The human immunodeficiency virus (HIV) epidemic in the United States has entered its third decade, and with the passage of time, new challenges have arisen for the medical community. Whereas the first decade of the epidemic was marked by careful study of viral biology and the opportunistic infections that complicate advanced HIV infection, the second decade offered an explosion of antiretroviral treatment options and new hope for long-term control of the virus. But this new optimism is tempered by the ongoing recognition that many HIV-infected patients still present late in the illness, often with serious opportunistic infections or late complications of disease that are only partially reversible (e.g., peripheral neuropathy, nephropathy). Therefore, the third decade of the American HIV epidemic opens with an important challenge that will largely fall to primary care physicians: the identification of all patients infected with HIV. The Centers for Disease Control and Prevention (CDC) estimate that up to 280,000 HIV-infected people in the United States are unaware of their diagnosis. Unless they are identified, these patients – and some portion of the 40,000 patients newly infected each year – will continue to suffer the consequences of advanced HIV infection while simultaneously (and unknowingly) propagating the spread of the virus and the continuation of the deadliest epidemic in more than 80 years.

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