Ottawa
3 min

HIV and the era of cocktail treatments

What you need to know

Credit: Capital Xtra files

HIV entered a new era in 1996. It was then that the protease inhibitors and new drug combinations came into use.Since then much has changed, and much has stayed the same.



One of the big successes is that HIV has for the most part become a chronic disease. Images of repeated hospitalizations, severe illness and wasting away simply no longer need apply. While there is still no cure, antiretroviral medications have been very successful at keeping the virus in check. As long as people stay on their pills to keep the virus inactive, the immune system does not come under attack and they remain healthy and lead normal lives.



Treatment of HIV, however, has its challenges. It still means pills every day. Side effects have become much less of a problem since different drug combinations and better dosing have been introduced, but side effects still exist. For some there is stomach upset, many have high cholesterol and anywhere from 10 to 50 percent have some form of lipodystrophy.



Viral resistance to the medications is also becoming an increasing concern. While we all remain optimistic about the future, it has to be said that there are no promises.



One of our failures in the battle against HIV is the increasing rate of infection. While there was a steady decline in the number of new infections throughout the 1990s, mostly attributable to consistent condom use and safer sex, the numbers have again begun to rise since the year 2000. More people have become infected with HIV in each of the last three years than in the year before.



What is going on? Why have people stopped being careful?



Certainly the increasing rates of HIV infection tell us that we need to revive information about safer sex and condom use. Most of the guys becoming sexually active now were born in the 1980s and do not remember page-long obituaries due to AIDS that regularly appeared in the gay papers. There is no place for lapses in education.



If you are HIV-negative, the best way to stay that way is to use a condom and be informed. To transmit HIV, two things have to happen. First there have to be fluids present that contain the virus. This means pre-cum, cum, blood and vaginal fluids. Second, there has to be a break in the skin for HIV to enter. Mucous membranes which line your mouth and rectum are particularly vulnerable because the layer of skin is thin and tends to be more fragile, and blood vessels lie much closer to the surface compared to our outer skin. Condoms for anal sex are a must. Anal fissures are common and often unnoticed, and are excellent ways for HIV to enter the body. Any other lesions around the anus or in the rectum are also open doors for HIV. The sores that form when people are initially infected with syphilis are a perfect example.



Oral sex is a bit more complicated. Infected gums at the base of the teeth (gingivitis) or even nicks in skin from brushing or flossing provide openings. Canker sores or even biting the inside of your lip by accident provide easy ways for HIV to enter. Good oral hygiene is essential. If you have any sore in your mouth, avoid oral sex until it heals. You can also reduce your risk by not letting someone cum in your mouth. Pre-cum is potentially infectious, but small amounts are likely diluted and washed away by saliva. A load of cum will obviously increase the exposure. If you don’t use condoms for oral sex, keep your mouth healthy and ask your partner not to cum in your mouth.



A question many people have begun to ask is: “If the viral load is undetectable, can HIV still be passed on?” The answer is “Yes.” Decreased virus in the blood generally coincides with decreased virus in cum. But we have never established a “safe” amount of virus that someone can be exposed to without becoming infected. Further, if you talk to people with HIV, they will tell you about their “blips.” Periodically, likely the result of immune stimulation, people on meds experience a sudden and unexpected rise in their viral load into the detectable range. This generally does not last long, and the virus returns to undetectable by their next clinic visit. The problem is, we really have no idea when or how often these blips occur. So tossing away the condoms if your partner is HIV-positive and on meds is at best a game of Russian roulette.



* Dr MacPherson is an assistant professor of medicine at the University of Ottawa, a specialist in the division of infectious diseases at the Ottawa Hospital General Campus, and a staff scientist at the Ottawa Health Research Institute. He is also a member of the Gay Men’s Wellness Initiative of Ottawa.