An inconvenient truth

Most people who have HIV became infected with the virus as a result of unprotected sex, and the majority of people with HIV remain sexually active following their diagnosis. This might seem obvious, but many people, including some professionals working in HIV, find this uncomfortable, even shocking. They need to get real.

This edition of HIV Weekly summarises a small Spanish study that looked to see what the risks of HIV transmission were in heterosexual couples where one partner was HIV-positive and taking antiretroviral drugs, and the other HIV-negative, who had unprotected sex to conceive. There were no cases of HIV transmission.

That’s not to say that there was no risk of HIV transmission – people taking HIV treatment, even if they have an undetectable viral load in their blood – are still potentially infectious as viral load in the blood and genital fluids can be different.

It should also be noted that the study was small – it only included 62 couples – and its design was such that no real conclusions can be drawn from it (and please don’t use this report as an excuse to put yourself or somebody else at risk of HIV or any other infection, and remember, people have been prosecuted and imprisoned for the reckless transmission of HIV in this country).

But the study did show how many people live in the real world. Rather than ignore or wish this away, it needs to be taken seriously. A good way of finding out about how people with HIV live their everyday lives is by reading the personal testimonies in NAM’s book Living with HIV . Free copies to HIV-positive people in the UK are available by emailing info@nam.org.uk. An excellent website has also recently been launched called www.dipex.com/hiv, where 50 people talk frankly about their experiences of the virus.

Drug resistance

HIV treatment

Ritonavir-boosted protease inhibitors provide important treatment options for many people with HIV. They are now used at all stages of HIV therapy, and two drugs that are particularly popular for first line anti-HIV treatment are lopinavir/ritonavir (Kaletra) and saquinavir/ritonavir (Invirase).

A head-to-head study, sponsored by Roche, the makers of saquinavir, has been conducted. It found that people taking either drug were equally likely to experience a fall in their viral load to undetectable levels, but after eight weeks, five people taking saquinavir/ritonavir had experienced a “rebound” in their viral load to above 400, compared to two people taking lopinavir/ritonavir.

The researchers also found that the same proportion of people taking either drug stopped treatment because of side-effects. However, after six months of treatment, the researchers found that more patients taking lopinavir/ritonavir had experienced a significant increase in levels of blood fats than people taking saquinavir/ritonavir. Long-term elevations in blood fats and blood sugars that some anti-HIV drugs can lead to an increase in the long-term risk of health problems such as heart disease.

Pregnancy and conception

Many HIV-positive people become parents after their diagnosis with HIV. Artificial methods of conception do not involve any risk of HIV transmission should one partner be HIV-positive and the other HIV-negative, and work just as well when people with HIV.

But, artificial conception is very costly and does have a high failure rate.

It is well known that many people with HIV have unprotected sex with HIV-negative partners. This involves an obvious risk of HIV transmission, but it is known that potent anti-HIV therapy does reduce the amount of HIV in sexual fluids and can reduce the risk of a person with HIV transmitting the virus to another. It’s important to remember, however, that viral load in blood and sexual fluids can differ and it cannot be automatically assumed that a person is unifectious because their blood viral load is undetectable . Indeed, studies have found that many people with undetectable viral loads in their blood have virus present in their genital fluids.

Now a Spanish study has found that 62 “discordant” (i.e. one partner was HIV-positive, the other HIV-negative) couples who had unprotected sex leading to pregnancy did so without transmitting HIV.

In all cases, the HIV-positive partner was taking potent anti-HIV therapy.

But the researchers add some cautious words about this finding.  First of all, they note that their study was “retrospective” (i.e. it looked back at patients’ medical records). They were unable to say how many times each couple had unprotected sex, and they stress that they are unable to draw any conclusions about the risks of HIV transmission for mixed-status couples having unprotected sex to conceive.

Another finding of the study was that the babies of HIV-positive women taking HIV treatment were five times more likely to die in the womb than those of HIV-negative women in the study. This was a very small study, so it is not possible to read too much into this finding. There is currently a lot of debate about the risks of HIV therapy to the development of a baby in the womb – the main concerns are about birth weight and premature birth. Results of studies are conflicting, but on the whole, doctors are optimistic that HIV treatment does not pose a significant risk to babies in the womb.