Article Title:HIV specialist: "It
Author or Credit:Chris Banks
Published on:14th March 2004 - 12:00 pm
Story ID:176
Text:An Auckland-based specialist who treats patients with HIV believes it's time for a reality check amongst the gay community regarding what living with HIV really means. Chris Banks talks with Dr Mark Thomas. We're living in a time of increased HIV infections, drug-resistant viruses, limited access to new HIV treatments, and public fatigue over the safe sex message. It would seem that there are people in our community who don't comprehend the dangers of HIV, or don't care. And in some ways, who can blame them? There seem to be a lot less sick and dying people about the place, after all. The early 90s wave of deaths is a distant memory now, so why should we be scared about HIV? “Well, anything to do with AIDS is scary,” says Auckland-based infectious diseases specialist Dr Mark Thomas, who year after year has treated patients with HIV. “You don't have to see too many people die of AIDS to know it's a bloody horrible disease. And anything that means that more people are going to die of AIDS is not what we want.” Taking a second to look at what HIV does to the human body is enough to make anyone scared. Once the virus enters the body through a break in the skin, it gets picked up by the filters of your immune system, which promptly attempts – as it does with any infection – to kill it. Problem is, it can't. Once it's inside you, it starts to multiply. And for those who still think modern drug combinations can fix the problem, they can't kill HIV either. “The drugs that are available in New Zealand work in two different ways; they either stop the virus making a copy of its genetic material, or they stop the virus maturing after it's been released from the infected cell,” says Dr Thomas. “It slows the production of more virus to the body, but there's no way that drugs can eradicate it completely.” The HIV virus doesn't just play hide and seek with your immune system though. It sets out to destroy it, one cell at a time, specifically your T-cells, which work to protect you from all manner of illnesses. If your body was a car, HIV would hijack it, drive it to the worst part of town, then leave it by the side of the road with the windows down and the keys in the ignition. It's important to understand that it is combinations of drugs, and not any one drug, that is your best chance of containing HIV once you have it. In the early days of the epidemic, single drugs – such as AZT – were prescribed, but eventually the virus would overcome them, forcing the patient to move onto a second drug, starting the process again. Ironically, these early forms of HIV treatment are now partially responsible for the drug-resistant strains of the virus that have made HIV potentially more life-threatening. Some men getting sick now have a ‘supervirus' of sorts that has been created through medical treatments. But if you were to be infected and diagnosed with HIV tomorrow, you'd be all right wouldn't you? The drug combinations we have available now are better, aren't they? “In a person who's got a virus that is not at all resistant to the drugs we use – a virgin virus you might call it – a combination of three drugs will, if taken absolutely reliably, reduce the production of virus to virtually zero,” says Thomas. “You can control the production of virus, that then allows the immune system to recover.” But eventually the virus gets cleverer than the drugs? “Not necessarily. The virus only gets cleverer if it gets a chance to make copies of itself, and if you can take your perfectly-working drug combination absolutely reliably and consistently, then the virus never gets a chance to make copies of itself.” It may even be possible, Dr Thomas says, that someone with HIV could have a normal life expectancy these days. Although it is not entirely certain at this point in time, with people who take their pills “absolutely meticulously”, it would appear that the virus is controlled. However, we need to define what “absolutely meticulously” means. Taking the pills means taking the pills. Miss dosages and you could be eventually signing your death warrant, as well as helping to create a new drug-resistant strain of HIV. “This is a virus that if you take less than 95% of your doses, then the virus starts multiplying. And if it multiplies, then it will produce mutants, and for sure one or more of the mutants will be resistant to one or more of the drugs that you're taking, so that if you don't take them reliably, you'll get a drug-resistant virus.” It's like a robber running from a bank with three policemen chasing him down the street, but in order to keep up with him (let alone catch him) the three policemen have to be holding hands the entire time. “Imagine you've got HIV, you've got a virgin virus – completely sensitive to drugs. Your immune system gets damaged sufficiently that you now have to start on pills because if you let it get damaged any more you're going to develop AIDS,” says Dr Thomas. “So you start on your HIV medicine, and you decide the combination your doctor's given you is pretty good, but it's probably a bit too strong. So instead of taking all the pills all the time, you'll take most of them most of the time.” “Or else you think the combination's just fine and the doctor's got it just right, but hey, you have a couple of drinks on Friday night and you forget to take your pills, you feel a bit hungover on Saturday and you miss your pills then too because you don't wake up till 3 in the afternoon, and on Tuesday you stay at your boyfriend's place and your pills aren't there... there are all sorts of other scenarios too, which basically mean you don't take your pills reliably.” Taking your pills reliably means on average one pill in the morning and two at night. Some people are taking pills up to three and four times a day, though, and the side effects are not pretty. Some can be relatively mild, but others are more dramatic. There's diarrhoea, nausea, indigestion, but also some scarier long-term effects. “A lot of the pills cause changes in the way that fat is distributed in the body. There's a term for it – lypodystrophy. This is where people lose fat from their arms, legs and face and deposit it in their abdomen. The particularly unattractive part of that is losing fat from the face, because it gives people a very gaunt appearance. That seems to be partly a result of the drugs and partly a result of people living longer with HIV.” The side effects are a roulette wheel. Pills affect different people in different ways. You may find you don't have any problems, or you may find the side effects so horrific that not taking the drugs is a preferred option. Dr Thomas says this does happen in some cases. With 93 new infections amongst men who have sex with men in 2003, 93 more men will be introduced to the wonderful world of HIV medication, and all that that entails. Provided they can cope with the side effects, and don't miss taking their pills, they could be OK. But are the drugs really a solution? Have we just managed to delay the inevitable? “What we'll end up with is essentially two populations, people who are taking the drugs absolutely reliably whose virus is under control, and who aren't going to die of HIV, and they'll make up about 50 or 60 per cent of the infected people,” says Dr Thomas. “Then we'll have people who haven't been taking their drugs reliably, or have been infected with a resistant virus from somebody else. They'll end up eventually with their immune system being destroyed, and end up dying of AIDS.” Dr Thomas says this is a while off yet. Five, ten, maybe fifteen years. But it is still going to happen. What can we do to stop it? With all of the changes in medical treatments, what does Dr Thomas believe the major issues around HIV prevention are today? “Condoms, condoms, condoms. Still the core issue,” he says. “Many people report that they're sick of using condoms and don't want to use them any more. I deal with the consequence of what people do about that. I think that the message is that people are still dying of AIDS. Some of them are dying before they get their HIV infection diagnosed so you can't be completely complacent.” What about HIV testing? Should we be concentrating on promoting testing so that those who have HIV aren't unwittingly transmitting it to others? “I think that is helpful, but I think that if you looked at the number of people with HIV in New Zealand, probably most of those who are infected know they've got it. For many people, if they know they've got HIV infection, it changes their sexual behaviour, but for some it doesn't. So I don't believe testing is a 100% reliable way of preventing infection – a condom is.” So we may be able to help people living with HIV, but there's still only one reliable way to avoid getting it. “The gay community needs to really think seriously about what they're doing to themselves, which is placing themselves at risk of dying of AIDS and of having to suffer a serious unpleasantness with the sort of medication that they are required to take to control HIV,” says Dr Thomas. “We've benefitted greatly from extremely good programmes put in place by the Ministry of Health and by the AIDS Foundation in the past, but... fatigue and complacency have moved in and now we're having to focus again on the problem.” Chris Banks - 14th March 2004    
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