Once detected, HIV can be manageable

Ten years ago, an intelligent, reserved software engineer — a woman with the complexion of Halle Berry and the physique of a marathoner — came to my infectious-disease clinic, accompanied by her fiance.

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They’d been referred to me a few weeks after a rash and pneumonia prompted a clinic doctor to test the woman for HIV. The test came back positive. Her fiance, tested later, was HIV-negative.

Choosing my words carefully, I answered their questions about their future relationship, emphasizing condom use as well as blood and body fluid precautions. They married as scheduled, and I placed her on a regimen of four medications: eight pills daily, taken at three different times throughout the day. As time went by, her health and immune system improved.

A few years after her diagnosis, my patient told me that she and her husband wanted to have a child. Concerned about the risk of transmitting HIV to her husband if they stopped using condoms, I said I would refer her to an in vitro fertilization clinic. But before I could do that, my patient informed me that she was pregnant.

A nearby academic medical center delivered her son by Caesarean section, using all precautions to protect the baby from infection. And it worked: He was healthy and HIV-negative. My patient did not breast-feed — again, to avoid transmission risks — and managed well as a new mother. Soon she went back to work and even got a promotion, to software manager. Some years later, she delivered a second son, also by C-section, also HIV-negative.

Her husband regularly took HIV tests; all were negative. (Not every unprotected sexual encounter results in infection, but it’s a kind of Russian roulette I don’t recommend.)

Over the years, my patient tolerated the usual side effects of the HIV medication: nausea, diarrhea and a rash. Her insurance covered the cost, so for a long time the most troublesome part was the pill burden and the regimented schedule. Since only her parents and husband knew of her HIV status, carrying pills to work or to a dinner party was awkward.

Then, several years ago she switched to Atripla, which combines three medications in one pill, taken once a day. Life became easier.

Her story is a remarkable chronicle of the advance of medicine and strong evidence of the importance of testing. Not only can my patient expect to live a relatively long and productive life, she can do it with the love and support of a healthy husband and children. None of this would have been possible without early detection and proper adherence to an HIV regimen.

In the early years of HIV, I recall feeling helpless as my patients’ bodies succumbed to the relentless attacks by the virus. As their immune systems disintegrated, common bacteria, parasites or tuberculosis organisms would infect their lungs or a usually innocuous fungus would invade the deep tissues of their brains, and eventually they died.

But in the mid-1990s, researchers developed HAART (highly active antiretroviral therapy) medicines that in various ways arrest the growth of the virus, reducing it to “undetectable levels.” Over the past decade and a half, for many in the developed world, HIV has become more like diabetes or hypertension: a chronic disease instead of a death sentence.

But to treat infected people, doctors have to know who has the virus. That is where testing and screening come in. My patient was told to get an AIDS test when visiting a doctor for other problems; what if she hadn’t? What if she had never been tested? What if she had unknowingly infected her future husband?

Today’s screening tests are 99.5 percent sensitive in spotting the disease. (By comparison, a mammogram is only about 80 percent sensitive in detecting breast cancer.) We have not yet made the most of screening because we refuse to reshape our thinking. We are caught up by the mistaken notion that HIV, and subsequently AIDS, is a terminal illness. Also, many still incorrectly believe that the stigma of being HIV-positive outweighs the benefits of early management, treatment and containment of the disease.

More than a million people in America have HIV, according to the Centers for Disease Control and Prevention. One in five are unaware they have the virus; they are responsible for transmitting more than half of the 56,000 HIV infections that occur annually. In 2006, the CDC recommended that a one-time HIV test become routine for all persons between ages 13 and 64, and that those with high-risk behavior such as intravenous drug use and multiple sexual partners be tested annually. Sadly, these recommendations are not followed comprehensively, and too few people are being screened.

Ten years down the line, my HIV-positive patient mentioned new methods that can lower the risk of mother-to-child transmission of HIV without a Caesarean section. Maybe she could try natural childbirth. …On second thought, she said with a nervous giggle, “I don’t think I want to go through that.”

It had nothing to do with AIDS. Like any busy woman with a stressful job, a husband and two kids, she was reacting to the idea of having a third child and to experiencing the pains of childbirth. I smiled, thinking how her HIV was not a lethal specter hanging over her life, but just one of that life’s details that needed to be managed.

Manoj Jain is an infectious-disease specialist and an adjunct assistant professor at the Rollins School of Public Health at Emory University.