When hospitalists and other physicians who regularly treat patients with human immunodeficiency virus (HIV) reflect on the infection’s initial days versus now, they are amazed at how far things have come. This year marks 30 years since 1995, the peak year for AIDS-related deaths in the U.S., when more than 50,000 deaths were reported.1
Dr. Rauch
“It’s really one of those unbelievable public health stories,” said Daniel Rauch, MD, FAAP, SFHM, professor of pediatrics with Hackensack Meridian School of Medicine, and director of the division of pediatric hospital medicine and the division of general academic pediatrics at Hackensack Meridian Children’s Health, both in Hackensack, New Jersey. Dr. Rauch worked with pediatric AIDS patients and mothers with HIV and AIDS in the early 1990s at Jacobi Medical Center in New York.
Although HIV still exists, affecting an estimated 1.2 million people in the U.S., it’s come a long way from a life-limiting disease to a chronic health issue that patients may manage just like they do diabetes or heart disease.1
Hospitalists and other in-hospital practitioners still play an important role in identifying HIV, beginning treatments if they have not been started yet, managing opportunistic infections for those with advanced AIDS, and linking patients to outpatient support and care coordination.
The Hospitalist spoke with several hospitalists, infectious disease specialists, and other physicians to find out how care for patients living with HIV has evolved—and how hospitalists can most effectively help. Here’s what we learned.
Pivotal Changes
Much of the change in HIV and how it affects patients is due to treatment revolutions. Many physicians note the introduction of azidothymidine, or AZT, for HIV/AIDS in 1987, but say the next round of treatments after AZT brought in the biggest change.
Dr. Davis
“I believe the most pivotal moment in HIV treatment was the development of highly active antiretroviral therapy, or combination therapy,” said Michael Davis, DO, MPH, an infectious disease physician at Parkview Health in Fort Wayne, Indiana. “The development of these therapies gave us a chance to fully control the virus, eliminate HIV as a death sentence, and turn it into a chronic disease.”
This type of therapy was introduced in the mid-1990s.
Combination therapy has decreased pill fatigue and allowed those with HIV to live longer, healthier lives with less hassle.2
Dr. Gandhi
Although combination therapy is effective, the initial combinations had many side effects and were hard for patients to take, said Monica Gandhi, MD, MPH, director of the UCSF-Bay Area Center for AIDS Research and professor of medicine and associate chief of UCSF’s division of HIV, infectious diseases, and global medicine. Dr. Gandhi is also the medical director of the Ward 86 HIV Clinic at San Francisco General Hospital in San Francisco. When side effects were hard to manage, physicians would encourage patients to use the therapy and then take a break, with the goal of lowering the viral load. This continued as a strategy until the mid-2000s, when a single-pill combination for HIV became available and when the Strategies for Management of Antiretroviral Therapy, or SMART, study showed that taking breaks in therapy was not good for long-term outcomes, Dr. Gandhi explains.3
The combination of using a few pills eventually led to single-tablet regimens, including Atripla and Genvoya, followed by single-tablet regimens with high barriers to resistance, such as Triumeq, Biktarvy, and Symtuza, Dr. Davis said.
Today’s common treatment regimens include antiretroviral therapy given by pill or injection. While these are effective at helping patients manage HIV, their cost can still be an issue and requires funding to maintain ongoing care via private or public health insurance and/or through the Ryan White HIV/AIDS Program, Dr. Davis said.
At Dr. Gandhi’s clinic, the main treatment goals are to start treatment the same day that HIV is diagnosed, try to use a single-pill combination for starting therapy (which can be changed later to the injectable combination), and ensure that patients become virologically suppressed, with no detectable level of virus in their blood.
Dr. Castro
“After the availability of medications that were effective and had lower rates of long-term side effects, the current focus is on convenience of administration while maintaining efficacy and minimal long-term side effects,” said Jose G. Castro, MD, FIDSA, clinical chief of the division of infectious diseases and program director for the Jackson Memorial Hospital/ University of Miami infectious diseases fellowship program in Miami. Future therapies aim for even more convenience for patients living with HIV.
Logistical Challenges, Stigma
Although HIV treatment has progressed tremendously, there are still challenges to managing it well.
