TREATMENT IS PREVENTION (?)
I attended the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in early September and learned some important facts about infections, including Hepatitis C and HIV. This is a different conference on which I discussed last month. I presented my poster showing that HIV is associated with increased death when having a heart attack, based on studying a large database; this should be confirmed by further study.
I discussed another poster with a member of the team lead by J. Gosn from Paris, who checked semen once and 2 weeks later in those who had undetectable HIV in their blood and sometimes they had virus in their semen. We are aware that having an undetectable virus in the blood results in much lower transmission when a condom is not used. And in fact we prescribe HIV medications to those who will not practice safe sex if they agree to take the medications. We also advise those who want to become pregnant to first have an undetectable viral load and only have sex around the time of ovulation. But I have not seen a study looking for virus in the semen when the viral load is undetectable.
This study checked the semen in men who have sex with men (MSMs) and made sure there were no sexually transmitted diseases (STDs) by exam and by asking the patient questions. Any sore in the genital area can leak or receive HIV much more easily than intact skin. Also, since the sore from syphilis is painless (not noticed) and may be inside a person, so they performed a blood test to double check for syphilis. They had to have an undetectable viral load for more than 6 months and be on the same antivirals for a long time. They agreed not to have sex for 48 hours prior to the semen collections. Their ages ranged from 27-67. The average time that their viral load was undetectable was 3.3 years and 63% had a stable partner. They checked the semen once and again in 2 weeks in 157 men.
80% had no virus in the semen on the two checks, but 12 % had virus once and 3% had virus seen twice, so 15% had virus in their semen on those two checks.
I wonder if they kept checking every 2 weeks over the next year, how many would have had detectable virus at least once. We know that the prostate is a sanctuary for HIV and medications have trouble achieving good levels there to kill the HIV sometimes so this result makes sense. They did not prove that this was enough virus to infect another person without the assistance of an STD.
So we conclude that condoms are still necessary and you are taking a risk if you don’t wear one, even if the viral loads are undetectable.
I attended a presentation by Joel Palefsky, MD of San Francisco General Hospital, who is a world expert on this subject. Rectal (and cervical) cancer is more common and more aggressive in HIV patients. He stated that the risk of having a serious anal cancer in men with HIV is less than 1%. If there is funding for the pap smears, the technicians to read them and perform the special anal exam with a magnifying scope, and the surgeons to biopsy and remove the spots, then it is a good idea to do the pap smears. I asked if there was a comparison between performing a rectal exam (Dr.’s finger in a glove with lubrication checking the anus, rectum and prostate) and the pap smear. He felt an annual rectal exam was essential and may be a good, low-cost alternative to the pap smear. He would welcome such a study since many men have abnormal pap smears and worry about them for months while undergoing many tests and procedures, only to find that there was nothing to worry about.
I mentioned to him that this reminded me of the current state of mammograms, that there are too many false findings so the current recommendation is for women over 50 to have them every 2 years to cut down on the unnecessary worry and tests. I also mentioned prostate cancer screening, that the current recommendation was to not perform the blood test routinely since that also created many unnecessary worry, procedures, and complications such as impotence and incontinence (losing your urine).
There are those who feel the more testing the better and finding 1 cancer while causing much trouble for many others is worth it. Most disagree.
The most common fracture of this type is a hip fracture. People over 50 should get their bone density checked to see if they are at risk for a fracture with a simple fall or trauma if they have an additional risk factor.. Other risks are alcoholism, smoking, previous fracture from a minor injury. Now HIV is also considered a risk for thin bones (osteoporosis) so discuss with your provider about getting a DEXA scan.
Keep those questions coming. Be Safe!
Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside
HIV Researcher, Desert AIDS Project