From BlackDoctors.org:
Ten years ago, National Black HIV/AIDS Awareness Day was created to raise awareness among African Americans about HIV/AIDS and its devastating impact on African American communities. But one aspect that many people don’t recognize is the ongoing effects of HIV on those already infected. Many individuals assume that after they have become HIV-infected, they no longer have to practice safe sex. This is a false and dangerous myth! The sad reality is that infected individuals do not always behave in a manner to prevent infecting other individuals. What is most disturbing about this line of thinking is the underlying lack of consideration about infecting others. But even from a selfish perspective, there are serious risks to unprotected sex for the infected individuals.
Below are three case scenarios that explore just why HIV-infected individuals still need to adopt safer sex practices (while the depicted clinical cases are real, the patients’ initials are not).
Case 1. J.M. is a 34-year-old African American woman diagnosed recently with HIV infection. She is in a monogamous relationship. Her screening labs started in the clinic include a CD4+ cell count of 501 cells and a viral load of 2,634 copies. Her CD4+ count indicates that she still has a relatively healthy immune system and a low amount of virus in the blood. She’s in pretty good shape and is scheduled for a follow-up appointment in three months. She misses her appt and shows up nine months later. Astonishingly, her CD4+ count is now 39 cells and her viral load is now 235,897 copies!
Case 1 Discussion. J.M. comes into the clinic in fairly good shape. Based on the current treatment guidelines, she does not require HIV medicines, although many clinicians are beginning to recommend earlier treatment. She is not at risk for infections or HIV complications at this point. However, when she comes in nine months later, her clinical status has dramatically deteriorated. She now has AIDS. A person not on treatment would take several years to progress to this point, but she progressed to this point in just a few months. She must now take medications to protect her from getting AIDS-related infections. She also desperately needs HIV medications to restore her immune system to a safe range. Unfortunately, she does not return to clinic. What happened? The most likely explanation is that she was re-infected by a very dangerous and aggressive strain of HIV different from what she was initially infected with. Either she or her partner was not monogamous and they were not using protection during intercourse.
Case 2. S.K. is a 45-year-old white gay male who has been diagnosed with HIV for over seven years and followed in the clinic. He comes in regularly for care and has not needed to start medications. His CD4+ count is now around 400 cells and his physician thinks he should consider starting medicine. S.K. agrees. Over the years, his physician has performed a genotype, a test which tells us which HIV medications should be active in controlling the virus. Now, as they prepare to start HIV meds, his physician studies the genotypes over the years, as well as a recent one. To his horror, he finds that S.K. has nearly a dozen resistance mutations. This means that many commonly used medications will not work for S.K. He has resistance to medications from three different classes of HIV drugs.
Case 2 Discussion. Resistance to medication means that a particular HIV-drug has reduced activity in controlling virus. If the patient has certain specific mutations or higher numbers of mutations, those medications affected may have no benefit at all. Resistance develops when the amount of medicine in the blood is not high enough to totally suppress the virus. This most commonly happens when the patient doesn’t take their medicine regularly as prescribed by the doctor. Missing doses reduces the amount of medicine that gets in the blood and its ability to control the virus. This gives the virus an opportunity to change genetically (acquire resistance mutations) and make the drug less effective. But S.K. has never taken HIV medicines before. Where did he get all these resistance mutations? Most likely, S.K. has engaged in regular unprotected sex from different partners. If his partners were resistant to medicines from not taking their drugs properly, these viruses could have infected S.K. This is called transmitted resistance.
Because of the problem of transmitted resistance, every newly diagnosed person should have a genotype before starting treatment. If there is transmitted resistance, we can avoid using the ineffective medicines and select a different regimen. S.K.’s case is extreme. He has so much transmitted resistance that it is difficult to find a combination regimen that will work for him. Just as problematic is having effective follow-up treatments when his first regimen fails.
Case 3. G.M. is a 36-year-old Ethiopian woman recently diagnosed with HIV disease. Her CD4+ count is 347 cells. As part of her routine care, she receives the first of three vaccinations for hepatitis B. She is started on her HIV medication regimen, a three-drug combination of Sustiva/Emtriva/Viread formulated into one pill for once a day dosing. When she comes in for her next scheduled visit, tests that measure liver enzymes are abnormally high. Other laboratory tests show that the patient is testing positive for hepatitis B antigens. These tests were previously negative.
Case 3 Discussion. This patient was positioned to have a good outcome from her HIV medications. However, when the elevated liver enzymes were seen, the HIV medications were stopped. Elevated liver enzymes are a sign that something is damaging the liver. The HIV drugs were stopped as a precaution. However, the hepatitis B antigens tests indicate that the liver damage is most likely being caused by a hepatitis B infection. She became infected with hepatitis B through unprotected sexual intercourse. This can be quite serious since hepatitis B can lead to cirrhosis of the liver and liver cancer. She has two things working in her favor. First, she has received one of her hepatitis vaccinations. Second, two of her HIV medicines, Viread and Emtriva, are also active against hepatitis B. These two actions give her an upper hand in fighting the infection. This patient soon launches an effective immune response against hepatitis B and clears the infection (she develops hepatitis B antibodies and the virus levels drop).
What Do These Cases Teach Us?
Case 1 – A healthy HIV patient can be infected by a more dangerous strain of HIV that rapidly destroys their immune system.
Case 2 – Drug resistance can be transmitted to a person who has never been on any medications. This can severely limit their treatment options. If the person is already on medications and their HIV infection is controlled, they can be infected by a strain of virus that is resistant to those medications.
Case 3 – There are other dangerous infections that can be transmitted, such as hepatitis B, hepatitis C, syphilis, gonorrhea, herpes and chlamydia. These infections may also be resistant to treatments. Furthermore, sexually transmitted diseases can increase the amount of HIV in the genital tract and in the blood.
What You Need To Do (Whether You’re HIV Positive Or Not)
• Use Condoms. Whether you have HIV or not, use of latex condoms protects against the transmission of HIV and many other sexuallytransmitted infections!
• Learn About HIV/AIDS. Educate yourself, friends, and family about HIV/AIDS and what you can do to protect yourself.
• Get tested/Follow Up With Your Doctor About Treatment. To find a testing site near you, call 1-800-CDC-INFO.
• Speak Out. Fight against stigma, homophobia, racism, and other forms of discrimination associated with
HIV/AIDS.
• Donate. Not just your money, but your time, to HIV/AIDS organizations that work within African American
communities.
–Dr. Keith Crawford, BDO Special Contributing Writer