Dear reader.

The leading cause of death among people with HIV in the US is liver failure. When did this happen? Well, it's been this way for a few years now. Sometime just after opportunistic infection rates plummeted with the widespread use of potent antiretroviral therapy (1996-1997) and just before federal funding for HIV/AIDS began to wither (circa 2002), the AIDS community began to feel a sense of uneasiness. Treatment did not work for everyone; people fell through the cracks. Death rates may have fallen, but that did not mean an end to losing friends or colleagues. The funerals and memorials still happen, only less frequently for most of us. Liver failure, cardiovascular events, cancers, and other maladies show us that even avoiding "full-blown AIDS" does not necessarily guarantee escape from other perils, some of which are related to or even exacerbated by having HIV disease.

But what's causing liver disease to be the leading cause of death in people with HIV in the US and other developed nations? The answer is hepatitis co-infection, and mainly co-infection with hepatitis C. This blood-borne disease has only been widely recognized within the last 10 to 15 years, and the worldwide epidemic is staggering. The global estimate of almost 200 million hepatitis C infections far outnumbers the estimated cases of AIDS worldwide. But while AIDS untreated can progress fairly rapidly, especially in resource-poor areas where nutrition deficiencies and endemic diseases alone can shorten lifespan, hepatitis C may not cause fulminant disease and death until years after infection--in some cases as many as 20 years or longer.

As presented in this issue of RITA!, much has been learned about the hepatitis C virus (HCV) and treatments have even been developed that can clear the infection in some individuals. Yes, remission--some even call it a cure--is possible with HCV, but HIV co-infection complicates matters and reduces an already less than ideal success rate. In addition, there are significant obstacles to HCV treatment access given the expense of treatment, and the current therapies carry with them substantial side effects and toxicities.

But perhaps most disturbing of all is what the hepatitis C epidemic in the US tells us about our society. Hepatitis C, like HIV/AIDS, carries with it a stigma and thrives in populations that are mostly unwanted, marginalized, or ignored by society at large. Homeless people, injection drug users, sexual minorities (including people with many sex partners), and yes, racial minorities, all have greater prevalence rates of HCV infection. In the journal Clinical Infectious Diseases (36, pp. 368-69, 9003), Camilla S. Graham wrote, "HCV antibody status may be serving as a marker for poorer access to care and competing problems with addiction that lead to delays in care or failure to implement the standard of care.... If we are to improve the health status of patients with HIV/HCV co-infection, perhaps we should focus on these issues as well as the presence of the 2 viruses."

As US government domestic funding for HIV/AIDS dwindles in the face of a steady epidemic (with its highest rates now in minority and underserved populations), I cannot help but wonder--is our society, in particular our political leadership, more at ease with denying basic care and support to people with HIV/AIDS who have less power and status than 10 or 20 years ago? Perhaps the same may be true for hepatitis C. Unabated rates of co-infection with both viruses may very well represent where our society has failed us.

Very truly yours, The Center for AIDS: Hope & Remembrance Project

Thomas Gegeny, MS, ELS Senior Editor