HIV - It’s just not cricket

Although the HIV story is rosier nowadays compared to yesteryear, there are still plenty of challenges ahead, says Sanjaya Senanayake

Like millions of Sri Lankans, I watched the cricket World Cup Final on April 2 and although the result was dreadfully disappointing, nevertheless I was filled with pride that Sri Lanka claimed a place in the final - a feat that other cricketing giants failed to achieve.

The other memory of the 2011 World Cup that filled me with pride took place off the cricketing field. It was a story about the Sri Lankan team visiting people with HIV in India to highlight the stigma and problems that confront these people on a daily basis. In addition, Kumar Sangakkara is a Champion for the Think Wise programme - a collaboration between the ICC, UNICEF, the Global Media AIDS Initiative and UNAIDS to promote awareness of HIV/AIDS.

As an Infectious Diseases specialist, I am so glad to say that we are in a much better place than we were 20-25 years ago when it comes to HIV. At that time, a diagnosis of HIV often meant progression to AIDS and death because the drugs weren’t there to provide effective treatment. The advent of combination antiviral therapy means that HIV-positive patients can lead normal lives on therapy.

Whereas in the past, looking after an HIV-positive patient meant treating exotic infections and cancers, nowadays it’s more about controlling their cholesterol! But does this mean we can close the book on HIV and forget about it? Unfortunately, no.

Although the HIV story is rosier nowadays compared to yesteryear, there are still plenty of challenges ahead. We still can’t cure HIV - patients have to remain on drugs for life. And while there are plenty of drugs to combat HIV, they may not be readily available to everyone, especially those in the developing world. Some people can’t tolerate the drugs due to side effects; others develop resistance to the medications. Don’t forget the discrimination. Although societies are more accepting of people with HIV than in the past, in many parts of the world a diagnosis of HIV carries with it enormous stigma and discrimination, the basis of which is often irrational. Many readers would be surprised to learn that there are still travel restrictions to a number of countries for individuals with HIV. Even such a progressive nation as the United States only lifted its ban on entry for HIV-positive patients in 2010!

Such negative attitudes can be detrimental to the individual and society as a whole. This is because people with HIV will refuse to be tested because they don’t want to be labelled with an infection that will stigmatize them for the rest of their life; therefore, they never get diagnosed, never get treated and may inadvertently pass the infection on to others since they are unaware that they are infected.

And despite the improved longevity achieved with combination therapy, people with HIV are still around 50% less likely to reach 70 years of age than someone without HIV. And have the numbers of HIV cases dwindled to an insignificant trickle? Not at all.

Current figures estimate that over thirty million people have HIV worldwide. About 2/3 of these live in sub-Saharan Africa. But more worrying than this overall figure is that there are over two million new cases of HIV annually - that’s over 7000 new cases per day! Of those two million cases, every single one is preventable. Also, while the advent of effective anti-HIV drug therapy is great, it has a downside: some people are less afraid of contracting HIV because they believe that effective therapy is available - so they are less likely to practise safe sex and put themselves at higher risk of getting HIV or other sexually transmitted infections.

There are number of medical strategies being trialled to prevent people getting HIV. In men, circumcision has been quite a revelation. Studies show that circumcised men are 50-60% less likely to get HIV through heterosexual sex than uncircumcised men. The jury’s still out on its effect in men who have sex with men. The benefit of circumcision probably relates to the fact that the foreskin provides a moist sheltered environment in which it is easier for HIV to survive. Also an uncircumcised penis probably has to “toughen up” without the foreskin to protect it. Circumcision has now become a valuable public health intervention in preventing spread of HIV, particularly in parts of Africa.

It is worth recollecting that HIV isn’t a disease of men alone. About 50% of the thirty million cases of HIV worldwide are women. Many of these women live in societies where HIV and being female by themselves can lead to difficulties, but together create a sinister synergy of stigma. In addition, these are often women of childbearing age who can transmit HIV to their unborn baby if appropriate treatment isn’t given during and after pregnancy.

One exciting finding in preventing HIV in women has been the use of a vaginal gel containing an anti-HIV medication. The use of the gel within a few hours before and after sex led to a 40-50% reduction in the risk of getting HIV. An unexpected benefit was that the gel also reduced the risk of getting genital herpes by about 50%. Apart from genital herpes being a serious infection by itself, having herpes also increases the risk of getting HIV; therefore, reducing the chance of getting herpes has two benefits.

In 2011, HIV is still a long way from being eradicated. But through a combination of medical research, progressive social attitudes and strategies for its prevention, there will be light at the end of the tunnel. So well done to Kumar and the boys - not only for making the finals - but also for highlighting issues around HIV.

(The writer is Associate Professor of Medicine, Australian National University)

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