Dr. Evans
One major challenge is reaching all patients who need care. For example, having the right medications is not important if someone can’t store them safely because they are unhoused, said Tyler Evans, MD, MS, MPH, who is CEO, chief medical officer, and co-founder of the Wellness Equity Alliance, which aims to address systemic inequities in health. Dr. Evans is also the author of “Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics from Plague to COVID-19” and has treated patients living with HIV around the globe. This is one reason he advocates bringing care directly to places like shelters, encampments, and schools versus waiting for people to come to clinics.
Building on Dr. Evans’ point, socioeconomics is often a factor in the care of those with HIV.
“Many patients who struggle with medication compliance and HIV control also may face issues with housing instability, poverty, mental health, or substance abuse,” Dr. Davis said. “The availability of wrap-around services such as social workers, case managers, therapists, and substance use disorder counselors can be essential to ensuring successful HIV control in patients.”
Dr. Bond
Getting patients to return for appointments in an outpatient setting can be a challenge because of everything else they manage in life, said Allison Bond, MD, MA, an assistant clinical professor in the department of medicine, divisions of infectious diseases and hospital medicine, and director of the department of medicine grand rounds at UCSF in San Francisco.
This is why many clinics focusing on HIV care have ways to connect patients with resources they need beyond just medical care. It also may be why HIV injections that are spaced apart by several weeks or months are often useful, Dr. Gandhi said.
“With everything else going on in life, patients will, if you call them, come in for their injection because they want to get that off their plate so they can concentrate on other issues. We use injectables in those with housing insecurity or other challenges, and it’s been successful,” she said.
Although living with HIV is less of a stigma than it once was, there still can be some resistance attached to that label, making treatment a challenge. Sometimes, the stigma comes from the patient’s own beliefs. Dr. Gandhi said she hears some patients say that they can take their blood pressure or cholesterol medications, but hesitate to accept that they need to take their HIV medications. Injectable treatments—which are given by healthcare practitioners and do not need daily pill-taking—can be useful to combat stigma.
Getting more patients who are at high risk to use preventive medications also can be a challenge, Dr. Castro said. He also encounters patients who live with HIV but don’t use treatment for it for a variety of reasons.
Health Complications
In addition to socioeconomic and logistical challenges, there are also health complications that patients living with HIV may sometimes face—especially when there is a late presentation of HIV infection.
Patients with end-stage AIDS are susceptible to a variety of “opportunistic infections” or infections which occur when the immune system is compromised, including fungal infections like cryptococcosis, pneumocystis pneumonia, and histoplasmosis; infections by viruses like cytomegalovirus and human herpes virus-8; parasitic infections like toxoplasmosis, accompanying infections such as viral hepatitis B and C, and other infections.
Dr. Evans often finds himself managing long-term comorbidities such as kidney disease, cancer, and metabolic issues. This is part of the reality of patients living longer but aging into chronic disease, often with fewer resources, he said.
Specialists say they also commonly see cardiovascular disease in patients living with HIV. “The mechanism for this increased risk is still not fully understood,” Dr. Davis said. “However, there is some speculation that there could be residual inflammation from the virus and immune activation that may contribute to the elevated risk.” There appears to be less of a risk among patients living with HIV who also use a statin, he said.
Obesity is another common comorbidity, as several of the newer antiretrovirals can have weight gain as a side effect. Some patients are able to maintain a healthy weight with lifestyle changes, while others struggle.
“With the widespread use of GLP-1 agonists, many HIV providers have been exploring the weight loss drug space and are starting some of their patients on GLP-1s,” Dr. Davis said.
The Role of Hospitalists in HIV Management
Hospitalists are in a particularly prime spot to help patients with HIV—be it newly diagnosed or not—to manage their health.
“Hospitalists have a lot of ability to change people’s lives, even if [people living with HIV] are leaving the hospital. And hospitalists can always call infectious disease if they need anything,” Dr. Gandhi said.
Here are just some of the ways that hospitalists can help:
- Help patients feel comfortable. A caring, affirming approach and tone with a patient may help them start to advocate for their own care, versus speaking with them in a dismissive or stigmatizing tone, Dr. Evans said.
- Be careful with the language that you use. Dr. Davis recommends trying to use inclusive language and understanding a patient’s gender identity or pronouns when addressing them. For example, “living with HIV” is preferable to “HIV patient.” He also said that new terminology has basically eliminated the use of the term AIDS, as that still has significant stigma. “For those patients that have low CD4 counts, we have transitioned to using the term ‘advanced HIV’ instead,” Dr. Davis said.
