What Does An Undetectable Viral Load REALLY Mean?

There are many well documented benefits to reducing the viral load of an HIV+ individual to an undetectable level. Unfortunately, there also remains a some haziness about the term "undetectable." In actuality, it is somewhat of a misnomer. For someone to truly have undetectable HIV would mean that the battery of sophisticated tests available could not find any virus in a person's body. Thus far there is only one case of an HIV+ individual, a German who received a bone marrow transplant from a donor who had a genetic resistance to the virus, who seems to have cleared HIV entirely from one's system. An undetectable viral load means that the HIV virus in one's blood has been suppressed to the point where either the HIV RNA is not present in your blood at the time of testing or that the level of HIV RNA is below the threshold needed for detection. Another factor is the sensitivity of the specific test that is utilized.

Viral suppression, as its called, may allow for the partial rejuvenation of one's immune system, thereby making one less vulnerable to certain opportunistic diseases. Perhaps one of the most intriguing recent findings (HPTN 052) is that viral suppression may help to reduce HIV transmission in sero-discordant heterosexual couples (where only one of the two is HIV+) by as much as 96%. An earlier study with MSM found an approximately 60% reduction. However, 60 or even 96 percent is not 100%.

The 2010 International AIDS Conference highlighted the following:

• With heterosexuals with one or both using antiretroviral treatment the risk of HIV
transmission is low, but not zero.
• In male same-sex partnerships, HIV transmission risk gets higher with repeated
exposure.
• In presence of other sexually transmitted infections (STIs), HIV transmission is
increased. STI seem to have a synergy with HIV and can increase the genital viral
load in a HIV+ person. Moreover, a person who is HIV- but already has other STIs
is actually more susceptible to HIV infection.

Now, a recent study of HIV+ MSM by Boston University School of Medicine found the presence of detectable HIV in the semen of approximately one-quarter of the men studied people with supposedly undetectable (through blood tests)viral loads. The researchers added that a major factor in the results of this study had to do with the high level of STIs in the study participants. While the study did not specifically look at whether these men were more likely to transmit HIV, it should serve to remind us that aggressive HIV treatment alone will not stop HIV transmission and that the importance of knowing one's status, treatment for STIs and condom use all remain as very important tools.

African Americans Stand to Lose from the War on Contraception

According to Webster’s Dictionary, “Contraception” is defined as the deliberate prevention of conception or impregnation by any of various drugs, techniques, or devices or; birth control. However, with the prevalence of sexually transmitted infections, many people tend to incorporate their contraceptive and sexual health prevention methods under a concept of risk reduction.

There are at least 25 know sexually transmitted infections (STIs) and infect about 15million people annually. As the debate rages about the need for and availability of contraception, we in the African American community should understand the huge stake that we have in this discussion.

African Americans have been disproportionately impacted by sexually transmitted infections, especially HIV. We represent ½ of the new HIV infections, those living with HIV and those who succumb to it each year in the United States. We also have higher rates for other STIs. We represent 50% of the 2.8 million new Chlamydia infections and our infection rates for Gonorrhea and Syphilis are 16 and 23 times those of whites respectively. Nowhere is this impact greatest than in young people, especially young women. A recent CDC study estimated that 48% of black adolescent girls in the United States had at least one STI. Moreover, many are unaware of it. Teenage pregnancy rates have risen to 42 births per 1000 females. Programs such a Planned Parenthood which offer free or low cost contraception services also provide comprehensive risk reduction services as well, services that are desperately needed in our community.

According to the National Center for Health Statistics, teen pregnancy and out of wedlock births are one of the major causes of infant mortality and are often cited as helping to keep the US infant mortality rates higher than in many industrialized countries.

Many studies point to the impact of poverty in exacerbating these rates. The latest recession has had a devastating impact of black people. Unemployment rates have risen as high as 15.9% (26.4 in youth). We have seen a significant decline in home ownership, and median household income. Poverty rates for blacks are double those for whites. And Africans Americans have consistently lower levels of health care than do whites.

In closing, African Americans definitely have a ‘dog in this fight.’ We cannot afford the impact of more unplanned pregnancies to more young women let alone the physical and economic hardship caused by sexually transmitted infections, especially HIV. We can and we must demand more, not less, ownership in our own sexual health.

And the beat goes on...

