An HIV-positive person spat at me, why was I denied PEP?

Dear James,
Many people living with HIV who are on ARVs experience similar challenges. They have to tolerate some side effects such as drowsiness and nightmares because they do not have access to alternate safer drugs, which are easier to swallow and have fewer side effects. We, however, now have a window of hope. For example, we now know that instead of taking 600mg of Efavirenz, the drug that makes you drowsy and is combined with Tenofovir and lamivudine to form the one table you swallow once at night; you can take 400mg of the same drug and your viral load will continue being suppressed without making you feel drowsy. The other drug, which can replace Efavirenz is called Dolutegravir. Dolutegravir can be used in combination with lamivudine and Tenofivir instead of Efavirenz. This is known as treatment optimisation, which should be done for all people living HIV. Nobody should have to tolerate taking drugs if there are better products like Efavirenz 400 mg and Dolutegravir, which are more durable, easier to swallow and have fewer side effects. So, discuss these possibilities with your service provider and enjoy good quality life while on ARVs. Lastly, I am writing this from Paris France at IAS 2017, a big international conference on HIV and AIDS. A lot of this information has been shared here. Our fellow PLHIV in developed countries no longer use many of the drugs we are using. However, while we are still advocating and lobbying for optimisation of our ARVs, continue taking the current ones because as the saying goes, "a bird in the hand is worth two in the bush".

November 6, 2017

Question

Dear doctor, I am HIV negative but my husband is HIV positive and doing well on ARVs. I knew he was HIV positive before we got married and because I love him, I agreed to the arrangement. We have been married for four years and we would like to have a baby but because we always use condoms when we have sex I cannot of course conceive. Recently he told me that we could try and have a baby but I am so scared because it means I could easily get infected and probably give birth to an HIV positive baby. Our families don't know what we are going through because we have not disclosed our predicament to them. Please advise. Jackie.

Answer

Dear Jackie, discordance, which you have described in the question above, is fairly common. Secondly, discordance is the basis of majority of new HIV infections and so we must deal with it firmly basing on scientific knowledge, which is now widely available. For example we now know that people living with HIV (PLHIV) who are on ARVs and have undetectable viral loads are actually not very infectious. In short, "undetectable is equal to un transmittable". We also know that if HIV negative people who are in discordant relationships are put on ARVs at a time of increased risk, such as when they have to have unprotected sex because they want to have a baby the risk of them acquiring HIV is significantly reduce. So, instead of living in fear, learn the facts. Encourage your husband to take his ARVs with good adherence and when his viral load is undetectable discuss with your doctor who will arrange to put you on ARVs before you have unprotected during the time of your menstrual cycle when you can conceive. This is known as PrEP or pre-exposure prophylaxis. Using two or more methods as described above to prevent HIV transmission is known as combination prevention and it is more effective than depending on only one. Lastly, all people need to know this so that PLHIV or their HIV negative partners are not stigmatized isolated and made to live in fear and shame.

November 5, 2017

Question

Dear doctor, I am HIV positive but my wife is negative. I am doing well on ARVs. We, however, have never used condoms and yet we have been living together for over ten years during which she has had four children who are HIV negative. Does this mean she could be immune to the disease or could it be that she is actually infected but it does not show and she could pass on the disease to our child since we would like to have another baby? Robert.

Answer

Dear Robert, the condition you describe here is known as discordance and it fairly common. Unfortunately, if not well handled, it is the reason behind the many new HIV infections that happen especially among married and cohabiting couples. Your wife is not immune to HIV but what could have helped her to remain negative is the fact that you are on ARVs, which when taken with good adherence drastically reduce the risk of HIV transmission. Secondly, the risk of transmission among couples that practice consensual sex is lower than in cases of non-consensual sex such as rape. However, now that you know, you need to adopt safer sex, which means you use condoms whenever you have sex.  When you want to have a baby you should ensure that your viral load is maximally suppressed then you can have unprotected sex for a period. During such encounters, it is wise for your wife to be put on ARVs, a practice known as pre exposure prophylaxis (PreP). Your doctor will guide you how this can be done once you share with him or her plans of wanting to have another baby with your HIV negative wife.

November 4, 2017

Question

Dear doctor, my mother who is in her fifties is HIV positive and has been on Septrin for close to ten years because her CD4 count has always been high. However, recently when she went to collect her Septrin the doctor out of the blue put her on ARVs and told her that it was now a government directive that all people who are HIV positive should be put on ARVs! She is now so disturbed and has refused to start taking the drugs because she feels she does not need them. Why should people who have high CD4 counts and are not sick be put on these strong drugs? Janat.

