threat to public health (Karon et al., 2001). Globally, the picture is starker. The Centers for Disease Control and Prevention (CDC) estimates that the number of people living with HIV/AIDS worldwide is 40 million, and that during 2001 the world’s death toll from AIDS reached 3 million (CDC, 2002a). Although the epidemic had slowed until recently in most of the developed world, the National Intelligence Council (2002) predicts that by 2010 the numbers of those infected with the virus could reach 75 million in Nigeria, Ethiopia, Russia, India, and China alone (NIC, 2002). In 2002, the United Nations Population Division lowered its estimate of the world’s population for 2050 by 400 million people, largely because of the effect of HIV/AIDS (United Nations, 2003).

If the epidemic has maintained a staggering pace, so too has the fight against it. Scientific discovery has resulted in a rapid gain in knowledge about the disease, dissemination of prevention and treatment information, and changes in expectation and outcomes. The first widely distributed reports of the disease occurred in 1981 and concerned homosexual men (CDC, 1981). Over the next two years, at-risk populations were further defined to include injection drug users, individuals with hemophilia and others who had received blood products, and Haitians; universal precautions for health care workers and other professionals whose work put them in contact with blood and other bodily fluids had been published; and the virus that caused the disease had been identified (CDC, 1982a,b,c,d,e, 1983; Barre-Sinoussi et al., 1983). Advances in knowledge and treatment options continued throughout the eighties and early nineties, and by 1996 combination antiretroviral therapy became (and remains) the standard of care for those infected with HIV. The impact of HAART was dramatic—the number of deaths from AIDS fell by 43 percent between 1995 and 1997 (Figure 2-1) (CDC, 2002a). In all, it took only 15 years from the first noted incidence of this new disease to the development of therapies that can be effective against it.

The rapid pace of the development of new technology to fight the disease continues. In January 2003 the Food and Drug Administration (FDA) announced the expansion of availability of a rapid HIV test, which returns results in a matter of minutes rather than days or weeks. The FDA approved the expansion in the hopes that combining administration and results of the test into one clinic visit would increase the numbers of people seeking the test and entering the care system if testing positive (FDA, 2003a). In March 2003, the first in a new class of drugs called fusion inhibitors was granted accelerated approval, expanding the options of those for whom other treatments have failed (FDA, 2003b).

This promising evolution of treatment does not, however, mean that the HIV epidemic is over or that it soon will be. The decrease in deaths brought about by new treatments, coupled with the steady number of new



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