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Prognosis
It is usual to wonder when you learn that you have a serious illness how long you will remain in good health, or how your health may fare in the future. The word used to forecast the probable course of a disease is prognosis, and comes from an ancient Greek word meaning ‘to know beforehand’.
The prognosis for people with HIV has changed dramatically since the first cases of AIDS were diagnosed in the early 1980s. In the early days of AIDS it was thought that most people would die within a few months of first being diagnosed with the condition. This improved, partly because it was recognised that HIV was the cause of AIDS and took many years to gradually destroy the immune system, and because doctors gradually learnt more about recognising and treating infections and cancers commonly seen in people with HIV. By the mid 1990s (before the introduction of HAART), it was thought that in rich countries such as the UK it would take between eight and fifteen years (on average) after infection with the virus for HIV to cause life-threatening illness or death.
Many HIV doctors now believe that provided a person with HIV receives effective anti-HIV treatment before the immune system has severely damaged by the virus; and that a person takes their drugs properly and are able to tolerate them, then they could live a more or less normal life span.
How is prognosis predicted in HIV?
Key tests used to assess prognosis are CD4 T-cell counts, which given an indication of the health of the immune system, and viral load tests which look at the amount of HIV in the blood. As the CD4 count falls and the viral load rises, the risk of becoming ill or dying as a consequence of HIV becomes higher over the short-term.
In discussing HIV prognosis, doctors often refer to research involving the Multicenter AIDS Cohort Study (MACS). This established the relationship between viral load, CD4 count and risk of developing AIDS or dying within the next three years. This information is often used to help decisions about when to start HIV treatment. (See NAM Booklet: Viral load & CD4).
HIV treatment and prognosis
The use of Highly Active Antiretroviral Therapy (HAART; drugs which slow down the rate at which HIV is able to reproduce) from the mid-1990s onwards, has led to dramatic improvements in the prognosis of people with HIV. For instance, AIDS deaths in the UK have fallen from a peak of over 1,500 in 1994 to approximately 400 a year at the moment. The AIDS deaths which still occur in this country commonly affect people who are diagnosed with HIV late in the disease process, when their immune system is already quite damaged.
Research into the prognosis of people starting HAART indicates that the risk of becoming very ill or dying because of HIV within the next three years is linked to five key factors: having a CD4 count below 200 or a viral load above 100,000 at the time of starting treatment; being aged over 50; being an injecting drug user; or having had a prior AIDS-defining illness.
In the UK it is recommended that anti-HIV treatment is started before your CD4 count falls below 200, an indication that HIV has damaged your immune system to such an extent that you are vulnerable to serious illness. It is also strongly recommended that you start anti-HIV drugs if you become ill because of HIV. Starting treatment in these circumstances has been shown to improve prognosis compared to delaying treatment until later.
Other factors to consider
Some non-AIDS-related illnesses are seen relatively frequently in people with HIV, despite the effectiveness of HAART. These include liver disease caused by hepatitis viruses B or C in people who are infected with these viruses; certain cancers, such as lung cancer, testicular cancer and anal cancer (although they are still rare); and mental illnesses such as depression. In addition, HIV treatments themselves can cause long-term side-effects which can seriously effect health or quality of life. Many studies (but not all) have now shown that people taking HAART have an increased risk of heart disease.
Obviously, there are many other causes of ill health apart from HIV, and so more general health advice (such as stopping smoking, taking regular exercise, eating a balanced diet) is also relevant to people with HIV.
Access to medical care
The prognosis for people with little or no access to specialist HIV services or health care is much less optimistic, with HIV usually causing illness and death within five to ten years. However, even where HIV drugs are not available, the use of treatments for infections such as TB can considerably improve prognosis.
Even in wealthy countries, it remains important that people with HIV receive care from doctors experienced in managing HIV infection, as this has been shown to improve prognosis.