDS has declined.In 1995,according to research,AIDS was the number-one cause of death for those between the ages of 25 and 44.Today it is the fifth leading cause of death in the same population.As all of these numbers indicate, disease management has taken — and should continue to do so — a prominent position in the treatment and delivery of care.

A Paradigm Shift

Disease management of persons with HIV/AIDS is a challenging and potentially rewarding enterprise.Effective disease management improves clinical outcomes, connects clients to the community,provides access to expert medical management, decreases transmission of HIV through maximum viral suppression by medication management,and ultimately saves lives.

In 1995 there was a paradigm shift in the approach,treatment and long-term management of HIV/AIDS.The first protease inhibitors were introduced,and they transformed the treatment modalities and level of care from the acute care treatment of HIV-associated opportunist infections and cancers to chronic outpatient management with durable viral suppression.The therapies have been so successful for those individuals who are adherent to their HAART (highly active antiretroviral therapy) that death rates have drastically reduced from the peak in 1995 of 10.3 per 100 persons with HIV to less than two per 100 persons with HIV in 2006,according to a study published in the Journal of Acquired Immune Deficiency Syndrome. The treatment revolution has led to evolving the care continuum for persons with HIV/AIDS from the palliative healthcare delivery to the approach which has embraced the chronic care model for management of persons with HIV.

Although there has been a true revolution in treatment,the number of persons infected with HIV in the United States continues to grow.The latest estimate of national HIV prevalence from the CDC at the end of 2003 was roughly 1 to 1.1 million.More ominous yet,the CDC estimates that approximately 24 to 27 percent of the 1 million are unaware of their HIV infection. The revised figures presented by the CDC ironically highlight this understated sense of awareness.

In this country the combination of decreasing death rates and increasing infection rates will increase the need for a disease management approach to managing persons with HIV to ensure that all persons infected with HIV have access to healthcare systems with expertise in managing the disease. This will be necessary because the factors that impact effective long- term management of the HIV epidemic continue to grow — for example,complicated drug regimens,significant drug-to-drug interactions, shifting demographics of the population affected (i.e.,increasing cases of minorities and women),access to care by HIV-experienced medical providers,social stigma,and cultural barriers.

Effective antiretroviral medication therapies have made HIV/AIDS a chronic disease,however,HIV/AIDS remains unlike any of the usual chronic diseases — such as diabetes,congestive heart failure and asthma — normally associated with disease management.Because it is a communicable disease that is transmitted through sexual or blood-borne exposure,HIV is a major and dangerous public health concern.

Implementing a disease management program to specifically address HIV not only improves adherence to therapy and clinical outcomes but also addresses the following situations and scenarios that can emerge (see chart below).