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, 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 disease, particularly in Australia where the incidence of new cases has remained relatively constant in the past 10 years. By contrast the incidence in Africa and Asia continues to rise at an alarming rate. The introduction of combination treatment with the protease inhibitors in November 1995 has changed the previously understood natural history of the disease and has given rise to renewed hope that HIV will become a chronic manageable 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 virions 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. It has taken over a decade to get this understanding of the dynamics of HIV infection. 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 general practitioner is central in prevention, diagnosis, counselling, monitoring and management of HIV disease. The GP must be alert to the benefits of early diagnosis as summarised in Table 24.1
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