It won’t happen to me… FAMOUS LAST WORDS
HIV / AIDS in the Gay Male Community
I hope that some of you out there saw yourselves or friends in the sexy summer edition’s article on body obsessions. It is a rising reality guys.
Well it’s this time of year again being faced with the realities of our times. It had come to my attention that gay men especially are so naïve about the whole HIV / AIDS issue it is actually scary. Yes I can see those queens going: “Oh, not another thing on moffies and HIV”. I know, I know, I know, but I think it’s time to leave the knitty gritty detail behind and focus on what is actual and applicable to the gay male scene currently.
The year 2006 marked the 25th anniversary of the first reported cases of HIV / AIDS. It was initially diagnosed in the US amongst homosexual men. Despite significant success in reducing HIV / AIDS rates amongst homosexual males in the late 1980s and early 1990s recent data indicate that HIV infection is resurging among this group.
People ask me what about blow jobs, kissing, rimming, anal sex… Well the sad thing is that there is no real hardcore (pardon the pun) evidence on transmission percentages. Some statistics will be released later in the article.
What is the difference between HIV and AIDS and what is all this CD4 talk
CD4 cells are a specific line of white blood cells (the soldiers that protect us against infection) that are attacked and lowered over time by HIV.
Table 1 : Ranges of Number of CD4 Cells:
| Normal CD4 Count | > 500 – 1000 x 106 / L |
| HIV | > 200 x 106 / L |
| AIDS | <>6 / L |
When the CD4 count lowers the risk of infections are on the up rise. Common opportunistic infections are as follows:
· Oral or Oesophageal thrush / Candida
· Pneumonia (Bacterial / TB / PCP)
· Meningitis (Viral / Bacterial / Fungal)
· Chronic diarrhoea
· Shingles (“gordelroos”)
· Oral Herpes (“koorsblare”)
· Sepsis
Other symptoms and signs that accompany HIV infection are loss of appetite, loss of weight (the so called “slow puncturing”) and generalised lymph glands (lumps underneath the chin, in neck, under armpits, middle inner side of arms, groin etc).
To give you some perspective for the South African gay and straight population
I was at a World Aids Day event on the 1st of December 2006 and the premier of the Western Cape, Ebrahim Rasool, quoted that 24 000 HIV positive patients are on ARVs (Anti Retro Viral Drugs) in the Western Cape. This statistic excludes those diagnosed but with CD4 counts > 200 x 106 / L. I worked as a community service doctor at Khayelitsha Site B CHC (Community Health Care Centre) from July to December 2006. There, 3000 - 4000 HIV positive patients are treated with ARVs, this is costing the government around R750 000 per month (between R250 - R350 per patient per month) just at one clinic.
The reality is then that 6 – 8 % of HIV positive people on ARVs in the Western Cape are treated at Khayelitsha Site B CHC.
HIV is all around guys and girls and we can’t ignore it because of our own ignorance and thinking that it won’t happen to me.
What increases susceptibility to HIV infection and put homosexual males more at risk
1 Biological Risk Factors
Anal Intercourse does increase an individual’s risk. Both vaginal and anal / rectal epithelium cells have receptors that easily bind to HIV. HIV receptive cells have been identified in the mouth, vagina, foreskin, urethra and rectum. Although vaginal intercourse have been shown to be an efficient route for transmission, rectal tissue is much more vulnerable to tearing during intercourse and the large surface area of the rectum and colon provides more opportunity for HIV penetration and infection. For these reasons, unprotected anal intercourse is believed to be at least 10 times more risky than unprotected vaginal intercourse for acquiring HIV.
Stage of infection influences HIV infection and transmission.
Late stage / AIDS (Acquired Immunodeficiency Syndrome)
· CD4 <>6 / L (LOW CD4 Count)
· In brief the lower the CD4 count the higher the viral load (viral amount in bloodstream).
Primary infection / “Window” Period
· Occurs during the period between first exposure to HIV and the appearance of antibodies against HIV in the bloodstream (AKA Seroconversion).
· Seroconversion happens around 3 weeks to a month after exposure.
· Reason is that viral loads are higher at the time of seroconversion and thus a peak in the transmissibility of HIV soon after a person is infected.
NB ARVs (Anti Retro Viral Drugs) is associated with a 50 % reduction in the sexual transmission of HIV and slows the progression of the disease and thus have an effect on the stage of infection. Important to remember that ARVs does not cure HIV / AIDS but “freezes” the virus, thus lowering viral load and increasing the CD4 count. This in turn improves the immune system and quality of life.
The presence of other STDs (Sexually Transmitted Diseases) facilitates HIV acquisition.
Genital ulceration (Syphilis, Genital Herpes, Chancroid etc)
Increases relative risk for HIV infection by 1.5 – 7 times (especially Genital Herpes).