As the controversy about HIV criminalization continues to rage, the state of Maryland has decided to 'up the ante,' so to speak, by proposing to add more teeth to their current HIV-specific criminal law, according to a recent article in the American Independent newspaper. Presently, a person convicted of knowingly transmitting or attempting to transmit HIV to another person may result in an $2500 fine and up to a three year prison sentence. However, Maryland state legislators are considering changing the law from a misdemeanor to a felony with an up to 25 year sentence. Despite the absence of evidence that these types of punitive methods are a deterrent and that people who know their HIV status, especially if they have achieved viral suppression with anti-retroviral therapy, are less likely to infect others, fear and and the desire for retribution continues to reign.

Another interesting article in the Philadelphia Daily News ("Its Payback Time," 3/6/12) chronicles William Brawner, an HIV+ man who knowingly had unprotected sex with several women while a student at Howard University. He eventually contacted all of the women and disclosed his HIV status. Fortunately, it does not appear that any of the women became infected. Mr. Brawner has gone on to start a non profit organization to help other HIV+ young people. I can't help but wonder if we would have ever heard his story and would he have had the opportunity to help other confused young people, as he was at one time, if he had been thrown in jail for 25 years. While there in no condoning his behavior, won't many more people benefit if he is a contributing member of society?

AIDS Denialism

Recently, someone named Curtis Cost wrote an article assailing the importance and validity of African Americans knowing their HIV status. Since the first widely reported cases in 1981, HIV has been mired in controversies, ranging from its origin to the possible existence of a cure. Sadly, over thirty years later, we continue to have many of the same conversations. What should NOT be in doubt any longer is that HIV disease is having a devastating impact on the African American community. Although African Americans represented only 14% of the US population in 2009, we accounted for 44% of all new HIV infections in that year. Overall, African Americans account for a higher proportion of HIV infections at all stages of disease—from new infections to death, than any other racial of ethnic group. Moreover, as many as 21% of people living with HIV are unaware of their status and, consequently cause up to 70% of the new infections. So why then, would Mr. Cost write such an impassioned plea for African Americans to NOT get tested for HIV? In short, we refer to people like Mr. Cost as AIDS Denialists. AIDS Denialists represent individuals or groups who deny that the human immunodeficiency virus (HIV) is the cause of Acquired Immune Deficiency Syndrome (AIDS). While the link between HIV and AIDS has long been established in the scientific community, AIDS Denialists continue to dismiss HIV as a harmless passenger virus and assign the cause of AIDS to anything from malnutrition to the drugs used to treat it. Now, before you dismiss the Denialists as just foolish or uninformed, let me remind you about Thabo Mbeki, the former President of South Africa and once a poster child for AIDS Denialism. By some estimates, his alleged 'fiddling while Rome was burning' may have led to as many as 330,000 AIDS deaths as well as almost over 200,00 new HIV infections.

The greatest weapon against AIDS Denialists is knowledge, ours. AIDS Denialists prey on our own cynicism, ignorance and, yes, our denial. It always amazes me how willing we are to jump on the bandwagon of someone offering very little in the way of proof and disavow decades of scientific evidence. Healthy skepticism can be a good thing. However, use that cynicism to motivate yourselves to seek more information. In other words, do your own homework!

Treatment is Prevention Part 1

Some of you may be aware that the annual HIV Prevention conference has been taking place in Atlanta this week. One of the unique aspects of HIV conferences is that they tend to bring together an eclectic mix of people: consumers, researchers, medical providers, non profits and other assorted advocates. As we, as a society, struggle with finding new and creative ways to reduce the transmission of HIV, it was only natural to consider the impact a medical model might have on this challenge. Perhaps one of the most exciting studies within the last several months demonstrates the benefit of immediate, aggressive HIV treatment in reducing transmission.

Historically, HIV prevention targeted those who were negative. Eventually, more emphasis was placed on "Prevention for Postives," which focused primarily on changing the potentially risky behavior of people who are HIV+. However the promising results of a study, known as HPTN 052,that evaluated whether the immediate use of HAART (Highly Active Anti-retroviral therapy) by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners (which would also potentially benefit the HIV-infected individual), demonstrates the increased role of medical treatmet in prevention. The results of the study were truly groundbreaking: there was a 96 percent reduction in risk of HIV transmission to the HIV-uninfected sexual partners.

The results of this study underscores previous efforts to test as many people as possible by making HIV a routine part of medical care as well as aggressive community mobilization by showing that if we can get HIV+ individuals into care and keep them there, it may reduce overall HIV incidence and save lives. Put another way, this study adds another needed weapon to our arsenal as we continue to make progress if our war against this formidable, entrenched enemy: HIV.

HIV at 30

For the two or three of you (lol) who follow my blog, you may have noticed that I haven't blogged in a while. A lot has happened to me over the last several months that I won't get into now. However, I have returned with a renewed sense of purpose and quite a lot to say.

