What a gratifying five years it's been working in HIV care. Potent new generation anti-retroviral medicines reduced HIV related morbidity and mortality upwards of 75% in clinical settings where patients were lucky enough to have access to these drugs (1). Such success against deadly pathogens has only been observed with the likes of vaccines for diseases such as small pox, or newly curative drugs for diseases such as tuberculosis and malaria. Of course, new anti-retroviral drugs, even in combination, do not cure HIV, and we anxiously await proof that their spectacular positive effects are durable. Furthermore, troubling side effects have been reported, and treatmentrelated declines in HIV RNA to levels below conventional limits of detection occur only about 50% of the time in real-world clinical settings. Yet, for patients taking these medications, morbidity and mortality gains appear to be holding, and we have yet to see increases in deaths or hospitalizations to remind us of the bad old days.
Changes in drugs are not the whole story. About the same time as the new effective medications became licensed in the United States, HIV RNA polymerase chain reaction (HIV PCR or "viral load") technology became widely available to evaluate viral burden and monitor the effects of treatment. Like Yang to Yin, adding understanding of virology to understanding of immunology contributed immensely to better understanding the whole of HIV disease. Viral burden, as measured by HIV PCR, drives immune deterioration, as measured by CD4 T cell loss. In untreated patients, combined analysis of viral burden and immune deterioration are powerful tools for prognosis, as is likely the case for treated patients (2).
In the midst of all this good news is the bad. With the explosion of therapeutics and diagnostics comes a similar explosion in complexity and cost. Choosing clinical management options that maximize quality while minimizing cost requires considerable finesse, and even HIV specialists can disagree on the specifics of therapy. But several generalizations can be made: at a minimum, a potent combination of anti-HIV drugs, appropriate prophylactic drugs and immunizations, and HIV PCR testing with CD4 T-cell enumeration form the bedrock of quality-care for patients with HIV disease.
Several publications exist to help the physician keep abreast of rapid changes in standards of care. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV infected adults and adolescents. These welcome, evidence-based, recom-