Answer

Dear Janat, what the doctor probably meant is that it is now government policy and practice to put all people living with HIV on ARVs in line with WHO guidelines.  This is known as "test and treat all ", where at least 90% of all people who are HIV positive are put on ARVs. However, no body is forced to take medication if he or she has not been convinced concerning the benefits of such treatment. So, since antiretroviral treatment (ART) isn't emergency treatment but treatment for life; more time needs to be spent counseling your mother and explaining to her the benefits of starting ART early, so that she is convinced and can adhere to the treatment once she starts. She needs to know that treating HIV is similar to repairing a tear in a cloth: the earlier you do it the better the outcome. The other advantage of treating HIV early and suppressing the viral load or amount of HIV in the blood of people infected as soon as possible is that it makes such people less infectious to others. Lastly such person's immune system, which protects him or her from catching diseases, is prevented from being damaged; meaning such a person does not easily develop AIDS. The other thing to remember is that nowadays we have ARVs that are more tolerable, easier to swallow and have fewer side effects and so there is no reason why anyone should keep putting off starting to take them for fear of having nasty side effects.

November 3, 2017

Question

Dear doctor, my sister was recently told she had TB. This was discovered following a cough, which she had had for more than three weeks. She was put on TB drugs and improved a bit but when they checked her sputum after two months she was told she still had TB germs. At the same time she was tested for HIV and found to be positive. Could it be that TB among people with AIDS does not get cured. We are worried! Musa.

Answer

Dear Musa, TB among persons living with HIV even if they have AIDS can be cured. However, the infected person must take the TB medicines with good adherence, meaning he or she must take the drugs in the right doses and at the right time as prescribed by the health service provider. What could have happened is that you your sister did not take the drugs with good adherence and so the TB germs could not be destroyed and may have even developed resistance to the medicines or she was infected with TB from someone who had what is known as "multi drug resistant TB" (MDR TB). This is TB that is resistant to rifampicin and isoniazid, two of the four drugs used in treating the disease. Your sister should be evaluated and counseled concerning what should be done next; including finding out if she has MDR TB, which is treated using a different regimen of TB medicines and for a time longer than the usual six months of TB treatment. She should also be put on ARVs as soon as it is possible and feasible. Lastly, all of you who have been in contact with her should be screened for TB. If these measures are taken, there is no need for being worried.

November 2, 2017

Question

Dear doctor, if an HIV positive mother who is on ARVs and her viral load is undetectable   breastfeeds her baby, will the baby be infected with the disease? Liz.

Answer

Dear Liz, the main reason why people living with HIV transmit HIV to others including women transmitting the virus to their babies via the mother to child transmission route is because such people have high viral loads and therefore very infectious. That is why all of us should embrace the "test and treat" programme of putting all people who test HIV positive on ARVs as soon as possible. So, if the HIV positive mother who is on ARVs and has an undetectable viral load follows the doctors' instructions of putting the child on ARVs soon after birth and exclusively breastfeeding for up to six months; the risk of such a child getting HIV from such a mother is very low. We have seen this work very well for parents who have done it, such that the number of children infected with HIV via the mother to child transmission route dropped from over twenty five thousand in 2011 to the current less than four thousand infections annually. This shows we can eliminate HIV infections among babies if we put in practice the elimination of mother to child transmission of HIV strategies.

November 1, 2017

Question
Dear doctor, I recently had unprotected sex with someone whom I later found out was HIV positive. I have not yet had the guts to go for an HIV test but wanted to know what the early signs of HIV infection are. Secondly, how can some tell that he or she has the virus without doing the HIV test? Jackson.

Answer

Dear Jackson, acute HIV infection could presents with flu-like symptoms like fever, skin rash, generalised body pains and sometimes swelling of the lymph glands; especially in the neck region. There are, however, many other viral illnesses, which could present in a similar manner and many people would never recall having such signs and symptoms. It is therefore important that we do not base a diagnosis on signs and symptoms only but to confirm it by doing an HIV test. The other thing worthy noting is that during the acute phase of HIV infection, the antibody HIV test when done would be negative. The only way you can detect the virus during this early stage of infection is by doing a more advanced test known as the DNA-PCR test. Equally important and of public health significance is that during this period, which could last up to three months; the infected person usually has a very high viral load and is therefore highly infectious. For such a person condoms are recommended if he or she must have sex. For women, getting pregnant during this period puts your unborn baby at higher risk of acquiring HIV through the mother to child route because of the high viral load or amount of HIV found in the blood. Lastly, it is safer to assume that any person whose HIV status you do not know is HIV positive and to always take measures to protect yourself. If exposed like you were, seeking to be put on post-exposure prophylaxis (PEP) by a health service provider trained to offer such a service as soon as possible would have been the best option.