Dear Dr. D,

You once said in one of your articles that the lower the viral load, the lower the risk of (HIV) transmission. I also read one expert saying that the risk of transmitting HIV when you have an undetectable viral load is next to nothing. Does this mean that two men on antiretrovirals with undetectable viral loads can have unprotected sex? What are the real “statistical” risks? An honest response please?

Anonymous
Knysna

Dear Anonymous,

Don’t ever ask a doctor for an honest response. You’ll rarely get the answer you want. That’s because, from a medical perspective, simple questions rarely have a simple answer. There are too many factors to give “absolutes,” and to do so would not only be disingenuous, but irresponsible, even harmful. So here’s the best I can do in a thousand words or less:

First consider your own words – “expert” and “next to nothing.” What exactly is an “expert” these days? What qualifications does one need at a time when anyone with a business card (or newspaper column) can hang up a shingle and proclaim special insight into HIV? I confess I find myself doing this at times at this very column, but in the end, one has to resist the drawing “absolutes” from complex clinical research. And that’s what the term “next to nothing” does. It takes what the current clinical research shows – that it’s easier to transmit the virus if you have a high viral load versus a lower one – and inadvertently infers that you have “next to nothing” to worry about if you are having unprotected sex with a low viral load. The responsible thing to do would be to present the data, with as little bias as possible, and to let those results speak for themselves. To let the reader draw his or her own conclusions. Easier said than done, I know, particularly when we all have (me included) our own emotional biases regarding topics like safer sex and/or barebacking.

But to get back to the heart of your question, there have been some recent published studies that add a new wrinkle to the debate. At the recent Conference on Retroviruses and Opportunistic Infections, which I was able to attend, University of Connecticut investigators compared the viral load in the blood of male patients versus the viral load in their semen. Compiling date from 19 different studies, the study showed that the level of HIV in the participant’s semen were, on average, seven times greater than the levels found in their blood. (It should be noted that the 19 studies each had small participant samples, and that the result should be considered more suggestive than absolute.)

But what it does suggest is that there can often be a discordance between what your blood test shows and the actual “amount” of HIV you’re actually transmitting in your cum. It suggests to us that we can’t presume anything, or that we can reasonably step back from the traditional safer sex message just because we have effective antiretroviral therapy.

What’s interesting to note, however, is that the most rigorous of the 19 studies did show near-perfect concordance between blood serum viral levels and semen viral levels. Why? In this study, participants were (1) all on antiretrovirals and (2) had no sexually transmitted infections (or “STIs”).

STIs appear to be one of the four main factors – alongside viral loads, drug adherence, and drug resistance – that potentially influence the relationship between blood and semen viral levels. Simply put, co-occurring STIs can increase the viral load in the semen, but not in the blood. Gonorrhea and Chlamydia (both of which we see in South African) were cited as particular culprits, the infections of which cause the inflammation of the urethra, which in turns facilities easier transmission of the virus. Other studies suggested that the greater number of sexual partner and higher rates of sexual intercourse increased the so-called “genital shedding of HIV.”

What’s concerning about all this is that it is often contrary to attitudes we see in the gay community. The University of Connecticut study went on to demonstrate that men who equate lower viral loads with lower risk of transmission were more likely to have unprotected sex AND, at the same time, were more likely to have poor adherence to therapy, increasing the risk of transmitting drug-resistant strains of HIV.

So what does this all mean? It simply says that there are no simple answers, no absolutes to diminish or distract from the central safer sex message. One has to be reasonable but vigilant, always aware of the facts (even as they change) and able to understand that HIV, by its very nature, has no certain no course. No absolutes.

As for “statistical” risk, I’m not going to even touch that one, other than to say that risk = gambling. That every roll of the dice, even if the odds are with you, can either come up good or bad. How many people do we know have gone to a casino and struck it rich? How many have gone and lost? In the end, if you play long enough, the casino always wins. Providing statistical risk is nothing more than playing the odds. It’s not science, it’s gambling.

One final word, please understand that “undetectable” does not mean no virus. It simply means that levels are low enough that the current tests, as amazing as they are, cannot detect them. From a “statistical” point of view, this means that semen with an undetectable viral load is still potentially infectious.

I hope this has given you what you need to make your own good decisions. Good luck and thank you for bringing up what remains a very important issue in our community.

Best regards,
Dr. D

LOW-COST HIV CARE

Dear Dr. D,

I can’t afford medical aid or the cost of private care... and I don’t want to go on the government HIV programme. My one experience with them has not been good and I don’t like being told things that I know are not true. I am on TB treatment and was told that I don’t need to take ARVs even though my CD4 counts is 180 because I will get “liver poisoning” and the TB meds “will get my CD4 count up like ARVs.” I don’t trust them. Is there anything someone like me can do?

Hopeless in Centurion

Dear Hopeless,

I suggest you check out a new clinic in Johannesburg CBD called Zuzimpilo Medical Centre. Zuzimpilo is located on the second floor of xxx Joubert Street at the corner of Jeppe, and offers low-cost HIV care, counselling, and treatment for those who cannot afford private medical aid. It’s operated by the esteemed HIV Perinatal Research Unit at the University of Witswatersrand, and is funded in part by PEPFAR, the U.S. government’s international AIDS initiative. They are not free, but the cost of medications is reasonable, while the price for such top-notch care is, for lack of a better word, a steal. You can phone them at (0860) IMPILO (0860-467-456) or, alternately, contact them through their website, www.zuzimpilo.co.za.

Let me know how things work out, and don’t lose hope!

Yours sincerely,
Dr. D
Please submit your questions, comments, and criticisms directly to EXIT or to denniss@netactive.co.za