SAN DIEGO, California — In San Diego County there are nearly 13,000 cases of known HIV infection. The County of San Diego Health and Human Services Agency estimates there are nearly 2,000 more men who have sex with men (MSM) who are HIV-positive but don’t know it.
With the recent headline-grabbing story of Thomas Guerra, a man accused by an ex-boyfriend in San Diego of deliberately infecting him with HIV, Social Media nationwide has been abuzz with questions about HIV, what “exposure” means and the confounding question of informed consent.
What has been missing in this lively debate has been any kind of HIV education. San Diego Gay and Lesbian News (SDGLN.com) has taken this opportunity to speak with some of the area’s best HIV practitioners and compiled the following HIV primer. In this article you will find life-saving information on the various symptoms of new HIV infection, the tests for HIV that are available and where you can get them for free as well as a close look at the current state of HIV prevention and the different methods available.
What is HIV?
HIV is a virus that methodically breaks down a body’s immune system by slowly killing off its natural defenses, specifically CD4+ T-cells. HIV doesn’t kill you, but it leads to Acquired Immune Deficiency Syndrome (AIDS), which means your body’s immune system is so weakened that it can no longer defend against the most benign ailments.
In other words, for people with AIDS, a common respiratory ailment can lead to fatal pneumonia.
However, when their CD4 cells are still holding these opportunistic infections at bay, people with HIV often feel relatively healthy, and without an HIV test to tell them so, might not even know they’re infected.
“A person with HIV can feel normal for weeks to months to years until their CD4 counts drop to a level at which they become susceptible to these opportunistic infections,” said Winston Tilghman, M.D., Senior Physician for the HIV, STD and Hepatitis Branch of Public Health Services at the County of San Diego Health and Human Services Agency.
But while a person may feel perfectly normal, they can also be highly infectious.
How do you get it?
HIV is primarily transmitted through sexual fluids (crudely: cum, precum and STD discharge fluids) as well as exposure to blood (most commonly by sharing needles during intravenous drug use).
“Over half of the new infections in San Diego County are from people who don’t know that they’re infected,” Dr. Tilghman said.
Following infection, in four out of five cases, patients will develop flu-like symptoms, the severity of which varies among patients. This is called Acute Infection Syndrome and according to Dr. Tilghman, this is when a patient is most infectious.
There are two HIV tests available through the County of San Diego Health and Human Services Agency.
The Rapid Test
The first test is commonly called the Rapid Test, so named because the results are available rapidly, usually within 20 to 40 minutes. The test is performed by swabbing a patient’s gums and treating it with special chemicals. Alternatively, a finger stick blood sample may be used.
The Rapid Test looks for HIV antibodies that the body produces against the virus. If no antibodies are detected the test will come back negative. But because it takes the body between three to six months to develop HIV antibodies following an infection, a negative Rapid Test doesn’t mean a patient is HIV negative. If the “infection event” happened earlier than three months before the test was given, a Rapid Test will not provide adequate information, and a negative result could be misleading.
The P24 Test
The second test the County offers is an “Architect” or P24 antigen-antibody “combination” test. In addition to the HIV antibodies, this test also looks for a specific protein found in HIV, meaning it looks for presence of the virus itself and not only the body’s reaction to the virus.
This test requires a blood draw and takes up to seven days before results are available. However, unlike the Rapid Test, the “infection event window” is only two weeks.
A negative combination test will mean that if a sexual encounter occurred more than two weeks before the test was given, it did not result in an HIV infection. However, if the “infection event” happened inside of that two week window, the combination test will not provide adequate information.
Both the Rapid Test and the combination test are available at several locations throughout San Diego County.
The Early Test
The test with the shortest “infection event window” is also the test with the longest turnaround time. “The Early Test” will tell you if you have HIV and, if you do, how many copies of the virus you have per milliliter of blood (the so-called “Viral Load”).
It’s called the Early Test because it is a tool for early detection. The test is so sensitive it can pick up any detectable levels of the virus after just one week after exposure. However, results take up to two weeks to analyze.
Because of its cost, this viral load testing is not available through the County of San Diego’s free testing program.
It is, however, available for free as part of the research arm of the University of California San Diego -- at the AntiViral Research Center, Lead the Way and The San Diego LGBT Community Center. For patients with solid medical insurance, a similar HIV viral load test is almost always available at most doctors’ offices.
How to avoid getting HIV
Until recently, the conversation on how to avoid sexually contracting HIV was limited to two primary methods: abstinence and condom use.
However, those methods alone have done little to curb the quickly spreading virus and fortunately, in recent years the science of HIV prevention has evolved.
What is PEP?
PEP (post-exposure prophylaxis) involves taking HIV medications after a single high-risk exposure to HIV (typically unprotected sex with an HIV-positive person) in order to prevent infection.
The idea of PEP is to decrease the virus’s ability to copy itself and infect cells in the exposed person and prevent the exposed person from becoming HIV-positive. In order to be effective, PEP must be started as soon as possible and not later than 72 hours after exposure. Two to three drugs are typically prescribed, and they should be taken for 28 days. Although PEP is not effective 100% of the time, starting it as soon as possible after a high-risk event and taking it every day as prescribed will maximize its effectiveness. Therefore, if you think that you have been exposed to HIV in the last three days, it is important to see a doctor right away to discuss this option. HIV testing must be repeated after the medications are finished to determine if PEP was successful or not.
