New HIV cases on the rise

Since January 1, 2011, I have diagnosed one new HV patient a week. They have all been men under 40, and more than half had no health insurance. What makes this most worrisome was that many were in the twenties.
 
In the current issue of the Journal, Levy et al. describes some of the issues associated with the emerging and evolving HIV epidemic in Israel. They not only documented that the absolute number of HIV infections has been increasing over the past decade, despite wide access to HAART, but that the preponderant number of those recently infected and newly diagnosed were MSM. Particularly concerning was the finding that 29% of the men were infected with HIV that was resistant to at least 1 of the antiretroviral classes, and coinfection with syphilis was common.
 
In my practice nearly half of the men diagnosed with HIV had a concomitant syphilis infection. Several contracted a strain of HIV with one or more major mutations. “These findings call to question some of the recent optimism about “treatment as prevention”, which presumed that if expanded efforts at increasing HIV testing and linkage to care could be undertaken, and individuals could be promptly treated, that the AIDS epidemic could be brought to a halt.”
 
That doesn’t seem to be true. The data suggests that a subset of these infected men may be engaging in unsafe sex. 
 
Why?
 
The current school of thought states there is a low risk for transmitting HIV to HIV negative partners if the patient is on medication which effectively suppresses the virus. One explanation for the increase in transmission is that a subset of HIV positive men are not compliant with their medications due to depression, drugs or forgetfulness. Also co-infection with a sexually transmitted disease can possess sufficient concentrations of resistant HIV in the genital tract secretions to transmit to uninfected sexual partners. “This study is not the first to document that some individuals are newly infected with resistant virus [27] and that syphilis is increasingly common in HIV-infected MSM [28, 29], but the combination of these factors and their association with an expansion of a national HIV epidemic heightens the acuity of the concern that a new generation of MSM could face an AIDS epidemic with constrained therapeutic choices.”

Why is this happening? 
 
Therapeutic optimism is only part of the explanation. Since the earliest days of the epidemic, affective disorders, like depression, as well as substance use, have been associated with unprotected sex and multiple partners [30, 31]. For some, early life experiences, ranging from sexual abuse to homophobic violence, may result in decreased self-efficacy and lowered self-esteem [32]. The use of disinhibiting drugs and unprotected sex may serve a depressed MSM as ways to “self-medicate” in an adverse environment [33, 34]. These conditions not only tend to co-occur, they synergistically interact to enhance the risk of engaging in unprotected sex and becoming HIV-infected [35]. Thus, attenuating the spread of HIV among MSM requires the scaling up of evidence-based programs that not only encourage HIV testing, linkage to care, and treatment, but also engage providers in the provision of culturally competent care to sexual and gender minority patients [36]. For example, drug treatment programs that are tailored to substance-using MSM have been shown to be more effective than those that do not acknowledge the participants’ sexuality [37]. Unfortunately, many MSM who engage in practices that put them at risk for HIV and other sexually transmitted infections (STIs) report that they are not always comfortable disclosing their behaviors to their medical providers [38, 39], creating multiple missed opportunities for slowing the epidemic every day around the world.
 
The last patient I diagnosed with HIV had been my patient for over five years. He was very distraught to learn he was HIV positive, and so I encouraged him to see a therapist. When the therapist called to confer with me, he asked if I knew the patient had a crystal meth addiction. I did not. Even after five years of treating this man, he denied ever using drugs whenever I asked.

“The Israeli study holds a mirror to the future of the epidemic in this population, suggesting that MSM should not assume that their partner is HIV-uninfected, and if he is infected, it is unwise to assume that his medication will make him noninfectious.

2 Comments

  1. Posted May 25, 2011 at 9:06 pm | Permalink

    Are you aware of the numbers of these patients practicing safe sex as oppose to those who are intentionally ‘bare backing’? And how do you think this relates to the ‘bare backing phenomenon?’

    I have been expecting some type of effect on society due to barebacking for many years now. I don’t know what type of research is available.

    Do people who practice unsafe sex generally even use medications? It seems to me that there are a large number of unmedicated people who practice unsafe sex and remain apparently healthy but I am not close enough nor studying the issue so do not know.

    It doesn’t seem to make sense that a compliant patient would also expose himself repeatedly, however I could see the faulty logic behind allowing a medicated individual to expose a non-infected person.

    I can not begin to comprehend the logic behind intentional infection or denial of a disease other than the folly of youth or having fallen victim to one’s own psychology…

    I wish people understood more about the virus as a living entity and would be of the mind set that we as individuals need to work as individuals to do what we can to prevent IT from continuing to feed on and host off of humanity.

    People remain primitively stupid.

  2. Peter
    Posted June 8, 2011 at 4:43 pm | Permalink

    It’s sad that so many decades have passed since AIDS and HIV studies clearly indicated unprotected sex as a primary source of the disease. Every time a fancy fund raising dinner for AIDS/HIV was hosted, NOBODY openly talked about the resurgence of barebacking. It’s ironic, that so many in a community of people, would be in denial to speak honestly about the practice of barebacking. I always had the impression that when people pay for a dinner at one of these fund raisers, and dress up in fancy clothes, it is somehow antithetical to the truth about the number of gay men continuing to practice unsafe sex. A great deal of money is raised for research, but no honest and direct reflection is spoken about, (what I call) the gay men’s community, “dirty little secret.”
    Why do I call it that? First, let’s look at all the bareback blogs on the internet. The one’s that champion unprotected sex. Second, let’s look at Craigslist and other web-sights where men advertise for unprotected sex. Third, let’s look at all the porn that shows barebacking. Where has the ‘gay community’ been and why have so many turned a blind eye to this? Is this openly discussed at the “fund raiser” dinners? Of course not. Nobody want’s to be seated at a $500 a plate dinner, dressed in their finest, and listen to the graphic and dark underside of what’s been going on. This is called a ‘lacuna.’ A gap, or space. A blind spot in the awareness discussions.
    For many years, gay publications and other media outlets just don’t want to discuss it. Why? Because it’s graphic. We have to not only say, but visualize the unprotected penis being inside the anus. Who want’s to think of such things dressed in a tuxcedo?
    It’s been two decades that unprotected sex has been on the rise. And now, you see the results weekly in your medical practice, of the resurgence of new HIV cases. And you are seeing just the tip of the iceberg. You don’t see the men who are asymptomatic practicing unsafe sex. You don’t see the men who just don’t care. You don’t see the men who are too depressed to continue treatment, or, because of certain drugs, too high to care.
    What about the Doctor’s who prescribe testosterone to men, but don’t mandate weekly counseling to those men to address the heightened sex drive they will surely have. And we all are very aware of the direct link between testosterone and impulse control. Add alcohol and or drugs to the mix, and it’s a prescription for the spread of the disease.
    I in no way imply that all men are irresponsible. I know that we all have lapses of judgement. But, as a community, we all need to be vigilant and responsible to do what we can.
    I am not against fund raisers for HIV/AIDS research. I just think that the “research” is useless unless we stop the unsafe sex. It worked in the early years of the 80′s. Then, it was fear that motivated safer sex practices. Now, it should be knowledge that motivates men to be safe.


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