Its easy to ascribe HIV with malevolent intent. It comes with so much baggage: the stigma and trauma of diagnosis, the branding of gay sex as immoral, and how the disease burden highlights global health inequalities. Yet HIV or human immunodeficiency virus is just a small piece of RNA in a lipid envelope: code with nasty side effects. All the emotional baggage is on us. HIV fuses with human cells and uses an enzyme it carries “reverse transcriptase” to produce viral DNA. Viral DNA is inserted into host cells’ own genomes and thus the cells are now wired to produce millions of copies of HIV before they die. HIV is specific about the type of cells it fuses with, mainly a type of immune cell called CD4, which has a coordination role in immune function. So whilst much of the immune system remains undamaged by HIV, the loss of CD4 results in a significant loss of immune function.
HAART (Highly Active Anti-retro-viral Therapy)
HIV infection is treated with antiviral drug therapy. Each drug targets a point in the viral replication process described above: fusion, transcription, insertion etc. The reverse transcriptase enzyme is highly error prone, and HIV mutations are common. HIV can quickly develop drug resistance and hence a combination of drugs is used, to avoid a resistance mutation gaining significance. Antiviral therapy has transformed HIV from fatal disease into a lifelong manageable infection. When I began working in the HIV field in 2000, there had been two inpatient wards at our hospital that treated people living with AIDS, and one had just closed as a result of the impact of combination therapy. Just a few years before the HIV+ community had been desperately campaigning for access to new treatments, despite unknown drug toxicity. As a colleague describes “they were living experiments”.
Despite the decrease in morbidity and mortality, and decades of health promotion advocating testing and condom use, UK incidence has risen year on year, primarily among gay and bisexual men. Condom use, the faithful barrier method, is straightforward enough, but sex is not generally straightforward. Its sometimes hard to comply once the pleasure button has been pressed.
Treatment as prevention
The use of PrEP (pre-exposure prophylaxis), has been one of the factors cited as responsible for the first reduction in incidence rates (32%) of new diagnoses in London since the mid-80s. It is hard not to exaggerate the importance of this statistic. PrEP is certainly not the only factor at work here, as many clinics now offer rapid testing (results within 60 seconds) with a subsequent increase in uptake. As a result diagnosis occurs closer to infection, the time when HIV is most infectious. Treatment with antivirals close to diagnosis reduces the amount of virus in bodily fluids (from billions per ml to an undetectable level) and hence prevents transmission. Arguably transmission among people who perceive themselves as negative, yet are extremely capable of passing the virus, has been the main driver of the UK epidemic.
PrEP consists of taking an antiviral pill (Truvada) prior to unprotected sex. The premise is that a therapeutic level of antiviral drugs will stop HIV from establishing itself, should you come into contact with it. You need to be sure you are HIV negative, otherwise PrEP could increase the chance of drug resistant HIV. Strong data supports the biological efficacy of PrEP, from France and the UK where the relative risk of acquiring HIV was reduced by 86%. However, PrEP is contentious, and potential users face criticism that they wantonly take risks. PrEP has been touted as a brief intervention that people use whilst they work on behavior change. It is expensive too (although not more expensive than lifelong HIV treatment), and these are the main barriers in the UK. Currently it is only available to 10,000 people as part of the 3-year IMPACT trial which seeks to study how long people take PrEP for.
The right to get PrEP
I have told many people that they are HIV positive, possibly more than a 1000. I was lucky because during this time HIV had become treatable and I could describe a largely optimistic future. Nevertheless I sometimes felt complicit in an act of violence, because giving the diagnosis precipitated a crisis. For me, the need for more prevention options is very clear. As in the 80s, activists have hit the streets to campaign for PrEP, and there is a website where you can buy PrEP online. The site uses a legal loophole, where generic drugs can be bought directly from overseas suppliers at a fraction of the price without prescription. This is also an example of remarkable joint work between NHS staff and PrEP campaigners, as medical staff at 56DeanSt provide drug-level testing to confirm that generic PrEP is effective.
Whilst the medical reasons for PrEP appear sound, PrEP is balancing on an economic see-saw, where NHS chiefs need to weigh up its cost versus other treatments. The £2 million investment into IMPACT, which aims to preventatively treat 200 people, could fund more than 350 hip replacements. It is inevitable that moral judgments creep into the debate. Yet what kind of complex equation could we possibly employ?
Take your medicine! 
1 thought on “HIV: the night before the morning after.”