Much has been written about the 30th anniversary of HIV. I plan to write throughout the year on this topic. It is long and complex area and I cannot begin to do it justice in one or two blogs. So hear I go......

My blog today will be more in the form of a rant. It comes on the heels of a recent radio show on which I appeared. During the show, I experienced a sense of déjà vu; that the conversation I was engaged in has happened before. After 30 years, I was answering many of the same questions, the same way:

* Why are the rates so high in the African Americans so high?
* Whay aren't the churches more involved?
* Why do so many African Americans have conspiracy theories?
* Isn't Magic Johnson cured?
* Why is the stigma so great?
* Isn't AIDS a gay disease occurred to me?

After 30 years, with so many ways to access the information, why hasn't it sunken in? Moreover, this 'HIV illiteracy' does not seemed to be impacted by SES (socio-economic status) I have had the same conversations with people ranging from 6th grade reading levels to doctorates.

Certainly the glass isn't completely empty. We have made strides. There is finally a National HIV strategy. Many cities have instituted robust social marketing and testing intitiatives. And, some faith-based institutions have become involved. But, as I have these daily conversations and watch the rates continue to rise, it still seems apparent that it just hasn't sunken in enough. Without our most important asset, knowledge, we still have a long way to go.

HIV may have been present for 32,000 years

Despite the persistent myth that HIV was a man-made disease, unleashed upon the unsuspecting, disenfranchised of our society (read gays and blacks), now comes more evidence that it may have been present in monkeys and apes for a millennia. New research, published in Science magazine last month, report the presence of the ancestor of the simian HIV virus in Africa possibly dating back as far as 78,000 years. This fascinating research, that studied monkey species on a volcanic island off of the coast of West Africa, who developed in isolation, found that four of the six species had been infected with HIV.

Although this study may help to answer certain questions, such as why HIV infects most simian species, but doesn't kill them, it fails to answer the main one: how did a relatively benign monkey virus become one of the greatest health crises in the history of mankind. Many still believe that the human HIV epidemic was caused by, purposely or inadvertently, human meddling.

Evidence of the great age of HIV does point to the likelihood that, over centuries, the virus killed off weaker monkeys leaving behind those who became resistant to it. However, does that mean that it will take thousands of years before we are able to adapt naturally to HIV? Can we survive that long with rising rates, declining government support and the aggressive mutation of the virus?

Our obvious advantage is, of course, our technological superiority. We now have over 30 medications to treat HIV and many believe that a cure is still possible. However, by following the path of HIV and other diseases, it hopefully reminds us of our fragility and vulnerability as we continue, sometimes in the interest of capitalism and expansion, to invade more exotic and isolated lands and interact with previously unknown species.

Opt-Out and Eliminating Consent for HIV Testing

President Obama's new AIDS Strategy calls for a renewed effort to reduce new HIV infections by 25%, increasing the number of people who know their status from 79% to 90%. Crucial to the success of this benchmark is to test more people for HIV. This is consistent with the Center for Disease Control's recent recommendations (in 2006) to encourage HIV testing to become a routine part of medical care. However, one of the more controversial aspects of this push is the distinction between 'opt -in' vs 'opt-out HIV testing. Opt-in testing generally refers to an opportunity for the patient to be asked, by a provider, if s/he would like to be tested for HIV. Opt-out testing means that a patient will be given an HIV test unless s/he chooses not to have one. The CDC has recommended opt-out testing as well as the elimination of written consent (a medical consent form that authorizes HIV testing).

As one might imagine, this is a pretty contentious topic, even among HIV advocates and medical providers. Supporters of opt -in testing and informed consent argue that people need to understand what they are being tested for and why. Moreover, they argue that eliminating written, or even verbal consent fails to address the reasons why so many people fail to be tested, at the expense of expediency. Ignorance, apathy, stigma and discrimination are still alive and well, they claim, and cannot be ignored. Opt-out testing proponents point to the growing members of people who do not know their HIV status, present for treatment in the latter stages of their disease and the glaring disparity of HIV among the poor and communities of color as evidence that the present system isn't working and that we need new strategies to address the soaring epidemic. They also minimize the impact of stigma and discrimination, due in part to the efforts to make HIV testing more routine.

