Pathogenesis of HIV disease: opportunities for new prevention interventions

Current efforts to prevent human immunodeficiency virus (HIV) disease, which largely focus on altering human behavior, have had some notable successes yet have failed to halt the spread of the acquired immunodeficiency syndrome pandemic. A greater understanding of the pathogenesis of HIV disease is providing us with the scientific rationale for additional approaches to prevention. Some of the approaches discussed in this article are available now. For example, we have the means to screen for and treat other sexually transmitted diseases that increase vulnerability to HIV, adult male circumcision is readily available in most properly equipped hospitals, and antiretroviral agents that decrease the viral load help prevent transmission from pregnant women to their infants. Other approaches discussed are under investigation. For instance, numerous topical microbicides are in various stages of development, incremental progress is being made toward creation of an HIV vaccine designed to prevent HIV transmission or slow the course of disease in people who become infected, and studies are under way to evaluate the risks and benefits of prophylactic antiretroviral therapy in individuals at high risk for HIV disease.