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The verdict for him too was death, not the inevitable death that horrified and yet was tolerable because science was helpless before it, but the death which was inevitable because the man was a little wheel in the great machine of a complex civilisation.

W Somerset Maugham (1874–1965), Of Human Bondage

HIV: a modern masquerade

HIV, the cause of the well-known AIDS, can rightly be included as one of the clinical masquerades of modern medicine. Public health measures in the Western world have limited the spread of the infection. By contrast, the incidence in Africa and Asia continues to rise at an alarming rate. The World Health Organization estimated that in 2010,1 34 million adults and children were living with HIV, including 23 million in sub-Saharan Africa and 25 000 in Australia, with 2.7 million newly infected and increasing, while 1.8 million people with HIV died. In 2012, the average age of people newly diagnosed with HIV infection was 37 years and about 86% were male; most infections are in men who have sex with men (MSM). The conversion rate of HIV to AIDS has been 33% but it is improving with antiretroviral therapy (ART), which has dramatically changed people's lives. HIV is now a chronic disease management problem. The introduction of combination treatment with the protease inhibitors in November 1995 changed the previously understood natural history of the disease.

The benefit of early diagnosis has become even more impressive since the discovery that HIV is not a latent infection throughout most of its course. Soon after initial infection, an explosive replication of HIV occurs, which is brought under control by the immune system in 6 to 8 weeks as the host-versus-virus interaction reaches an active and dynamic equilibrium. This dynamic situation continues throughout a person's lifetime, with as many as 10 billion new viroids produced and up to 2 billion CD4 lymphocytes destroyed and replaced daily. Clinical immunodeficiency develops when the body's ability to replace CD4 cells is finally exhausted, resulting in further uncontrolled viral replication. Viral load assays based on molecular techniques have revolutionised our understanding of the natural history of HIV disease. These advances make it imperative to make the diagnosis early in the course of the disease in order to start combination treatment to lessen the viral load.

The management of HIV infection is a specialised field but the GP is central in prevention, diagnosis, counselling, monitoring and shared management of HIV disease. The GP must be alert to the benefits of early diagnosis as summarised in Table 27.1.

Table 27.1

The benefits of early HIV diagnosis

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