What is PrEP
PrEP (Pre-Exposure Prophylaxis) operates on a similar trajectory of PEP with a few differences. Rather than taking large doses of HIV medication following a single encounter with HIV, PrEP aims to keep the anti-HIV drugs in your system all the time by taking one pill every day (currently a drug called Truvada). PrEP is particularly desirable for people who may be at repeated or ongoing risk of HIV infection.
This method of prevention was approved by the U.S. Food and Drug Administration in 2012 and has been something of a spark for controversy among HIV and AIDS Service providers, to say nothing of the gay and bisexual male population.
While some label this method of prevention a “party drug,” including the well-heeled AIDS Healthcare Foundation, others find it a useful and effective tool for keeping people from contracting HIV, like University of California San Diego Medical Centers, which regularly conducts clinical trials on the drug.
The controversy has, of course, devolved into name-calling. Intended as a derogatory term, the phrase “Truvada Whore” was coined to describe people who would intentionally engage in unsafe sexual practices feeling they were safe from HIV if they took the medication as directed. However, the phrase has been adopted by many taking the drug in an effort to spread education about the prevention technique.
According to the U.S. Centers for Disease Control and Prevention (CDC), PrEP has an efficacy rate as high as 92%. In case you were wondering, according to the Canadian AIDS Treatment Exchange (a resource for medical providers specializing in HIV) condom use alone came in at roughly 80% effectiveness. PrEP is not meant to replace condom use, but taking Truvada daily in combination with traditional preventive methods appears to be the most efficacious prevention tool to date.
Undetectable viral loads
What has become the layman’s common school of thought is that someone with an undetectable viral load has little-to-no risk of passing HIV on to sex partners, even during unprotected intercourse.
That’s only partially true, says Dr. Susan Little with the AntiViral Research Center at UCSD. “The greatest challenge I believe with addressing transmission risk among men with undetectable viral loads is the issue of timing. Most HIV infected people get a viral load test every three to six months. This means that these HIV infected people are typically assuming that they are at minimal (or no) risk, when in fact, they may not have an undetectable viral load today.”
Dr. Little also explained that viral load in a blood sample may well be different than the viral load in the semen, which is obviously more important. “Given that most HIV in the US is transmitted sexually, it is also important to know what the viral load in the genital tract may be. Though again, an undetectable measure one day does not guarantee an undetectable level weeks later,” she said.
“Finally -- there are other sexually transmitted infections (syphilis, gonorrhea, chlamydia, etc.) that are often associated with an increase in the genital tract viral load. So overall, persons with an undetectable viral load are generally at very low risk of transmission -- but VERY LOW risk does not mean no risk.”
If you’re thinking about entering into a romantic relationship or having a sexual encounter with someone who has a different HIV status than you, there are some things you should know.
A lot of research has been done on the transmission rates of HIV among “serodiscordant” (mixed-status) couples and the news is mostly very good but there are a few conditions.
According to Dr. Little, when an HIV positive partner is steadily following their medication regimen, there is a “markedly reduced” risk of infecting their partner. But that requires that the HIV positive partner is on medication and takes it regularly.
Various scientific studies point to virtually no infections among mixed-status couples when the HIV positive partner maintains strict adherence to an effective medication regimen.
In fact, early results from a massive research project called “The PARTNER Study” says that in the first two years of that study, no one in the study with an undetectable viral load has passed HIV on to their partner after an estimated 16,400 sexual encounters.
Statistical analysis shows that the maximum likely chance of transmission via anal sex from someone on successful HIV treatment was 1% a year for any anal sex and 4% for anal sex with ejaculation where the HIV-negative partner was receptive; but, according to the study’s authors, “the true likelihood is probably much nearer to zero.”
Where to get tested
The following is a list of resources available for free and confidential HIV testing. In almost every one of these locations, if a patient tests positive, counselors are available to help patients deal with the diagnosis, provide tools for disclosing their status to any partners and help them connect with health providers. For more information, visit knowanddisclose.com for more information on these and other resources.
County Health Services Complex
3851 Rosecrans St., Suite S
San Diego, CA 92110
Testing is available Monday, Tuesday and Friday from 7:30 am to 4 pm
Wednesdays 11 am to 7 pm
Thursdays 10 am to 4 pm
North Coastal Public Health Center
104 S. Barnes St.
Oceanside, CA 92054
Wednesdays 12:30 to 7:30 pm
Central Region Public Health Center
5202 University Ave.
San Diego, CA 92105
Tuesdays 1 to 7:30 pm
Fridays 10 am to 4 pm
South Region Public Health Center
690 Oxford St.
Chula Vista, CA 91911
Thursdays noon to 6 pm
The County also funds testing at the following facilities. Click on the links for times.
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(Editor's note: Articles written by San Diego Gay & Lesbian News and its contributors may not be reprinted without the written consent of Hale Media, Publisher Johnathan Hale or Editor-in-Chief Ken Williams. Any lifting of quotes or republishing of any content published by SDGLN must be accompanied by a proper link back to our original story and full credit to the author and this online media source. Ken Williams is Editor in Chief of SDGLN and GLBTNN. He can be reached at firstname.lastname@example.org, @KenSanDiego on Twitter, or by calling toll-free to 888-442-9639, ext. 713.)