HIV: Two Patients Face The Diagnosis

I frequently meet with patients who have recently been diagnosed with HIV infection. Some of these individuals have been tested for HIV on a regular basis and know that they have just recently been infected, while others had not been previously tested and are unaware of when the infection might have occurred. People who are dealing for the first time with the realization that they are HIV-infected have provided me with a great deal of insight as to how and why HIV is still being transmitted, as well as what the current understanding of HIV disease is in the community. Two patients I recently met very aptly demonstrated some of these issues.

One patient was a 45 year old homosexual man who had been tested approximately every year for the last 7 years and was told that his most recent HIV antibody test was positive. After the test was repeated, he was referred to me for further evaluation. Needless to say, he was upset and confused. As is usually the case, he was perplexed as to how he became infected as his pattern of behavior had not changed during the past 7 years. In fact, he stated that he was sexually active with only 4 men in the last 2 years and always used condoms during intercourse and was unaware of any incidences wherein the condom broke. He did admit to oral sex without condoms but did not believe that this could be how the HIV was transmitted since he had been engaging in this activity for 10 years and had never become infected in the past. --- Misconception #1. I explained to him that while transmission could have occurred from a condom break or leak, it was also possible that it occurred as a result of oral sex. Although this is an activity that is less risky than intercourse, it does represent a potential means of infection.

We then discussed the natural course of HIV disease and I explained to him that with good medical care I was confident that he would do very well with his infection. I also told him that I anticipated that he would remain free of any AIDS-defining complications for decades. Although he was pleased to hear this, he was surprised and initially not convinced. He believed that HIV infection and AIDS were essentially the same and that it was only a matter of months to a few years before he would be ill. --- Misconception #2. I explained to him that the average time from the initial infection to the onset of symptoms of AIDS in those who do not have access to HIV drugs (antiretroviral therapy) is estimated to be 8 to 10 years. With treatment that is appropriately followed, it is conceivable, and frankly expected on my part, that he could remain healthy for years to decades beyond this period. Finally, we discussed the potential role of antiretroviral therapy. He told me that he believed that therapy would require taking dozens of pills a day and that he would suffer many side-effects. He also thought that treatment would need to be initiated as soon as possible. --- Misconception #3. I summarized for him how the HIV viral load and CD4 cell numbers are monitored in deciding when therapy should be started and that many people can defer therapy for years. Moreover, we discussed that there are currently 15 approved drugs that are used in 3 or 4 drug combinations, many of which require taking as few as 1 to 6 pills twice per day. In addition, I explained the types of side effects that might be expected and the fact that with the many options available, most people can find a regimen that is tolerable. By the time this patient left my office, he realized that while the diagnosis of HIV will forevermore be a part of his life, it was a part that he was going to be able to live with. This is the first step in dealing with the psychological trauma associated with this diagnosis.

A second patient I met approximately 12 months ago was a 33 year old heterosexual female who had no history of intravenous drug use and had only had sex with 3 men in her entire life. As far as she knew none of them were bi-sexual or used intravenous drugs. I met her when she was in the hospital after having been admitted with pneumonia that failed to respond to routine antibiotics. She ultimately underwent a bronchoscopy and was found to have Pneumocystis carinii pneumonia. Subsequent HIV testing was found to be positive and her CD4 cell count was measured at 20 cells/uL. She too was devastated by the diagnosis and perplexed as to how she acquired the infection. I explained to her that in all likelihood, it was from one of her previous partners and that she probably became infected many years ago since it would have taken on average 8 to 10 years for the disease to have progressed to her current stage of immune suppression (represented by the significantly low CD4 count). Furthermore, I told her that heterosexual women represented one of the fastest growing groups of newly infected individuals.

Unlike the previous patient, she had already progressed to severe immune suppression and was in need of antiretroviral therapy. While the prognosis prior to 1995 for someone in her situation would have been poor, with currently available treatments, there was reason for optimism. Although emotionally distraught and terrified, she completely recovered from her pneumonia and ultimately started an antiretroviral regimen that included a protease inhibitor. Although she initially experienced some nausea and diarrhea, these symptoms cleared and she has tolerated the treatment very well with no missed doses during the last 8 months. Her CD4 cell count has increased to between 300 and 450 cells/uL and her viral load has remained undetectable for the last 6 months. She is seeing a therapist to help her deal with the psychological issues surrounding her new diagnosis and is feeling great. She comes in regularly for monitoring and asks me, "How am I doing and how long will I be able to stay healthy?" I always respond that she is doing great, which is true, and that while I do not have a crystal ball, my belief is that as long as she stays on her therapy, the sky's the limit.

We have seen unprecedented advances in the management of HIV disease and can offer hope to people in both the early and late stages of HIV disease. Nevertheless, new infections continue to occur. The focus needs to remain on the prevention of transmission and regular testing to assure early diagnosis. Once a diagnosis of HIV infection is made, establishing a comfortable relationship with a health care provider who has expertise in managing HIV disease will allow patients to live with HIV as a chronic, yet controllable disease. For more, please see the HIV review article.

Medical Author: Eric S. Daar, M.D.
Medical Editor: Leslie J. Schoenfield, M.D., Ph.D.

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