Nowhere is this debate raging more than in New York City, which still hold the crown for the highest incidence of HIV of any US city. New York State requires written consent, but the current policy is being reexamined. So what is the right policy? One thing is clear: both sides seem to be focused on the same outcome, a reduction of HIV infection. Unfortunately, in an era of dwindling resources it is sad that there is not more consensus on this issue. What isn't clear if if the present policies around informed consent aren't working. There is evidence that many medical providers are not offering HIV testing to their patients, due in part to their discomfort with the subject. Moreover, there is evidence, some of which comes from New York itself that HIV testing is rising under the current rules.

I am concerned that if people are not given an opportunity for consent for HIV testing and to have the conversation that would likely take place with that medical provider, that much of the ignorance and misconceptions about HIV will remain. Moreover, if provider feel a conversation about HIV testing is uncomfortable, then how will they feel about giving someone a positive result? We clearly have a long way to go before our society sees HIV/AIDS as just a medical condition. Before eliminating informed consent, I feel that more training for medical providers, more and robust social marketing to reduce HIV stigma and a renewed emphasis to ensure that HIV testing is being offered in routine medical settings are more effective measures to increase HIV testing.

Does Pregnancy Pose an HIV Infection Risk for Men?

Previous studies have demonstrated that pregnant women are at greater risk of HIV infection. However, a new study, presented at the International Microbicides Conference in Pittsburgh in May seems to demonstrate that men have almost double the risk of HIV infection if their partner is pregnant and HIV+. The study, conducted in 7 countries in Africa, involved over 3,300 serodiscordant (one partner is HIV+ and the other is not) couples. Over two years and 800+ pregnancies it was demonstrated that pregnancy increased the risk of HIV infection for both males and females. The study reports that several factors other than pregnancy, such as sexual behavior, probably contributed to the increased risk for women. However, even when accounting for those factors and even circumcision, the heightened risk for men seemed much more direct. The researchers theorized that certain physiological and immunological changes that occur in a woman during pregnancy may be behind this remarkable finding. Therefore, further study to zero in on these changes is warranted. However, for those who may feel that pregnancy gives one a 'free pass' as far as the concern of the woman getting pregnant, this study demonstrates that it is even more imperative to use protection, especially if HIV status is unknown.

Will the recession increase HIV infection?

The answer is, probably. We all know that one of the first casualties of economic down times are programs that help those in the most need. Its hard enough to make ends meet when there is less money and rising prices. People who were living check to check can find themselves out on the street if that check stops coming. Now comes word that two states with the highest numbers of persons living with HIV/AIDS, California and Pennsylvania, may be making significant cuts in vital HIV prevention and direct care services. The Governator (Arnold Swarzenegger) is proposing 55.5 million in funding cuts to HIV prevention, education and treatment programs. The Republican version of the state budget proposes to cut PA State AIDS Programs by 25%. Sadly, some of the proposed cuts could jeopardize federal matching funds, further spreading the pain.

It s not to late to send a message to state government legislators that cutting HIV/AIDS funding as well as other services to the poor and disabled in the midst of a surging epidemic is penny wise and pound foolish and will only exacerbate the problem.

Who's infected and doesn't know it

Recent data from the CDC provides more detail about the approximately 232,700 living in the U.S. living with HIV who do not know it:

• Over 113,000 are African American
• Men infected through heterosexual contact (male/female) were more likely to be undiagnosed that either MSM (male-male) or hetersexual women.
• Almost half (47.8%) of the young people (ages 13-24) living with HIV were undiagnosed, a greater proportion than any other age group.

Clearly, HIV testing remains a essential tool to addressing the HIV epidemic. At least one quarter (1/4) to one-half (1/2) of all new HIV infections are transmitted by undiagnosed people. Studies show that most HIV diagnosed people make an effort to protect their partners. Moreover, early detection is a key to successful treatment.

Are you positive that you're negative (for HIV) ?

World AIDS Day

World AIDS Day was December 1st. Maybe its just me but I heard very little about it this year-even less than last year. Have we become too complacent about HIV/AIDS? Or is it because it has become a condition that disproportionately affects people of color. I understand that the election and our struggling economy has taken the spotlight lately, but we can't spend one day to acknowledge perhaps the greatest health crisis of modern times?

Guess I can't complain too much, but...

Barack Obama's speech last night to accept the Democratic nomination for President of the United States and to lay out his goals for his administration was almost everything that I could have expected. It was inspiring, emotional, challenging, historic, and I can go on and on. So should I be concerned that the greatest killer of people of African descent in history wasn't mentioned? Am I being nick-picky? Just because George Bush has made it a priority, should I have expected Barack to follow suit? After all, there are many other important issues that we face, as a country. Maybe I am biased, but I just feel that HIV/AIDS is one of them. I hope and pray that he makes it a priority of his administration after he gets elected.