- Screen more patients. About 13% of patients who have HIV don’t know it, according to the U.S. Department of Health and Human Services.1 More screening can help more people start treatment if needed. “Normalizing HIV testing will help to decrease the stigma of the infection,” Dr. Castro said. Policies about HIV testing may vary by facility. Other health facilities may choose to screen only patients who are at a higher risk for HIV but are at the hospital for any reason. “Hospitalists should think about being aggressive with testing. Got a broken ankle? Get an HIV test. We’ve picked up so much by establishing that,” Dr. Gandhi said. This includes finding people with HIV who may consider themselves low risk, such as post-menopausal women. The U.S. Preventive Services Task Force recommends HIV screening for everyone between the ages of 15 and 65 years old.
- If someone is newly diagnosed, start HIV medications in the hospital. This is also applicable if someone has a prior HIV diagnosis, but they aren’t virally suppressed, Dr. Bond said. “Work to start that medication in the hospital and facilitate outpatient follow-up to the best of your ability,” she said. “This cross-section of the population also tends to have a lack of engagement in care. This might be the time that they are a captive audience, and we can really help move their care forward.”
- Connect them with outpatient providers for coordination of care. Of course, you also can connect them with an HIV team if you have one at your hospital, Dr. Bond said. “I think for every patient with HIV who is not yet in care here, we try to have a warm handoff between the patient’s inpatient team and the outpatient infectious disease physician and the social worker,” she said.
- Work with younger patients on medication adherence. Although medications are more tolerable nowadays, adherence can still be hard for younger patients, Dr. Rauch said. “Teenagers are still teenagers. Work with them and try to get them to be responsible because it’s a chronic disease at this point and not an imminent death sentence. They really can look forward to participating in life, going to college, and having a family,” he said.
Policies and Prevention
Going forward, in addition to continuous improvement of treatments, there’s more that can be done related to policies and prevention, according to physicians.
The number of new HIV infections decreased by 12% from 2018 to 2022, from 36,300 to 31,800, respectively.1 This decrease likely occurred due to a jump in pre-exposure prophylaxis, or PrEP, prescriptions, viral suppression, and more HIV testing, according to the Department of Health and Human Services. Still, “it’s not gone, so we need to keep the messaging about safe sex and keep the diagnostic question in our mind,” Dr. Rauch said.
That includes making patients aware of pre-exposure prophylaxis. Plus, the “U=U” campaign, which stands for undetectable equals untransmittable, is particularly helpful, physicians say.
“As the message implies, if your HIV viral load is undetectable in blood, then the transmission risks are negligible,” Dr. Davis said. Viral load levels less than 200 copies essentially prevent risk for transmission to others.4“Knowing that you can still live around friends and families or even be in an intimate relationship with your partner without being afraid of transmission is a huge burden taken off the shoulders of those living with HIV.”
Continued education for the public and community outreach, especially in underserved areas, remains important. This includes sexual education to help prevent sexually transmitted diseases and taking patients’ comprehensive sexual history to help educate on preventive strategies, Dr. Castro said. In addition to hospitalists, emergency department, urgent care, and primary care practitioners all have a role to play in prevention messages.
Maintaining federal funding through the Ryan White HIV/AIDS Program and helping to provide affordable health insurance for underserved populations remains crucial, Dr. Davis said. “Without access to medications, HIV incidence will likely increase due to the inability to afford medications that keep viremia controlled and therefore prevent transmission,” he said.
As part of comprehensive care for patients, increased funding for comprehensive mental health and substance use care is also important, Dr. Davis said.
“Policies should be enacted that will facilitate strategies to prevent ‘leaks’ where people drop out of care, enabling targeted interventions to improve engagement and outcomes like maintaining an undetectable viral load, which prevents transmission,” Dr. Castro said
Vanessa Caceres is a medical writer in Bradenton, Fla
References
1. U.S. Department of Health and Human Services. Fast facts. HIV.gov website. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics. Updated September 18. 2025. Accessed October 29, 2025.
2. AIDS.org. The Future of HIV Treatment: Long-Acting Injections and Beyond. AIDs.org blog post. https://aids.org/the-future-of-hiv-treatment-long-acting-injections-and-beyond/. Accessed October 29, 2025
3. Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355(22):2283- 96. doi: 10.1056/NEJMoa062360.
4. U.S. Department of Health and Human Services. Viral suppression and an undetectable viral load. HIV.gov website. https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/viral-suppression. Updated October 24, 2025. Accessed October 29, 2025
