Not All HIV Risks are Created Equal

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Steve Fallon

Executive Director of Latinos Salud talks HIV

People living with HIV have different levels of infectiousness at different times in their lives. They have the highest levels during the window of uncertainty, immediately after initial HIV infection. Unfortunately, at this time of high infectiousness, they are least likely to know their correct HIV status, but most likely to infect others.

This reporter interviewed Stephen Fallon, Ph.D., Executive Director of Latinos Salud and consultant to the Centers for Disease Control (CDC) among other agencies about this and other subjects.

Fallon said, “If somebody has been recently infected, they honestly don’t, and can’t know, that not only are they HIV-infected but they are also highly infectious.” While Fourth Generation HIV tests can detect the presence of the virus earlier than other tests, according to the CDC no current test can detect HIV prior to three weeks after initial infection.

To explain this process, Fallon used the image of a castle with all of its cannons pointing outward. “Our immune system … doesn’t know to look inside itself where HIV is growing. It’s inside the castle.” Without a response from the immune system, HIV grows uncontrollably. The population of the unchecked virus can become enormous, up to 2,000,000 viral particles of HIV per milliliter of blood,” Fallon reported.

“At some time after initial infection, the immune system figures out that HIV is there. Then, you start getting sick with HIV conversion-flu.” That conversion-flu means that the immune system is beginning to control HIV. “Now you’re in a tug of war. We do know that without medication, eventually, you will lose that tug of war. But, thank God, the immune system was there to take it to a tug of war, rather than a rout,” he continued.

“If you were to have a slip up, with somebody in the first two months after their infection, they are 12 to 20 times more contagious than they will be for the rest of their life. You would actually be safer going to a hospital where someone was horribly ill with opportunistic infections related to AIDS and having unprotected sex with them. That would be safer than having unprotected sex with someone newly infected.“

This high level of infectiousness can become self-sustaining. As more people become newly infected and highly infectious, they can then go on to infect others who become highly infectious. This second group then goes out and infects even more people, like a snowball rolling down a hill picking up more snow. It only stops when people test and learn their accurate HIV status and reduce their risk behavior.

In order to understand how South Florida provides a particularly risky environment for HIV infection, people need to understand “prevalence.” Stephen Fallon defined prevalence as “the presence of a disease, or condition in a given group.” Sometimes prevalence is expressed as a “1 in X chance of encountering someone with that condition.”

“When we talk about background HIV prevalence, we’re talking about probability. If you have a slip up tonight with a sexual partner,” the background prevalence affects the “probability that your partner might be HIV positive.” This type of information is useful for public health planning. Fallon cautioned that at the individual level prevalence has less usefulness compared with individual protections, such as condom use, PrEP, or negotiated safety.

Fallon found it credible that some epidemiologists have estimated national HIV prevalence to hover around 1 out of 8 among gay and bi men. He believes that the local situation differs. “I don’t think everyone realizes just how dire the epidemic is down here in Miami-Dade and Broward Counties,” Fallon said. “Miami-Dade County is number one, and Broward County is number two in the nation for new HIV diagnoses.” These two counties had to “compete” with 3,005 other counties in U.S. for that “distinction.”

While Fallon has not recently crunched the numbers for Broward County, he estimated HIV prevalence in this area to be about 1 in 4 among Black gay men, about 1 in 8 among Latino gay men, and about 1 in 13 among White gay men. Fallon emphasized that in certain zip codes or subcultures, prevalence could increase to a chance of 1 in 3 that your partner tonight could be capable of infecting you.

If prevalence lacks utility at the individual level, it can help people understand that as HIV prevalence increases, room for error decreases. High prevalence results in high probability of encountering someone capable of infecting someone uninfected. “The more HIV infection in a group,” Fallon cautioned, “the more necessary, it is to have some type of individual protection, such as condoms, PrEP, etc.” This becomes particularly important in areas such as South Florida where new cases of HIV infection are increasing.

The CDC has recommended that all gay and bi men take the HIV test at least once per year. It has also suggested that gay and bi men with higher risk, for example those with more than one sexual partner, could benefit from testing every three or six months. “A recommendation should be a guideline and not a rule. It is a good idea to have a regular schedule for HIV testing, but it has to be one that works for you and your partner(s),” Fallon clarified.

What works for someone today may not work for him or her tomorrow. Fallon supports something like the “birth control model” for HIV prevention. Women use different forms of birth control at different points in their lives, to match the changing circumstances of their lives. Similarly, gay and bi men may find condoms work at one point, PrEP at another, and negotiated safety at yet another, as their lives change.  

Fallon repeatedly stressed discussion and clarity with the other(s) involved   “Anytime that we’re going to be entering a potentially risky situation, we should first define our terms and make sure we’re on the same page with our partner. If I say I ‘love you,’ have I just pledged monogamy? Or, did I just mean I feel close to you at this specific moment? We owe it to ourselves to make sure we heard what our partner truly meant.”

The CDC has estimated that 14 percent (1 in 7) of all gay and bi men living with HIV are unaware of their HIV status. They are the Unaware Infected. While some of them have never tested, some are now in that highly infectious window of uncertainly, but others have become infected since their last HIV test. The Unaware Infected pose a major, if seldom recognized, challenge to HIV prevention. We need to recognize this challenge.

Stephen Fallon has served as a consultant to the CDC, Health Resources Services Administration, the U.S. Office of Minority Health, Human Rights Campaign, and a dozen state Departments of Health. The interview has been edited for clarity and brevity.

To read the full interview, which touches on many HIV-related subjects, please visit http://HowStandardIsYourDeviation.blogspot.com.

For more information, please visit http://www.cdc.gov/features/ngmhaad/ and http://www.cdc.gov/hiv/testing/index.html

The Fourth Generation HIV Test can reduce that window of uncertainty by 15.5 days. Latinos Salud offers that test.

 


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