The treatment of HIV disease has always been a roller-coaster ride. Clearly, the direction since the release of protease inhibitors has been upward. But I have a sense that we're heading downhill fast. HAART is failing more and more people, and it's folly to think that the return of the virus in the blood will not ultimately cause sickness and death.

I first noticed this trend last spring, when two clinic staff members asked for grief counseling. I started looking at the numbers of deaths of patients here (all treated for several years), and saw that they had gone up significantly. The strange thing is, I'm not sure why these patients are dying. Often, they just go into wasting for unknown reasons. And many deaths now are caused by liver failure. From Hepatitis C? Drug toxicity? HIV itself? We don't know. In retrospect, it was unrealistic to believe that the vast majority of patients on HAART would maintain undetectable viral loads forever, amen. Today, when starting a patient on HAART, clinicians should have a game plan for what happens when this first regimen fails. If we aren't preparing our patients for failure, we're doing them a disservice.

I'm critical of AIDS researchers (myself included) for implying we knew the answers after just a few years of using these drugs. All of us need to be humble in the face of our vast ignorance. We must commit to respect—and aggressively address—the unknown.