Genital discharges (Gonorrhoea, Chlamydia, Trichomonas etc)
Increases relative risk for HIV infection by 60 – 360 %.
NB It is important to mention at this stage that if you contracted an STD it is of utmost importance to also get yourself tested for HIV. Hopefully to exclude HIV infection. It is also vital to realize that Hepatitis B Infection (presenting with jaundice) is 80 times more infective than HIV and is part of the STD spectrum of disease.
Male circumcision has a protective effect against HIV infection because the presence of foreskin indicates more receptors for HIV binding sites. The prevalence of HIV infection is 1.7 – 8 times higher in men with foreskins than in circumcised men (so there you go those guys who are into cut cocks…).
2 Behavioural Risk Factors
Specific sexual acts increase the risk of HIV infection.
Unprotected Receptive Anal Intercourse > Unprotected Insertive Anal Intercourse > Oral Sex
Table 2 : Estimated per act risk for acquisition of HIV by exposure route
| Exposure Route (Without Protection) | Risk / 10 000 Exposures From An Infective Source | Percentage (%): |
| Kissing | None | 0 % |
| Giving Oral Sex | 1 | 0.01 % |
| Receiving Oral Sex | 0.5 | 0.005 % |
| Passive Anal Intercourse (Bottom) | 50 | 0.5 % |
| Active Anal Intercourse (Top) | 6.5 | 0.065 % |
| Needle Pricks / Sharing Needles | 30 – 67 | 0.3 – 0.67 % |
| Blood Transfusion | 9000 | 90 % |
| Penile-Vaginal Intercourse | 5 – 10 | 0.05 – 0.1 % |
Multiple sexual partners / Steam rooms / Sex clubs
Inconsistent condom usage
Lack of knowledge and ignorance about HIV and its risks
Negative attitudes towards safer sex
Drugs (especially TIK / Crystal [Methamphetamines] and Poppers) and alcohol use leads to lowered sexual inhibition and increased likelihood of unsafe sex
Depression
Young gay males especially with a history of sexual abuse
The Internet (personal advertisements and chat rooms like Gaydar, Mambaonline etc). Studies have found that gay men who use the internet as a means to find sex partners are more likely than other men to report an STD and are more likely to engage in risky sexual behaviour.
3 Socio-Cultural Risk Factors
Experience and perceptions of homosexual stigma and discrimination
Homophobia
Racism
Internalized oppression and denial of ones sexuality
Drug and alcohol usage
Poverty / Unemployment / Lack of Health Care Access. In South Africa studies supported a recent review that indicates that black homosexual males are more likely than other homosexual males to contract STDs that facilitate the acquisition and transmission of HIV and are also less likely to be tested for HIV or to know their HIV status
Optimism about the availability en efficacy of HIV therapies (ARVs) has been associated with sexual risk behaviour especially in younger gay males. This reduces the individuals concerns about becoming infected and rationalises unsafe sexual practices.
HIV Prevention Interventions and the future
There are 3 main areas of prevention of transmission and infection:
1 Behavioural Interventions
· Encouraging condom usage
· Encouraging safe sex rituals
2 Early detection and treatment of STDs
3 Biomedical approaches (THE FUTURE)
· Pre-exposure prophylaxis (PrEP)
· Rectal Topical Micro biocides (Non-Oxynol 9 Formulations etc) and Douching
· Vaccines
NB However, the introduction of vaccines could intensify the epidemic if risky sexual behaviour increases as a result of the perception that vaccines give total protection from HIV infection.
How do I test for HIV?
1 HIV Eliza test
· Tests for presence of HIV antibodies in the bloodstream
· Will test negative in the “Window” period before seroconversion
· Individuals become HIV antibody positive around 3 weeks to a month after exposure.
· Less expensive (Around R80 - State Hospital Rates)
2 HIV PCR test
· Replicates and multiplies HIV DNA
· Can identify HIV even within the “Window” period
· Individuals become HIV DNA positive around day 12 after exposure
· More expensive (Around R400 - State Hospital Rates)
Conclusion
There is a great deal of scientific evidence supporting the effectiveness of HIV prevention interventions for homosexual men. Despite these interventions, recent increases in HIV diagnoses indicate that those prevention efforts have not been scaled up and intensified sufficiently to curb the spread of HIV infection in gay domestic and the gay international population.
Difficulties in collecting accurate data on HIV infection in gay males in South Africa and ongoing stigma and discrimination against gay, bisexual and transgender people remain significant barriers to implementing effective interventions.
Adequate resources must be dedicated to improving accurate data collection, addressing the socio-cultural issues that contribute to gay male risk sexual behaviour, and implementing evidence-based behavioural, biomedical, and social interventions that address growing rates of HIV infection in multiple settings.
This information was made available with the help of my esteemed colleague Dr Craig Corcoran, a Consultant at the Medical Virology Department at Groote Schuur Hospital in Cape Town.
