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HIV now firmly established in the Middle Ages.

Monty Python’s hit Broadway musical Spamalot (based on their earlier movie Monty Python and the Holy Grail) is cast in medieval England at the time of transition from the Dark Ages to the Middle Ages. The second song of the show highlights one of the play’s most famous lines, ‘‘I’m not dead, yet,’’ uttered by a character who was presumed to have died from plague. In today’s world, owing to breathtaking advances in medical science, many patients who surely would have died due to the AIDS plague in the 1980s are still alive, thriving, and transitioning from the Dark Ages of AIDS to the ‘‘Middle Age.’’ In this issue of Clinical Infectious Diseases, Hasse et al [ 1 ], from the Swiss HIV Cohort, clearly document the number of human immunodeficiency virus (HIV)– infected patients who have entered ‘‘middle age’’ over the past 2 decades. Just a cursory glance at Figure 1 in their report tells the story: From 1990 to 2010, the proportion of patients in their cohort who were 50–64 years of age increased from ,3% to nearly 25%. If the trend demonstrated in that figure continues over the next decade, up to 50% of patients in their cohort will be .50 years of age. Such an outcome was unimaginable 30 years ago, when AIDS was first described. Hasse and colleagues [1] describe the emerging medical conditions associated with the middle-aged patients in their cohort. Remarkably, there were relatively few HIV-related events (n 5 195), compared with non-AIDS comorbidities (n 5 994), during the period of observation, underscoring the success of treatment against the virus. Not surprisingly, the non-AIDS comorbidities are the conditions encountered in normal healthy populations of aging individuals: myocardial infarctions, strokes, malignancies, diabetes mellitus, and osteoporosis. Their study could not address, however, the relative frequency of these conditions in HIV-infected patients, compared with age-matched HIVuninfected control subjects. However, this was not the point of their report. Rather, their study reveals the remarkable success of the modern treatment era of AIDS care and raises a question to both providers and health care policy makers: What’s next?